Can I get a PPO plan through my employer?

Yes, some employer plans still offer PPO options. Read More: https://www.nevadainsuranceenrollment.com/health/ppo-plans-vanish-from-nevada/

Does my employers have to give me paperwork for health insurance options?

Yes. According to the U.S. Department of Labor, employers subject to the Fair Labor Standards Act (FLSA) must provide these notices to all new employees within 14 days of their hire date. In Nevada, employees are directed to Nevada Health Link, the state’s official Marketplace, where they can review coverage options and check eligibility for financial assistance. Why Employers Must Provide Marketplace Notices The ACA requires these notices so that employees are aware of their right to explore health insurance outside their workplace plan. Notices give employees clear, standardized information to compare employer coverage with Marketplace options. Nevada Health Link emphasizes that Marketplace plans may provide more affordable coverage, especially if premium tax credits are available. The U.S. Department of Labor confirms that while employers must distribute notices, there is currently no fine for failing to do so. Read More: https://www.nevadainsuranceenrollment.com/health/employer-health-insurance-notices/

How Do Health Insurance Notices Help Employees?

Health insurance notices from employers, officially called Notices of Coverage Options, are documents required under the Affordable Care Act (ACA). These notices explain the Health Insurance Marketplace (sometimes called the “Marketplace”) and guide employees on how to explore alternatives to employer-sponsored coverage. Read More: https://www.nevadainsuranceenrollment.com/health/employer-health-insurance-notices/

How Do I Find My Modified Adjusted Gross Income?

Calculating INCOME When you apply for a health insurance subsidy, you’ll need to estimate your income (before taxes) for the year in which you’re applying for insurance. If you are not sure, you’ll have to make your best estimate. We recommend you speak with your accountant to get your MAGI (Modified Adjusted Gross Income) calculation. Modified Adjusted Income for most folks will be the Adjusted Gross Income on line 37 of your 1040, or 21 of your form 1040A or line 4 of your 1040EZ of your tax return. Add: You and your spouse’s income, if you’re married and will file a joint tax return Any dependents who make enough money to be required to file a tax return You’ll need to include: Wages Salaries Tips Alimony – After 1/1/2019 DO NOT include. Unemployment compensation Self Employed or business (generally the amount of money you take in from your business minus your business expenses) Social Security payments, including disability payments – but not Supplemental Security Income (SSI) Retirement income, Investment income, pension income, rental income, prizes, awards, gambling winnings Generally withdrawals from an IRA (Not Roth IRA.) See IRS Form 8606 Withdrawals from a 401k plan (less distributions from a Roth Account) See IRS Pub. 575 Excluded (untaxed) foreign income Capital Gains Don’t include: Gifts Child support Supplemental Security Income (SSI) Veterans’ disability payments Workers’ compensation Qualified withdrawals from a Roth IRA. See IRS Pub. 590 Proceeds from loans (like student loans, home equity loans, or bank loans) We suggest you refer to your federal income tax return to get a quick estimate of your AGI. On your tax return, please refer to: Line 4 if you filed a Form 1040EZ Line 21 if you filed a Form 1040A Line 37 if you filed a Form 1040 Keep in mind, the subsidies are based off the “Household Modified Adjusted Income.” We recommend you speak with your accountant to get your “Modified Adjusted Gross Income” calculation. Read More: https://www.nevadainsuranceenrollment.com/health/stating-income-subsidy/ Disclaimer: The material in this site is provided for educational purposes only and does not substitute consultation with an Attorney or Accountant. We do not guarantee the accuracy or completeness of the definitions or any information or other items within this website. Any inclusions of incorrect data or omissions of correct data is unintentional. We will make periodic changes to these materials at any time and make no commitment to update the information contained herein, although we will continue to update as often as possible. The Nevada Insurance Enrollment Marketplace shall not assume any responsibility or liability for any such inadvertent errors or inaccuracies, and shall have no obligation to honor transactions or information affected by such inaccuracies.

How Do PPO Plans Offer More Flexibility?

PPO plans provide greater choice by allowing members to see providers outside the network, such as specialists for conditions like diabetes, without pre-approval. This flexibility comes at a higher cost, as out-of-network services have higher deductibles and coinsurance. In contrast, HMO plans limit members to in-network providers, and EPO plans offer a middle ground by eliminating referral requirements. Read More: https://www.nevadainsuranceenrollment.com/health/hmo-ppo-epo-differences/

How Does the Summary of Benefits Differ from Other Documents?

