This chapter may be cited as the
Uniform Health Policy Provision Law.
(Added to NRS by 1971, 1751)
Nothing in this chapter applies to or affects:
1. Any policy of liability or workers’ compensation insurance with
or without supplementary expense coverage therein.
2. Any group or blanket policy.
3. Life insurance, endowment or annuity contracts, or contracts
supplemental thereto which contain only such provisions relating to
health insurance as to:
(a) Provide additional benefits in case of death or dismemberment
or loss of sight by accident or accidental means; or
(b) Operate to safeguard such contracts against lapse, or to give a
special surrender value or special benefit or an annuity if the insured
or annuitant becomes totally and permanently disabled, as defined by the
contract or supplemental contract.
4. Reinsurance, except as otherwise provided in NRS 689A.470
to 689A.740 , inclusive, and 689C.610 to 689C.980 , inclusive, relating to the program of
reinsurance.
(Added to NRS by 1971, 1751; A 1997, 2899)
A policy of health insurance
must not be delivered or issued for delivery to any person in this state
unless it otherwise complies with this Code, and complies with the
following:
1. The entire money and other considerations for the policy must
be expressed therein.
2. The time when the insurance takes effect and terminates must be
expressed therein.
3. It must purport to insure only one person, except that a policy
may insure, originally or by subsequent amendment, upon the application
of an adult member of a family, who shall be deemed the policyholder, any
two or more eligible members of that family, including the husband, wife,
dependent children, from the time of birth, adoption or placement for the
purpose of adoption as provided in NRS 689A.043 , or any children under a specified age which
must not exceed 19 years except as provided in NRS 689A.045 , and any other person dependent upon the
policyholder.
4. The style, arrangement and overall appearance of the policy
must not give undue prominence to any portion of the text, and every
printed portion of the text of the policy and of any endorsements or
attached papers must be plainly printed in light-faced type of a style in
general use, the size of which must be uniform and not less than 10
points with a lower case unspaced alphabet length not less than 120
points. “Text” includes all printed matter except the name and address of
the insurer, the name or the title of the policy, the brief description,
if any, and captions and subcaptions.
5. The exceptions and reductions of indemnity must be set forth in
the policy and, other than those contained in NRS 689A.050 to 689A.290 , inclusive, must be printed, at the
insurer’s option, with the benefit provision to which they apply or under
an appropriate caption such as “Exceptions” or “Exceptions and
Reductions,” except that if an exception or reduction specifically
applies only to a particular benefit of the policy, a statement of that
exception or reduction must be included with the benefit provision to
which it applies.
6. Each such form, including riders and endorsements, must be
identified by a number in the lower left-hand corner of the first page
thereof.
7. The policy must not contain any provision purporting to make
any portion of the charter, rules, constitution or bylaws of the insurer
a part of the policy unless that portion is set forth in full in the
policy, except in the case of the incorporation of or reference to a
statement of rates or classification of risks, or short-rate table filed
with the Commissioner.
8. The policy must provide benefits for expense arising from care
at home or health supportive services if that care or service was
prescribed by a physician and would have been covered by the policy if
performed in a medical facility or facility for the dependent as defined
in chapter 449 of NRS.
9. The policy must provide, at the option of the applicant,
benefits for expenses incurred for the treatment of abuse of alcohol or
drugs, unless the policy provides coverage only for a specified disease
or provides for the payment of a specific amount of money if the insured
is hospitalized or receiving health care in his home.
10. The policy must provide benefits for expense arising from
hospice care.
(Added to NRS by 1971, 1752; A 1973, 546; 1975, 446, 1108, 1848;
1979, 1176; 1983, 1933, 2035; 1985, 1568, 1772; 1989, 738, 1031)
1. An insurer shall not charge a provider of health care a fee to
include the name of the provider on a list of providers of health care
given by the insurer to its insureds.
2. An insurer shall not contract with a provider of health care to
provide health care to an insured unless the insurer uses the form
prescribed by the Commissioner pursuant to NRS 629.095 to obtain any information related to the
credentials of the provider of health care.
3. A contract between an insurer and a provider of health care may
be modified:
(a) At any time pursuant to a written agreement executed by both
parties.
(b) Except as otherwise provided in this paragraph, by the insurer
upon giving to the provider 30 days’ written notice of the modification.
