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«Nevada Medicaid Fact Book This is a time of expansion and transformation of the Medicaid program. The Patient Protection and Affordable Care Act and ...»

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Division of Health Care Financing & Policy (DHCFP)

1100 E. William Street, Carson City, NV 89701

Tel (775) 684-3676


Nevada Medicaid Fact Book

This is a time of expansion and transformation of the Medicaid


The Patient Protection and Affordable Care Act and an array of

program reforms represent the most sweeping changes to Medicaid

since its enactment.

We at the Division of Health Care Financing & Policy (Nevada

Medicaid) are controlling costs and delivering care in innovative and practical ways – including through the managed care model and the Health Care Guidance Program, integrating physical and behavioral health care. We are expanding efforts to detect fraud, waste, and abuse so funds can be allocated for medically necessary services.

We are honored to be a part of Medicaid in these changing times as we work to improve the health of Nevada Medicaid beneficiaries.

Laurie Squartsoff Administrator Division of Health Care Financing & Policy The mission of the Nevada Division of Health Care Financing and Policy (Nevada Medicaid and Nevada Check Up) is to: purchase and provide quality health care services to low-income Nevadans in the most efficient manner; promote equal access to health care at an affordable cost to the taxpayers of Nevada; restrain the growth of health care costs; and review Medicaid and other State health care programs to maximize potential federal revenue.

What is Medicaid?

Medicaid is the nation’s main public health insurance program for people with low incomes and the single largest source of health Total Medicaid coverage in the U.S. In Nevada, Medicaid covers over 600,000 and Nevada Check individuals. Medicaid is administered by the states within broad Up Spending in federal requirements, and states and the federal government finance the program jointly.

SFY 2014:

$1,778,419,393 The program facilitates access to care for beneficiaries, connecting most with managed care plans and their networks of providers, covering a broad range of benefits. As a major payer, Medicaid is a core source of financing for safety-net hospitals and health centers that serve lowincome communities. It is also the main source of coverage and financing for nursing home and community-based long-term care.

Who does Medicaid cover?

Before the enactment of the Patient Protection and Affordable Care Act (PPACA), federal law provided Medicaid federal funding for specific categories of low-income individuals: children, pregnant women, parents of dependent children, individuals with disabilities, and certain Medicare beneficiaries. Medicaid programs cover people in these groups with income levels up to federal mandatory minimum thresholds.

Key Patient Protection and Affordable Care Act Reforms The PPACA extended coverage to many of the non-elderly uninsured people nationwide. The June 2012 Supreme Court Ruling made Medicaid expansion optional for states, and Nevada elected to join the expansion and maximize federal dollars. Effective January 1, 2014, this move broadened Medicaid eligibility to nearly all adults under age 65 with income at or below 138% of the Federal Poverty Level (FPL). At the end of SFY 2014 that meant that there were an additional 125,989 new enrollees in Nevada Medicaid, and increased expenditures of $154,816,777.00.

These new expenditures are 100% federally funded.

For details on requirements for Medicaid eligibility, see the Division of Welfare and Supportive Services Fact Book.

How is Medicaid structured?

Federal/state partnership The cost of Medicaid and Nevada Check Up is shared by the federal government and the State.

The federal government matches state Medicaid spending based on a formula specified in the Social Security Act. In SFY 2014, the blended Federal Medical Assistance Percentage (FMAP) was 62.26% for most eligible beneficiaries. The FMAP for family planning services is 90%, Title XIX payments to Indian Health Services for tribal members is 100%, coverage for individuals with Breast and Cervical Cancer is funded with the blended Enhanced FMAP at 73.58%. In addition, the Children’s Health Insurance Program (CHIP, known as Nevada Check Up) was funded at the SFY 2014 blended Enhanced FMAP rate of 73.58%. The expansion population (newly eligibles) are funded at 100%.

States administer Medicaid within broad federal guidelines Each state creates a single agency that administers Medicaid. For Nevada, that agency is the Division of Health Care Financing & Policy (DHCFP). Federal law specifies core requirements, and beyond that states have broad flexibility regarding eligibility, benefits, provider payments, delivery systems, and other aspects of their programs. Every state has a Medicaid State Plan that describes its program in detail. To make a change in its program, a state must receive federal approval from the Centers for Medicare and Medicaid Services (CMS).

States may seek federal waivers of regular rules to administer programs The Health and Human Services (HHS) Secretary may waive statutory and regulatory requirements for Medicaid, for budget-neutral research and demonstration purposes that are “likely to assist in promoting the objectives of the program.” States also have the option of Section 1915 “program waivers” that permit them to provide care for certain beneficiaries and to obtain federal match to provide community-based long term support services to beneficiaries who would otherwise need nursing facility care.

What does Medicaid cover?

Services depend upon program and beneficiary Because of the diverse and complex needs of the Medicaid population, Medicaid covers a broad array of health and long-term care services, including many services not covered by traditional insurance like transportation, long term care (nursing facilities) and home and community-based services. Benefits to children are comprehensive, while states have more latitude in defining benefits for adults.

–  –  –

Medicaid is a significant source of coverage for children Medicaid, together with CHIP, covers more than one in every three children nationally. These are vital services for all children – especially those with disabilities and special needs.

Medicaid covers many with complex health care needs Medicaid provides health and long-term care coverage for people with severe physical and behavioral health conditions and disabilities (e.g., cerebral palsy, Down Syndrome). Addressing the spectrum of needs and limited ability to pay out-of-pocket, Medicaid covers medical services and, in addition may provide services like transportation and community-based long-term care.