The summary of benefits is distinct from the Agreement of Coverage (AOC), sometimes called the Certificate of Coverage (COC). While the SBC is a concise 4-page overview, the AOC is a detailed document, often exceeding seventy pages, that outlines all plan coverages, exclusions, and legal terms. The AOC provides an in-depth look at what is covered, such as specific procedures like an MRI (Magnetic Resonance Imaging), and what is excluded, like experimental treatments. Unlike the SBC, the AOC is typically available after enrollment, while the SBC is provided when shopping for plans. Read More: https://www.nevadainsuranceenrollment.com/health/summary-of-benefits/

How Has Cost Impacted The Loss of PPO Plans in Nevada?

The loss of PPO plan options is heavily influenced by specific cost-related factors. Nevada Health Link explains that HMO and EPO plans reduce expenses through smaller provider networks, lowering administrative costs for maintaining contracts compared to PPO plans’ broader networks. HMO plans manage these costs by limiting specialist visits and tests through referrals, ensuring predictable expenses. In contrast, PPO plans’ out-of-network flexibility increases insurer costs, contributing to PPO plan reduction. Read More: https://www.nevadainsuranceenrollment.com/health/ppo-plans-vanish-from-nevada/

What are Essential Health Benefits?

What are Essential Health Benefits and who must have them? From 1/1/2014 and forward, all new health insurance plans (insured small group and individual health insurance plans) must cover the 10 bulleted benefits below, called “Essential Heath Care Benefits” to qualify as being an ACA plan (Obamacare). Qualified Health Plans MUST cover these 10 items without any lifetime or annual limits on these “Essential Health Benefits.” These essential benefits include: Outpatient care Prescription drugs Laboratory services Prenatal and postnatal care Hospitalization, such as for surgeries and overnight stays Pediatric services, including vision and dental care for children Chronic disease management and preventative and wellness services Emergency services, including services provided at an out-of-network hospital Rehabilitative and habilitative services for policyholders with injuries, illnesses or chronic conditions Treatment for mental health and substance abuse disorders, such as counseling services and psychotherapy These essential health benefits are the minimum requirements for all Marketplace ACA (Obamacare) plans. They are broad categories, and the specific services that are covered vary from one state to another, depending on what that state requires. In addition to these requirements, Qualified Health Plans must also comply with limits regarding your cost-sharing expenses (your out-of-pocket expenses) including deductibles, co-payments and annual out-of-pocket limits. Read More: https://www.nevadainsuranceenrollment.com/health/qualified-health-insurance-plan/

What Does a Health Insurance Carrier Do?

A health insurance carrier offers plans that cover medical expenses, such as doctor visits, hospital stays, and prescription medications. Insurers partner with healthcare providers to offer financial protection against high medical costs. By paying a monthly premium, policyholders gain access to a network of doctors, hospitals, and clinics, ensuring they receive necessary care without overwhelming expenses. Read More: https://www.nevadainsuranceenrollment.com/health/new-health-insurance-plan/ https://www.nevadainsuranceenrollment.com/health/health-plan-benefits/

What Does Purchasing Health Insurance OFF Exchange Mean?

Health Insurance purchased Off Exchange is simply not enrolling on the Government’s Marketplace website (Nevada Health Link). If you do not want a subsidy, or make too much money to qualify for a subsidy, you can shop for health insurance Off Exchange (in the private market), using the same health insurance carriers as ON the exchange. In Nevada we have HMO, EPO and PPO health insurance plan options available to enroll into. When you buy a health insurance plan in the private market, you don’t need to disclose your income or worry about updating your account throughout the year. You set it and forget it. In addition, the prices “OFF Exchange” are often less expensive than “ON Exchange”. These plans are Qualified Health Plans that contain the 10 Essential Health Benefits that cover pre-existing conditions, no matter what the condition is. Read More: https://www.nevadainsuranceenrollment.com/health-insurance/no-subsidy/ https://www.nevadainsuranceenrollment.com/health/state-based-health-insurance-exchange/

What Does Purchasing Health Insurance ON Exchange Mean?

Health Insurance purchased ON Exchange is simply enrolling on the Government’s Marketplace website (Nevada Health Link). Depending on your household income, you may or may not qualify for financial assistance (subsidy) in paying for your health insurance plan. If you do qualify for a Government subsidy, you’ll then shop Nevada Health Link. We’ll assist you from beginning to end and throughout the year. Note: If you do not want a subsidy, or make too much money to qualify for a subsidy, you can shop for health insurance Off Exchange (in the private market), using the same health insurance carriers as ON the exchange. Health Insurance plans purchased ON and OFF the Exchange are Qualified Health Plans that contain the 10 Essential Health Benefits that cover pre-existing conditions, no matter what the condition is. Read More: https://www.nevadainsuranceenrollment.com/health-insurance/subsidy/ https://www.nevadainsuranceenrollment.com/health/state-based-health-insurance-exchange/

What Factors Should I Consider When Choosing a Health Insurance Carrier?