If the provider fails to object in writing to the modification within the
30-day period, the modification becomes effective at the end of that
period. If the provider objects in writing to the modification within the
30-day period, the modification must not become effective unless agreed
to by both parties as described in paragraph (a).
4. If an insurer contracts with a provider of health care to
provide health care to an insured, the insurer shall:
(a) If requested by the provider of health care at the time the
contract is made, submit to the provider of health care the schedule of
payments applicable to the provider of health care; or
(b) If requested by the provider of health care at any other time,
submit to the provider of health care the schedule of payments specified
in paragraph (a) within 7 days after receiving the request.
5. As used in this section, “provider of health care” means a
provider of health care who is licensed pursuant to chapter 630 , 631 , 632 or 633 of NRS.
(Added to NRS by 1999, 1647 ; A 2001, 2729 ; 2003, 3355 )
REQUIRED PROVISIONS
1. Except as provided in subsections 2 and 3, each such policy
delivered or issued for delivery to any person in this state must contain
the provisions specified in NRS 689A.050 to 689A.170 , inclusive, in the words in which the
provisions appear, except that the insurer may, at its option, substitute
for one or more of the provisions corresponding provisions of different
wording approved by the Commissioner which are in each instance not less
favorable in any respect to the insured or the beneficiary. Each such
provision must be preceded individually by the applicable caption shown,
or, at the option of the insurer, by such appropriate individual or group
captions or subcaptions as the Commissioner may approve.
2. Each policy delivered or issued for delivery in this state
after November 1, 1973, must contain a provision, if applicable, setting
forth the provisions of NRS 689A.045 .
3. If any such provision is in whole or in part inapplicable to or
inconsistent with the coverage provided by a particular form of policy,
the insurer, with the approval of the Commissioner, may omit from the
policy any inapplicable provision or part of a provision, and shall
modify any inconsistent provision or part of a provision in such a manner
as to make the provision as contained in the policy consistent with the
coverage provided by the policy.
(Added to NRS by 1971, 1753; A 1973, 547; 1985, 1059)
1. Each policy of health insurance must include a procedure for
binding arbitration to resolve disputes concerning independent medical
evaluations pursuant to the rules of the American Arbitration Association.
2. If an insurer, for any final determination of benefits or care,
requires an independent evaluation of the medical or chiropractic care of
any person for whom such care is covered under the terms of the contract
of insurance, only a physician or chiropractor who is certified to
practice in the same field of practice as the primary treating physician
or chiropractor or who is formally educated in that field may conduct the
independent evaluation.
3. The independent evaluation must include a physical examination
of the patient, unless he is deceased, and a personal review of all X
rays and reports prepared by the primary treating physician or
chiropractor. A certified copy of all reports of findings must be sent to
the primary treating physician or chiropractor and the insured person
within 10 working days after the evaluation. If the insured person
disagrees with the finding of the evaluation, he must submit an appeal to
the insurer pursuant to the procedure for binding arbitration set forth
in the policy of insurance within 30 days after he receives the finding
of the evaluation. Upon its receipt of an appeal, the insurer shall so
notify in writing the primary treating physician or chiropractor.
4. The insurer shall not limit or deny coverage for care related
to a disputed claim while the dispute is in arbitration, except that, if
the insurer prevails in the arbitration, the primary treating physician
or chiropractor may not recover any payment from either the insurer,
insured person or the patient for services that he provided to the
patient after receiving written notice from the insurer pursuant to
subsection 3 concerning the appeal of the insured person.