–  –  –

Beneficiaries have a federal entitlement to coverage Medicaid is an entitlement program, meaning that states who participate in the Medicaid program are federally mandated to provide services to any person who meets the state’s eligibility criteria. The state cannot limit enrollment or establish a waiting list. This guarantee of coverage should be distinguished from Medicaid waiver programs, CHIP and other block grant programs, in which funding levels are pre-set and enrollment can be capped.

Mandatory services Federal law requires this set of “mandatory services.”

–  –  –

Optional services offered in Nevada Many of these optional services are vital for people with chronic conditions, disabilities, or the elderly. These services, typically provided in a home or community-based environment, aid to reduce the overall cost of health care while contributing to the individual’s quality of life.

–  –  –

How do Medicaid beneficiaries receive care?

Beneficiaries obtain care primarily from private providers and health plans Medicaid is publicly financed, but is not a government-run health care delivery system. The state pays medical providers for services furnished to beneficiaries on a fee-for-service basis or through risk-based contracts with managed care plans. Managed Care Organizations (MCOs) are paid on a capitation basis – a monthly premium based on the financial risk for providing comprehensive Medicaid benefits.

How is DHCFP structured?

–  –  –


The DHCFP administration provides the leadership for the agency, working with federal, state, industry and customer stakeholders to ensure the Medicaid and CHIP programs operate within the agency Mission. The leadership works to promote innovation and change to ensure Nevada’s Medicaid and CHIP programs evolve and provide quality up-to-date programs. The DHCFP administration also manages the agency fiscal oversight and policy, including document control processes.


The Human Resources Unit serves as liaison between the DHCFP and the Division of Human Resources Management, the Public Employees Retirement System (PERS), the Public Employees Benefit Program (PEBP), and the Division of Risk Management.


The Accounting and Budget Unit’s functions are divided into four sections:

Finance and Accounting This section is responsible for cash receipts, including deposits and federal draws for Medicaid Title XIX, CHIP Title XXI, and all other grants. The Accounting section is also responsible for the accounts payable for contract payments, cost containment and drug rebate invoices and payments, Medicare Buy-In payments, interagency billings, and purchase orders, along with regular accounting functions.

Budget The Budget Section completes the biennial budget for Medicaid, Nevada Check Up, DHCFP Administration, Intergovernmental Transfer, and Fund to Increase the Quality of Nursing Care.

This section continuously monitors the budget versus actual expenditures and adjusts as necessary.

Contracts The Contract Section is responsible for monitoring contracts as well as assisting other Division staff in creating contracts.

Medicaid Management Information System (MMIS) Finance/Reporting This section maintains the MMIS budget and finance functions, monitors MMIS budget authority, and resolves issues with claims pended because of MMIS budget issues. The section responds to requests for information/data and supports financial and budget operations by providing critical financial reports.

The reporting staff files Medicaid related revenue, expenditure, and forecasting reports to CMS quarterly. This staff requests and monitors the transfer of federal dollars between the state and federal treasury departments and ensures the state is reimbursed for all claims in accordance with applicable federal requirements. The reporting staff also makes Medicaidrelated financial reports to the State Controller’s Office and other state agencies.

This section also oversees the County Match Program, School Based Services Program, and para-transit non-emergency transportation services through the Regional Transportation Commissions. This includes invoicing and collecting the Intergovernmental Transfer funds related to the programs identified above as well as setting cost-based reimbursement rates. This section is also responsible for all Certified Public Expenditure funding for Targeted Case Management, Behavioral Health services and Adult Day Health Care services, and for the Division’s Cost Allocation Plan.


The Rates and Cost Containment Unit’s functions are reimbursement rate setting, management of supplemental payment programs, collection of data, reporting on provider finances, claims data analysis, and county contracts related to Intergovernmental Transfer. The

Unit is divided into two sections:

Rates This section sets rates for fee-for-service providers, establishes payment rates for hospital, nursing facility, and other provider type services, applying existing Nevada State Plan methodologies, federally allowable reimbursement methodologies, other state methodologies, and industry standards. They research and prepare responses to audits and rate appeals.

Cost Containment This section manages the supplemental payment programs, some of which are described


 Disproportionate Share Hospital, providing supplemental payments to hospitals providing a disproportionate share of services to the indigent and uninsured.

 Upper Payment Limit, allowing Medicaid to pay hospitals under a fee-for-service environment an amount that would equal what Medicare would have paid for the same services.

 Graduate Medical Education payments, currently only provided to non-state governmentally owned hospitals (University Medical Center of Southern Nevada).

 Federally Qualified Health Center (FQHC) “wraparound” payments to cover the difference between what is paid by the Managed Care Organizations and the FQHC’s prospective payment system cost-based rate.

The Unit collects Medicare and Medicaid cost reports from hospitals and other health care facilities and oversees contracted auditors who review cost reports for cost settlement purposes.

The unit prepares annual financial and utilization reports that are provided to governmental entities and the general public. They have oversight of Nevada Compare Care, a transparency website created by and administered under contract to the Center for Health Information Analysis (CHIA) at the University of Nevada, Las Vegas.


The IS unit provides technical oversight of the agency’s IS resources, and is divided into three sections: Information Technology, Application Development and Business Services.

Information Technology (IT) The IT section provides technical oversight of the agency’s IT resources and information system security.

The agency has a designated Information Security Officer (ISO) who ensures appropriate application of the Health Insurance Portability and Accountability Act’s (HIPAA) Security Rule and protection of personally identifiable information through the development and implementation of Division security policies, standards, and procedures; education on the same;

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