When selecting a health insurance carrier, evaluate these factors: • Network Size: Does the carrier include your preferred doctors or hospitals in its network? • Coverage Options: Are essential services, like preventive care or prescription drugs, included? • Customer Service: Is support available for questions about claims or coverage? • Premium Costs: Can you afford the monthly payments alongside out-of-pocket costs like deductibles? • Reputation: Does the carrier have a strong history, as verified by resources like Nevada Division of Insurance? These considerations ensure your carrier aligns with your healthcare and financial goals. Read More: https://www.nevadainsuranceenrollment.com/health/health-plan-benefits/

What Information Does the Summary of Benefits Include?

The summary of benefits provides a clear snapshot of a health insurance plan’s key features. It includes essential details to help you evaluate coverage options without wading through complex insurance documents. The main components are: Coverage Details: Lists services covered, such as doctor visits, hospital stays, prescription medications, and preventive care. Cost-Sharing: Explains costs like premiums (monthly payments), deductibles (amount paid before coverage starts), copays (fixed fees for services), and coinsurance (percentage of costs shared after meeting the deductible). Coverage Examples: Shows how the plan manages common scenarios, like managing diabetes or a hospital stay for childbirth, including estimated costs. Limitations and Exceptions: Notes specific restrictions, such as services requiring pre-authorization or limits on certain treatments. This standardized format ensures all health insurance companies present information consistently, simplifying plan comparisons. Read More: https://www.nevadainsuranceenrollment.com/health/summary-of-benefits/

What Information Is Included in Notices of Coverage Options?

A typical health insurance notice from an employer provides: An explanation of what the Marketplace is and how to access it (in Nevada, through Nevada Health Link). Guidance on premium tax credits, including eligibility if the employer’s plan: Covers less than 60% of allowed costs, or Costs more than 9.04% of household income in 2025. A reminder that choosing a Marketplace plan may mean losing the employer’s contribution toward premiums, which could also affect tax advantages. These details help employees understand how Marketplace coverage compares to their workplace plan. Read More: https://www.nevadainsuranceenrollment.com/health/employer-health-insurance-notices/

A EPO (Exclusive Provider Organization) is a type of health plan that offers a local network of doctors and hospitals for you to choose from. A EPO can be described as somewhat of combination of a PPO and HMO. You don’t have to select a primary care doctor, and you may see any of the providers in the EPO network, but there are no out of network benefits. If you choose to get care outside of your plan’s network, you will pay full price, there is no coverage, unless it’s an emergency. If you’re looking for lower monthly premiums, and are okay with using local doctors and hospitals, but don’t want to have to get referrals for specialists, you may want to consider a EPO plan. Read More: https://www.nevadainsuranceenrollment.com/health/hmo-ppo-epo-differences/

What is a Health Insurance Carrier?

A health insurance company, also known as a health insurance carrier, is an organization that provides health insurance plans to individuals, families, or groups. Read More: https://www.nevadainsuranceenrollment.com/health/health-insurance-carrier/ https://www.nevadainsuranceenrollment.com/health/new-health-insurance-plan/ https://www.nevadainsuranceenrollment.com/health/health-plan-benefits/

What is a Health Insurance Co-Pay?

A health insurance co-pay (copayment) is a set dollar amount you pay for a procedure or office visit (look at your plan summary very carefully). A co-pay is helpful because you’ll GENERALLY pay just the co-pay (unless other procedures are billed by your doctor in addition to the co-pay). For example, let’s say you see your family doctor for a sore throat. If your plan has a co-pay of $35 dollars, you’d pay the $35. Read More: https://www.nevadainsuranceenrollment.com/health/co-payment/

What is a Health Insurance Deductible?

How Much Deductible Must I Pay? A deductible is an amount you pay before the Insurance Company starts paying. Health insurance plans will have different deductibles. Low deductible examples might be a “Gold” plan, with example deductibles of $500, $1,000, $2000, etc. An example of a “Silver” plan might have a higher deductible such as $4,000, $5,000, etc. A higher deductible would be seen in a “Bronze” plan at a deductible of about $8,700. But still, what is a deductible? You Must Pay Your Deductible First Think of it like getting to 1st base in a game of baseball. You start on home plate, and when you get your first medical bill, you’d start running towards 1st base. Beginning to pay towards meeting your deductible. You’ll be expected to pay the whole medical bill out of your own pocket until you’ve paid your deductible, or in other words, reaching 1st base using our analogy. The very good news is, no matter what the deductible is, you will most likely pay what the insurance company has “negotiated” with the doctor or hospital, even before you’ve paid off your full deductible. As an example, if you have a $1,000 doctor bill because you visited a dermatologist for burning off a wart, the insurance company may have a negotiated a price of about $300 with that doctor, instead of having to pay the full $1000. That $300 you pay will apply to your deductible. So, if you have a $4000 deductible, now you’d have $3700 left of your deductible. Make sense? Once you’ve paid all your deductible, you are standing on 1st base, using our baseball analogy. Until you’ve paid all $4000 using our deductible example, you’ve not reached 1st base yet. But once you’ve come out of pocket the full $4000, now you’ll begin to move towards 2nd base – “Co-Insurance”. During this time, co-insurance is where you and the insurance company split the medical bills. Some examples, 70/30, 80/20 or 60/40. Make sure to look at your health plan to see what your deductible and co-insurance are. Continue Reading: https://www.nevadainsuranceenrollment.com/health/deductible/