(Added to NRS by 1989, 2114)
1. A policy of health insurance must provide coverage for medical
treatment which a policyholder or subscriber receives as part of a
clinical trial or study if:
(a) The medical treatment is provided in a Phase I, Phase II, Phase
III or Phase IV study or clinical trial for the treatment of cancer or in
a Phase II, Phase III or Phase IV study or clinical trial for the
treatment of chronic fatigue syndrome;
(b) The clinical trial or study is approved by:
(1) An agency of the National Institutes of Health as set
forth in 42 U.S.C. § 281(b);
(2) A cooperative group;
(3) The Food and Drug Administration as an application for a
new investigational drug;
(4) The United States Department of Veterans Affairs; or
(5) The United States Department of Defense;
(c) In the case of:
(1) A Phase I clinical trial or study for the treatment of
cancer, the medical treatment is provided at a facility authorized to
conduct Phase I clinical trials or studies for the treatment of cancer; or
(2) A Phase II, Phase III or Phase IV study or clinical
trial for the treatment of cancer or chronic fatigue syndrome, the
medical treatment is provided by a provider of health care and the
facility and personnel for the clinical trial or study have the
experience and training to provide the treatment in a capable manner;
(d) There is no medical treatment available which is considered a
more appropriate alternative medical treatment than the medical treatment
provided in the clinical trial or study;
(e) There is a reasonable expectation based on clinical data that
the medical treatment provided in the clinical trial or study will be at
least as effective as any other medical treatment;
(f) The clinical trial or study is conducted in this State; and
(g) The policyholder or subscriber has signed, before his
participation in the clinical trial or study, a statement of consent
indicating that he has been informed of, without limitation:
(1) The procedure to be undertaken;
(2) Alternative methods of treatment; and
(3) The risks associated with participation in the clinical
trial or study, including, without limitation, the general nature and
extent of such risks.
2. Except as otherwise provided in subsection 3, the coverage for
medical treatment required by this section is limited to:
(a) Coverage for any drug or device that is approved for sale by
the Food and Drug Administration without regard to whether the approved
drug or device has been approved for use in the medical treatment of the
policyholder or subscriber.
(b) The cost of any reasonably necessary health care services that
are required as a result of the medical treatment provided in a Phase II,
Phase III or Phase IV clinical trial or study or as a result of any
complication arising out of the medical treatment provided in a Phase II,
Phase III or Phase IV clinical trial or study, to the extent that such
health care services would otherwise be covered under the policy of
health insurance.
(c) The cost of any routine health care services that would
otherwise be covered under the policy of health insurance for a
policyholder or subscriber participating in a Phase I clinical trial or
study.
(d) The initial consultation to determine whether the policyholder
or subscriber is eligible to participate in the clinical trial or study.
(e) Health care services required for the clinically appropriate
monitoring of the policyholder or subscriber during a Phase II, Phase III
or Phase IV clinical trial or study.
(f) Health care services which are required for the clinically
appropriate monitoring of the policyholder or subscriber during a Phase I
clinical trial or study and which are not directly related to the
clinical trial or study.
Ê Except as otherwise provided in NRS 689A.04036 , the services provided pursuant to
paragraphs (b), (c), (e) and (f) must be covered only if the services are
provided by a provider with whom the insurer has contracted for such
services. If the insurer has not contracted for the provision of such
services, the insurer shall pay the provider the rate of reimbursement
that is paid to other providers with whom the insurer has contracted for
similar services and the provider shall accept that rate of reimbursement
as payment in full.
3. Particular medical treatment described in subsection 2 and
provided to a policyholder or subscriber is not required to be covered
pursuant to this section if that particular medical treatment is provided
by the sponsor of the clinical trial or study free of charge to the
policyholder or subscriber.
4. The coverage for medical treatment required by this section
does not include:
(a) Any portion of the clinical trial or study that is customarily
paid for by a government or a biotechnical, pharmaceutical or medical
industry.
(b) Coverage for a drug or device described in paragraph (a) of
subsection 2 which is paid for by the manufacturer, distributor or
provider of the drug or device.
(c) Health care services that are specifically excluded from
coverage under the policyholder’s or subscriber’s policy of health
insurance, regardless of whether such services are provided under the
clinical trial or study.
(d) Health care services that are customarily provided by the
sponsors of the clinical trial or study free of charge to the
participants in the trial or study.
(e) Extraneous expenses related to participation in the clinical
trial or study including, without limitation, travel, housing and other
expenses that a participant may incur.
(f) Any expenses incurred by a person who accompanies the
policyholder or subscriber during the clinical trial or study.
(g) Any item or service that is provided solely to satisfy a need
or desire for data collection or analysis that is not directly related to
the clinical management of the policyholder or subscriber.
(h) Any costs for the management of research relating to the
clinical trial or study.
5. An insurer who delivers or issues for delivery a policy of
health insurance specified in subsection 1 may require copies of the
approval or certification issued pursuant to paragraph (b) of subsection
1, the statement of consent signed by the policyholder or subscriber,
protocols for the clinical trial or study and any other materials related
to the scope of the clinical trial or study relevant to the coverage of
medical treatment pursuant to this section.