What is a Health Insurance Network?

A Network is a group of providers which could be hospitals, doctors, labs, radiology centers, urgent care’s, etc., that have contracted with an insurance company on many things including pricing. So having a large network, of many choices for “providers” to choose from can be important. It’s always important, however, to make sure that you get “prior authorization” for services that require prior authorization, for certain tests, prescriptions and procedures. If you don’t get prior authorization for a procedure, test, or prescription, you may have to pay that bill in full out of your own pocket. Read More: https://www.nevadainsuranceenrollment.com/health/insurance-network/

What is a Health Insurance Subsidy?

aka Advance Premium Tax Credit A “Subsidy” is a special tax credit that you can take to help lower the cost of your monthly health insurance premiums. If you qualify for a Health Insurance Subsidy, it’s kind of like getting a gift card from the Government to help pay your health insurance premium. This subsidy is sent directly to the insurance company, which pays a portion of your premium, and you will be responsible for paying the remaining balance. The factors that affect the premium you pay (after you’ve had your subsidy calculated and applied), would be your household income, and the number of family members on your tax return. Qualifying for a Government Subsidy (Financial Assistance) When you sign up for health insurance coverage at Nevada Health Link, you provide an estimate for how much income you expect to bring in for that year. Based on that amount, you may qualify for a premium tax credit. Instead of receiving that tax credit on your federal tax return, you can use any amount (up to 100%) of the credit in advance to lower your monthly health insurance premium. See if you qualify: https://www.nevadainsuranceenrollment.com/health-insurance/subsidy-chart-federal-poverty-levels/ Read More: https://www.nevadainsuranceenrollment.com/health-insurance/

HMO (Health Maintenance Organization) is a type of health insurance plan that has a group of local doctors and hospitals for you to choose from. You must choose a Primary Care Doctor (General practice, Internal Medicine, Family Practice, OB/GYN, Pediatrician) as your primary doctor to visit. You must see your primary doctor for a referral to see specialists to have any tests or procedures done. A HMO usually has lower monthly premiums than a PPO. A HMO may be right for you if you’re comfortable choosing a primary doctor, also called a PCP, to coordinate all of your health care. Read More: https://www.nevadainsuranceenrollment.com/health/hmo-ppo-epo-differences/

A PPO (Preferred Provider Organization) is a type of health insurance plan that offers a larger network (generally speaking), so you have access to more doctors and hospitals. Your out-of-pocket costs can be higher with a PPO than with an HMO or EPO plan. You will have network doctors and hospitals (depending on the network) which are contracted with the insurance company to accept lower payments. Or, you may see providers that are out of the network, but you’ll pay more for out of network providers. With a PPO plan you can see providers in and out of a network if you choose. Read More: https://www.nevadainsuranceenrollment.com/health/hmo-ppo-epo-differences/

What is a Pre-existing Condition?

This refers to any healthcare issues you had prior to your health insurance plan’s effective date. Prior to 2014, purchasing individual health insurance with a pre-existing condition, an insurer might have declined covering your condition, or they might have denied you coverage altogether. However, now with the ACA (Affordable Care Act), insurers must provide individual health insurance (with the “10 essential health benefits”) and can no longer exclude, limit, or deny coverage solely because of a pre-existing condition. Read More: https://www.nevadainsuranceenrollment.com/health/pre-existing-conditions-explained/

What is a Prescription Deductible?

A Prescription Deductible is the amount of money you will pay out of your pocket before the insurance company begins to pay. A prescription deductible is the portion you’d pay first, then after you’ve paid the deductible, you may only have to pay a co-pay after that when you pick up your medication. If you are single, you would only have to meet your prescription deductible. If you have two or more people in your family, each member may have to meet their own prescription deductible. Usually, the insurance company will have two deductibles per family, but you must read the summary of benefits first to find that out. A prescription deductible is different and separate from the medical deductible. They are separate deductibles. One deductible is for hospitalization etc., and one for filling your prescriptions. The prescription deductible may only apply to certain “Tiers” on your insurance company’s “Formulary” (the list of drugs on your insurance plan the insurance company covers). So based on what tier your prescription drug is, may determine if you start paying for it with just a co-pay, or if you have to pay the deductible first, then co-pays. Some health insurance company’s may put a deductible on Tier 3 and Tier 4 medication, but not Tier 1 or Tier 2 medication. Some insurance companies don’t put a prescription deductible on any of their plans. It’s important to look for your medication in the formulary, find out what tier it is, then look to see if there is a deductible for that tier. This is important to do before you buy your health insurance plan. You must look at your own individual policy. Read More: https://www.nevadainsuranceenrollment.com/health/prescription-drug-deductible/ https://www.nevadainsuranceenrollment.com/health/prescription-drug-formulary/ https://www.nevadainsuranceenrollment.com/health/prescription-tier-pricing/

What is a Prescription Drug Formulary?

Prescription Drug List A prescription drug formulary is a list of the prescription drugs that your health insurance company has agreed to cover when you fill your prescription, the medications you won’t have to pay the full price of. In most cases, formularies are comprised of drugs that are the safest, most effective, and most affordable. The health insurance company determines what these drugs will cost its customers. In most cases, the health insurance company covers a greater portion of the cost of more affordable drugs, such as generics and inexpensive brand name drugs, giving customers an incentive to opt for these over more expensive options. Drug formularies are comprised of drug tiers. Some health insurance companies only divide their formularies into two tiers while others may have as many as five or six. The tier that your medication is in determines your portion of the drug cost. In most cases, each tier is associated with a specific co-pay, and the lower the tier, the smaller your co-pay. For example, your health insurance company may cover almost all the cost of a generic medication that is on the first tier, but you may pay a significant portion of the cost of a third- or fourth-tier drug. Read More: https://www.nevadainsuranceenrollment.com/health/prescription-drug-formulary/ https://www.nevadainsuranceenrollment.com/health/prescription-tier-pricing/ https://www.nevadainsuranceenrollment.com/health/prescription-drug-deductible/

A Provider is any Ambulatory Surgical Facility, Dentist, Hospital, Physician, Skilled Nursing Facility, Practitioner, Urgent Care Center, Surgical or Prescription Fulfillment Service, Medical Supplies or Devices, or any other person or licensed entity by the State of Nevada or any entity acting within their medical scope to practice their licensed services. Read More: https://www.nevadainsuranceenrollment.com/health/insurance-network/

What is a Qualified Health Insurance Plan?

Qualified Health Insurance A Qualified Health Plan (QHP) is a health insurance plan that provides coverage for the 10 essential benefits outlined in the 2010 Affordable Care Act. What are Essential Health Benefits and who must have them? From 1/1/2014 and forward, all new health insurance plans (insured small group and individual health insurance plans) must cover the 10 bulleted benefits below, called “Essential Heath Care Benefits” to qualify as being an ACA plan (Obamacare). Qualified Health Plans MUST cover these 10 items without any lifetime or annual limits on these “Essential Health Benefits.” These essential benefits include: Outpatient care Prescription drugs Laboratory services Prenatal and postnatal care Hospitalization, such as for surgeries and overnight stays Pediatric services, including vision and dental care for children Chronic disease management and preventative and wellness services Emergency services, including services provided at an out-of-network hospital Rehabilitative and habilitative services for policyholders with injuries, illnesses or chronic conditions Treatment for mental health and substance abuse disorders, such as counseling services and psychotherapy These essential health benefits are the minimum requirements for all Marketplace ACA (Obamacare) plans. They are broad categories, and the specific services that are covered vary from one state to another, depending on what that state requires. In addition to these requirements, Qualified Health Plans must also comply with limits regarding your cost-sharing expenses (your out-of-pocket expenses) including deductibles, co-payments and annual out-of-pocket limits. Read More: https://www.nevadainsuranceenrollment.com/health/qualified-health-insurance-plan/

What is a Special Enrollment Period?

Purchasing Health Insurance Outside Open Enrollment If you’ve experienced a Qualifying Life Event (QLE) within the last 60 days, it triggers a Special Enrollment Period (SEP), and you may be able to sign up for (or make changes to) health insurance outside of the Open Enrollment period. Understanding which situations are considered qualifying life events will help you make smart decisions regarding your coverage. The special enrollment period is always within 60 days of a Qualifying Life Event. You’ll have to act relatively quickly from the date of your Life Event because you only have 60 days from the time of your Life Event to enroll into a health insurance plan. This 60 days is your “Special Enrollment Period”. Some examples of a Life Event are: Losing your existing health insurance coverage Cobra expiring Turning 26 and losing coverage through a parent’s plan or moving away or to college Changes in marriage, birth or adoption of children, death Gaining or losing a dependent No longer eligible for Medicaid Moving to a different zip code or county Working seasonally and losing coverage, moving to or from a shelter Changes in your income that affect the coverage you would qualify for Becoming a US Citizen Leaving incarceration Membership into a federally recognized tribe or status change as an Alaska Native AmeriCorps members change in service Terminating (cancelling) your own insurance is not a life event. Read More: https://www.nevadainsuranceenrollment.com/health/qualifying-life-event-explained/

What is a Summary of Benefits?