6. An insurer who delivers or issues for delivery a policy
specified in subsection 1 shall:
(a) Include in the disclosure required pursuant to NRS 689A.390
notice to each policyholder and
subscriber under the policy of the availability of the benefits required
by this section.
(b) Provide the coverage required by this section subject to the
same deductible, copayment, coinsurance and other such conditions for
coverage that are required under the policy.
7. A policy of health insurance subject to the provisions of this
chapter that is delivered, issued for delivery or renewed on or after
January 1, 2006, has the legal effect of including the coverage required
by this section, and any provision of the policy that conflicts with this
section is void.
8. An insurer who delivers or issues for delivery a policy
specified in subsection 1 is immune from liability for:
(a) Any injury to a policyholder or subscriber caused by:
(1) Any medical treatment provided to the policyholder or
subscriber in connection with his participation in a clinical trial or
study described in this section; or
(2) An act or omission by a provider of health care who
provides medical treatment or supervises the provision of medical
treatment to the policyholder or subscriber in connection with his
participation in a clinical trial or study described in this section.
(b) Any adverse or unanticipated outcome arising out of a
policyholder’s or subscriber’s participation in a clinical trial or study
described in this section.
9. As used in this section:
(a) “Cooperative group” means a network of facilities that
collaborate on research projects and has established a peer review
program approved by the National Institutes of Health. The term includes:
(1) The Clinical Trials Cooperative Group Program; and
(2) The Community Clinical Oncology Program.
(b) “Facility authorized to conduct Phase I clinical trials or
studies for the treatment of cancer” means a facility or an affiliate of
a facility that:
(1) Has in place a Phase I program which permits only
selective participation in the program and which uses clear-cut criteria
to determine eligibility for participation in the program;
(2) Operates a protocol review and monitoring system which
conforms to the standards set forth in the Policies and Guidelines
Relating to the Cancer-Center Support Grant published by the Cancer
Centers Branch of the National Cancer Institute;
(3) Employs at least two researchers and at least one of
those researchers receives funding from a federal grant;
(4) Employs at least three clinical investigators who have
experience working in Phase I clinical trials or studies conducted at a
facility designated as a comprehensive cancer center by the National
Cancer Institute;
(5) Possesses specialized resources for use in Phase I
clinical trials or studies, including, without limitation, equipment that
facilitates research and analysis in proteomics, genomics and
pharmacokinetics;
(6) Is capable of gathering, maintaining and reporting
electronic data; and
(7) Is capable of responding to audits instituted by federal
and state agencies.
(c) “Provider of health care” means:
(1) A hospital; or
(2) A person licensed pursuant to chapter 630 , 631 or 633 of NRS.
(Added to NRS by 2003, 3519 ; A 2005, 2009 )
1. The provisions of this section apply to a policy of health
insurance offered or issued by an insurer if an insured covered by the
policy receives health care through a defined set of providers of health
care who are under contract with the insurer.
2. Except as otherwise provided in this section, if an insured who
is covered by a policy described in subsection 1 is receiving medical
treatment for a medical condition from a provider of health care whose
contract with the insurer is terminated during the course of the medical
treatment, the policy must provide that:
(a) The insured may continue to obtain medical treatment for the
medical condition from the provider of health care pursuant to this
section, if:
(1) The insured is actively undergoing a medically necessary
course of treatment; and
(2) The provider of health care and the insured agree that
the continuity of care is desirable.
(b) The provider of health care is entitled to receive
reimbursement from the insurer for the medical treatment he provides to
the insured pursuant to this section, if the provider of health care
agrees:
(1) To provide medical treatment under the terms of the
contract between the provider of health care and the insurer with regard
to the insured, including, without limitation, the rates of payment for
providing medical service, as those terms existed before the termination
of the contract between the provider of health care and the insurer; and
(2) Not to seek payment from the insured for any medical
service provided by the provider of health care that the provider of
health care could not have received from the insured were the provider of
health care still under contract with the insurer.
3. The coverage required by subsection 2 must be provided until
the later of:
(a) The 120th day after the date the contract is terminated; or
(b) If the medical condition is pregnancy, the 45th day after:
(1) The date of delivery; or
(2) If the pregnancy does not end in delivery, the date of
the end of the pregnancy.