A summary of benefits, formally called the Summary of Benefits and Coverage (SBC), is a standardized document provided by health insurance companies to explain how a health insurance plan works. This 4-page, double-sided document outlines key coverage details, such as what medical services are covered, cost-sharing requirements, and how the plan compares to others. Read More: https://www.nevadainsuranceenrollment.com/health/summary-of-benefits/

What is considered a Qualifying Life Event?

Purchasing Health Insurance Outside Open Enrollment If you’ve experienced a Qualifying Life Event (QLE) within the last 60 days, it triggers a Special Enrollment Period (SEP), and you may be able to sign up for (or make changes to) health insurance outside of the Open Enrollment period. Understanding which situations are considered qualifying life events will help you make smart decisions regarding your coverage. The special enrollment period is always within 60 days of a Qualifying Life Event. You’ll have to act relatively quickly from the date of your Life Event because you only have 60 days from the time of your Life Event to enroll into a health insurance plan. This 60 days is your “Special Enrollment Period”. Some examples of a Life Event are: Losing your existing health insurance coverage Cobra expiring Turning 26 and losing coverage through a parent’s plan or moving away or to college Changes in marriage, birth or adoption of children, death Gaining or losing a dependent No longer eligible for Medicaid Moving to a different zip code or county Working seasonally and losing coverage, moving to or from a shelter Changes in your income that affect the coverage you would qualify for Becoming a US Citizen Leaving incarceration Membership into a federally recognized tribe or status change as an Alaska Native AmeriCorps members change in service Terminating (cancelling) your own insurance is not a life event. Read More: https://www.nevadainsuranceenrollment.com/health/qualifying-life-event-explained/

What is Cost Sharing Reduction?

If your family size and income ranks you at under 250% of the Federal Poverty Level, this cost reduction will reduce your total out of pocket responsibilities in overall medical costs. You’ll get additional financial assistance to cover more of your portion of the medical expenses for your “Silver” plan (70/30.) So in addition to getting the “Advanced Premium Tax Subsidy,” you’ll also have the “Cost Sharing Reductions” to reduce deductibles, co-pays, and co-insurance. Your overall medical costs will be a smaller percentage of your income to pay for medical bills and expenses. The Cost Sharing Reduction is ONLY available on SILVER Plans. Read More: Health Insurance WITH a Subsidy

What is Prior Authorization? Why Do I Need it?

Prior Authorization is you or your provider (doctor) getting pre-approval from the insurance company before receiving, or planning to receive, any non-emergency healthcare services. You must do this for those services to be considered covered services. Essentially you are getting permission before the services have happened in order for the services to be covered. Read More: https://www.nevadainsuranceenrollment.com/health/hmo-ppo-epo-differences/

What is the difference between a PPO, HMO, and EPO Health Plan?

PPO Plans: Allow visits to out-of-network providers at higher costs, offering flexibility without requiring referrals for specialists. HMO Plans: Require members to use in-network providers and obtain referrals for specialists, focusing on cost control. EPO Plans: Cover only in-network providers (except in emergencies) but do not require referrals, balancing flexibility, and cost. Read More: https://www.nevadainsuranceenrollment.com/health/hmo-ppo-epo-differences/

What is the Federal Poverty Level?

Everyone has a Federal Poverty Level (FPL), even wealthy people. They just have a higher FPL. People that have a household income that falls between 138% up to 400% of the FPL, can get assistance (in the form of a subsidy) with paying for their health insurance premiums with an Advanced Premium Tax Credit. If you make less than 138% of the FPL, in Nevada you qualify for Medicaid which is Free. The less money you make the more financial help you will get, the more money you make, the less financial assistance you get. If you make over 400% of the FPL, you won’t qualify for any financial assistance. You can buy your “qualified health plan” (see definition) insurance anywhere you want, but if you want a “subsidy” your income must be between 138% – 400% FPL. Call us for help with all subsidized and unsubsidized health plans. Subsidy Chart: https://www.nevadainsuranceenrollment.com/health-insurance/subsidy-chart-federal-poverty-levels/ See if you qualify: https://www.nevadainsuranceenrollment.com/health-insurance/

What is the Health Insurance Subsidy Cliff?

No More Subsidy Cliff for those making over 400% of the Federal Poverty Level. For the first time, many Nevadan’s (those making over 400% of the Federal Poverty Level), may now be eligible for a health insurance subsidy! Plus, for existing members, the rate you are paying will most likely decrease. For instance, if you were a 60 and 61 year old married couple, and your income was projected to be over $68,960 in 2021 you would not have qualified for a tax credit. Now, since the changes, that same couple making $80K per year would qualify for $1007 per month. This is HUGE! You can now get a Government subsidy to help you pay for your health insurance premiums. Before these changes, if your income was over $51,040 for a single person in tax year 2021, or $104,800 for a family of 4, you were not eligible for a tax subsidy. Now there is no income limit to receive these subsidies. The subsidy amount gradually slopes off to be no more than 8.5% of your household income (Modified adjusted gross – for most people, their “Adjusted Gross Income”). So, for many Nevadan’s, they’ll now be eligible for tax credits! See if you qualify: https://www.nevadainsuranceenrollment.com/health-insurance/subsidy-chart-federal-poverty-levels/ Read More: https://www.nevadainsuranceenrollment.com/health-insurance/ https://www.nevadainsuranceenrollment.com/health/stating-income-subsidy/

What Type of Plans Are Offered by Health Insurance Carriers?

Health insurance carriers provide a range of plans to suit diverse needs. Common types include: • Health Maintenance Organization (HMO): Requires using in-network providers and often a referral from a primary care physician for specialists. • Preferred Provider Organization (PPO): Allows visits to out-of-network providers, but in-network care is less expensive. • Exclusive Provider Organization (EPO): Covers only in-network care, except in emergencies, like an ER (Emergency Room) visit. • Point of Service (POS): Blends HMO and PPO features, requiring referrals but allowing out-of-network care at a higher cost. Each plan offers a balance of cost, flexibility, and coverage, so selecting one depends on your healthcare needs and budget. Read More: https://www.nevadainsuranceenrollment.com/health/metal-plans-explained/

When is Health Insurance Open Enrollment?

Obamacare Open Enrollment Each year, you can only buy Health Insurance during Open Enrollment which is November 1st through January 15th, unless you have a Life Event ie. Marriage, Divorce, Relocation, Birth, etc. Read More: https://www.nevadainsuranceenrollment.com/health/why-have-open-enrollment/ https://www.nevadainsuranceenrollment.com/health/open-enrollment-missed/ https://www.nevadainsuranceenrollment.com/health/obamacare-health-insurance-open-enrollment/ https://www.nevadainsuranceenrollment.com/health/special-enrollment-period/

Where can I get my Summary of Benefits?

You can request it from your insurer (the health insurance company you purchased your plan from), your health insurance agent, or find it on Nevada Health Link when shopping for plans. Read More: https://www.nevadainsuranceenrollment.com/health/summary-of-benefits/

Who Receives Notices of Coverage Options?

Employers covered by the FLSA must give these notices to: All new employees within 14 days of hire, regardless of whether they qualify for the employer’s health plan. Both part-time and full-time workers. Employees at nearly all businesses with one or more employees. Notices are not required for dependents or non-employees, since the law focuses on informing workers directly about Nevada Health Link coverage. Read More: https://www.nevadainsuranceenrollment.com/health/employer-health-insurance-notices/

Why Do Prescriptions Have Tiers For Pricing?

Medication Pricing Tiers determine the level of coverage your prescription drug plan offers for a specific type of medication. Many prescription drug plans use a 4-tier system, while some insurers have an additional 5th or even 6th. Your insurer’s formulary and tier system are available on the company website or in the documents you received when you enrolled in your prescription drug plan. Tier 1 Prescriptions: This tier is usually the cheapest and generally includes generic medications. Tier 2 Prescriptions: This tier includes brand name drugs that are preferred by your health insurance company. Just as your health insurance company provides better coverage for in-network healthcare providers, it provides better coverage for preferred drugs. It can also include more expensive generic medications. Tier 3 Prescriptions: This tier includes brand name drugs that are not preferred by your health insurance company. These drugs are still covered, but you will likely pay more out of pocket than you would for a preferred drug. Tier 4 Prescriptions: This tier, includes specialty drugs, such as those used for cancer treatment. These drugs have a much higher out-of-pocket cost. Tier 5 Prescriptions: This tier, which is not included in all prescription drug plans, includes highest cost specialty drugs. Tier 6 Prescriptions: This tier many companies will use and not charge their insureds a copay at all, using a tier-6 medications for “maintenance medication”. Why Is Tier Pricing Used? The primary purpose of tier pricing is to help health insurance companies manage their costs. In most cases, the drugs listed on a plan’s formulary are both effective and the most economically priced for treating a condition. To promote the use of generics or more cost-effective brand name drugs, health insurance companies may cover a larger portion of the costs for Tier 1 and Tier 2 drugs. You must look at your own individual policy. Read More: https://www.nevadainsuranceenrollment.com/health/prescription-tier-pricing/ https://www.nevadainsuranceenrollment.com/health/prescription-drug-deductible/ https://www.nevadainsuranceenrollment.com/health/prescription-drug-formulary/

Why Has PPO Plan Use Declined in Nevada?