4. The requirements of this section do not apply to a provider of
health care if:
(a) The provider of health care was under contract with the insurer
and the insurer terminated that contract because of the medical
incompetence or professional misconduct of the provider of health care;
and
(b) The insurer did not enter into another contract with the
provider of health care after the contract was terminated pursuant to
paragraph (a).
5. A policy subject to the provisions of this chapter that is
delivered, issued for delivery or renewed on or after October 1, 2003,
has the legal effect of including the coverage required by this section,
and any provision of the policy or renewal thereof that is in conflict
with this section is void.
6. The Commissioner shall adopt regulations to carry out the
provisions of this section.
(Added to NRS by 2003, 3354 )
Except as otherwise provided in NRS 689A.04033 :
1. No policy of health insurance that provides coverage for a drug
approved by the Food and Drug Administration for use in the treatment of
an illness, disease or other medical condition may be delivered or issued
for delivery in this state unless the policy includes coverage for any
other use of the drug for the treatment of cancer, if that use is:
(a) Specified in the most recent edition of or supplement to:
(1) The United States Pharmacopoeia Drug Information; or
(2) The American Hospital Formulary Service Drug
Information; or
(b) Supported by at least two articles reporting the results of
scientific studies that are published in scientific or medical journals,
as defined in 21 C.F.R. § 99.3.
2. The coverage required pursuant to this section:
(a) Includes coverage for any medical services necessary to
administer the drug to the insured.
(b) Does not include coverage for any:
(1) Experimental drug used for the treatment of cancer if
that drug has not been approved by the Food and Drug Administration; or
(2) Use of a drug that is contraindicated by the Food and
Drug Administration.
3. A policy of health insurance subject to the provisions of this
chapter that is delivered, issued for delivery or renewed on or after
October 1, 1999, has the legal effect of including the coverage required
by this section, and any provision of the policy that conflicts with the
provisions of this section is void.
(Added to NRS by 1999, 759 ; A 2003, 3522 )
1. A policy of health insurance that provides coverage for the
treatment of colorectal cancer must provide coverage for colorectal
cancer screening in accordance with:
(a) The guidelines concerning colorectal cancer screening which are
published by the American Cancer Society; or
(b) Other guidelines or reports concerning colorectal cancer
screening which are published by nationally recognized professional
organizations and which include current or prevailing supporting
scientific data.
2. A policy of health insurance subject to the provisions of this
chapter that is delivered, issued for delivery or renewed on or after
October 1, 2003, has the legal effect of including the coverage required
by this section, and any provision of the policy that conflicts with the
provisions of this section is void.
(Added to NRS by 2003, 1334 )
1. Except as otherwise provided in this section, a policy of
health insurance which provides coverage for prescription drugs must not
limit or exclude coverage for a drug if the drug:
(a) Had previously been approved for coverage by the insurer for a
medical condition of an insured and the insured’s provider of health care
determines, after conducting a reasonable investigation, that none of the
drugs which are otherwise currently approved for coverage are medically
appropriate for the insured; and
(b) Is appropriately prescribed and considered safe and effective
for treating the medical condition of the insured.
2. The provisions of subsection 1 do not:
(a) Apply to coverage for any drug that is prescribed for a use
that is different from the use for which that drug has been approved for
marketing by the Food and Drug Administration;
(b) Prohibit:
(1) The insurer from charging a deductible, copayment or
coinsurance for the provision of benefits for prescription drugs to the
insured or from establishing, by contract, limitations on the maximum
coverage for prescription drugs;
(2) A provider of health care from prescribing another drug
covered by the policy that is medically appropriate for the insured; or
(3) The substitution of another drug pursuant to NRS
639.23286 or 639.2583 to 639.2597 , inclusive; or
(c) Require any coverage for a drug after the term of the policy.
3. Any provision of a policy subject to the provisions of this
chapter that is delivered, issued for delivery or renewed on or after
October 1, 2001, which is in conflict with this section is void.
(Added to NRS by 2001, 857 ; A 2003, 2298 )
1. A policy of health insurance must provide coverage for benefits
payable for expenses incurred for:
(a) An annual cytologic screening test for women 18 years of age or
older;
(b) A baseline mammogram for women between the ages of 35 and 40;
and
(c) An annual mammogram for women 40 years of age or older.