The PPO plan decline has reshaped Nevada’s individual health insurance market since the Affordable Care Act (ACA) was implemented in 2014. Preferred Provider Organization (PPO) plans, known for their flexibility in allowing out-of-network provider visits without referrals, are no longer available as nationwide network options for individuals and families purchasing coverage through Nevada Health Link or directly from insurers. According to Nevada Health Link, Health Maintenance Organization (HMO) and Exclusive Provider Organization (EPO) plans now dominate the individual market as of 2025, reflecting a Nevada health plan shift driven by cost and regulatory pressures. The PPO plan decline in Nevada’s individual market stems from several factors: Cost Containment: Nevada Health Link notes that HMO and EPO plans control costs better than PPO plans by using pre-negotiated reimbursement rates with in-network providers, making expenses predictable. For example, an HMO might pay a fixed rate for an MRI (Magnetic Resonance Imaging), while a PPO plans out-of-network MRI could cost more due to non-contracted rates. ACA Requirements: Healthcare.gov outlines ACA mandates for essential health benefits, including maternity, mental health, and pre-existing conditions, without medical underwriting. Kaiser Family Foundation reports that record-breaking Marketplace enrollment (24.3 million in 2025) due to enhanced subsidies from the American Rescue Plan Act (ARPA) and Inflation Reduction Act (IRA) has made HMO and EPO plans more appealing, as their lower costs align with subsidized coverage. In Nevada, Nevada Health Link notes that these subsidies have increased enrollment by 15% since 2023, favoring cost-effective plans. Medical Loss Ratio (MLR): Nevada Division of Insurance enforces the ACA’s MLR rule, requiring insurers to spend at least 80% of premiums on medical claims. HMO and EPO plans, with tighter networks, help meet this requirement more easily than PPO plans. Pre-Existing Conditions: Healthcare.gov confirms the ACA’s prohibition on denying coverage for pre-existing conditions, which increases utilization (e.g., doctor visits, medications). HMO plans manage these costs through referrals and network restrictions, unlike PPO plans. Read More: https://www.nevadainsuranceenrollment.com/health/ppo-plans-vanish-from-nevada/

Why Should You Read the Summary of Benefits?

Reading the summary of benefits is essential for making informed decisions about your health insurance. It helps you: Compare Plans: The standardized format lets you evaluate different plans side-by-side, focusing on costs and coverage. Understand Costs: It clarifies how much you will pay for services like an ER (Emergency Room) visit or prescription drugs. Assess Coverage: It shows whether key services, like preventive care or hospital stays, are included. Plan for Healthcare Needs: Coverage examples illustrate how the plan manages scenarios like chronic illness or emergencies. Read More: https://www.nevadainsuranceenrollment.com/health/summary-of-benefits/

Why You Should Read the Health Insurance Notices From Your Employer

Marketplace notices empower employees by providing consistent, easy-to-understand details. For example: Nevada Health Link publishes open enrollment dates (November 1 to January 15). Coverage usually starts January 1 or February 1, depending on when enrollment is completed. Special enrollment periods are also available for qualifying life events, such as job loss, marriage, or birth of a child. The Nevada Division of Insurance ensures these notices remain accurate and aligned with federal rules. The Kaiser Family Foundation has found that employees often rely on agents for help interpreting eligibility for subsidies, comparing premiums, and choosing between employer and Marketplace plans. Notices create the foundation for these decisions. Taking time to review these notices can help employees: Explore Nevada Health Link plans during open enrollment. Determine whether they qualify for subsidies. Compare total costs between employer-sponsored and Marketplace options. Understand the trade-off of losing employer contributions when selecting a Marketplace plan. The Role of Health Insurance Notices in Nevada In Nevada, these notices play a key role in connecting employees to affordable coverage. Regulated by the Nevada Division of Insurance, they ensure workers are aware of open enrollment periods, subsidy opportunities, and the flexibility of Nevada Health Link. Employers can deliver notices either on paper or electronically, as long as employees receive them promptly. Read More: https://www.nevadainsuranceenrollment.com/health/employer-health-insurance-notices/

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