2. A policy of health insurance must not require an insured to
obtain prior authorization for any service provided pursuant to
subsection 1.
3. A policy subject to the provisions of this chapter which is
delivered, issued for delivery or renewed on or after October 1, 1989,
has the legal effect of including the coverage required by subsection 1,
and any provision of the policy or the renewal which is in conflict with
subsection 1 is void.
(Added to NRS by 1989, 1888; A 1997, 1729)
1. A policy of health insurance which provides coverage for the
surgical procedure known as a mastectomy must also provide commensurate
coverage for:
(a) Reconstruction of the breast on which the mastectomy has been
performed;
(b) Surgery and reconstruction of the other breast to produce a
symmetrical structure; and
(c) Prostheses and physical complications for all stages of
mastectomy, including lymphedemas.
2. The provision of services must be determined by the attending
physician and the patient.
3. The plan or issuer may require deductibles and coinsurance
payments if they are consistent with those established for other benefits.
4. Written notice of the availability of the coverage must be
given upon enrollment and annually thereafter. The notice must be sent to
all participants:
(a) In the next mailing made by the plan or issuer to the
participant or beneficiary; or
(b) As part of any annual information packet sent to the
participant or beneficiary,
Ê whichever is earlier.
5. A plan or issuer may not:
(a) Deny eligibility, or continued eligibility, to enroll or renew
coverage, in order to avoid the requirements of subsections 1 to 4,
inclusive; or
(b) Penalize, or limit reimbursement to, a provider of care, or
provide incentives to a provider of care, in order to induce the provider
not to provide the care listed in subsections 1 to 4, inclusive.
6. A plan or issuer may negotiate rates of reimbursement with
providers of care.
7. If reconstructive surgery is begun within 3 years after a
mastectomy, the amount of the benefits for that surgery must equal the
amounts provided for in the policy at the time of the mastectomy. If the
surgery is begun more than 3 years after the mastectomy, the benefits
provided are subject to all of the terms, conditions and exclusions
contained in the policy at the time of the reconstructive surgery.
8. A policy subject to the provisions of this chapter which is
delivered, issued for delivery or renewed on or after October 1, 2001,
has the legal effect of including the coverage required by this section,
and any provision of the policy or the renewal which is in conflict with
this section is void.
9. For the purposes of this section, “reconstructive surgery”
means a surgical procedure performed following a mastectomy on one breast
or both breasts to reestablish symmetry between the two breasts. The term
includes augmentation mammoplasty, reduction mammoplasty and mastopexy.
(Added to NRS by 1983, 614; A 1989, 1889; 2001, 2218 )
1. A policy of health insurance must include a provision
authorizing a woman covered by the policy to obtain covered gynecological
or obstetrical services without first receiving authorization or a
referral from her primary care physician.
2. The provisions of this section do not authorize a woman covered
by a policy of health insurance to designate an obstetrician or
gynecologist as her primary care physician.
3. A policy subject to the provisions of this chapter that is
delivered, issued for delivery or renewed on or after October 1, 1999,
has the legal effect of including the coverage required by this section,
and any provision of the policy or the renewal which is in conflict with
this section is void.
4. As used in this section, “primary care physician” has the
meaning ascribed to it in NRS 695G.060 .
(Added to NRS by 1999, 1943 )
1. Except as otherwise provided in subsection 5, an insurer that
offers or issues a policy of health insurance which provides coverage for
prescription drugs or devices shall include in the policy coverage for:
(a) Any type of drug or device for contraception; and
(b) Any type of hormone replacement therapy,
Ê which is lawfully prescribed or ordered and which has been approved by
the Food and Drug Administration.
2. An insurer that offers or issues a policy of health insurance
that provides coverage for prescription drugs shall not:
(a) Require an insured to pay a higher deductible, copayment or
coinsurance or require a longer waiting period or other condition for
coverage for a prescription for a contraceptive or hormone replacement
therapy than is required for other prescription drugs covered by the
policy;
(b) Refuse to issue a policy of health insurance or cancel a policy
of health insurance solely because the person applying for or covered by
the policy uses or may use in the future any of the services listed in
subsection 1;
(c) Offer or pay any type of material inducement or financial
incentive to an insured to discourage the insured from accessing any of
the services listed in subsection 1;
(d) Penalize a provider of health care who provides any of the
services listed in subsection 1 to an insured, including, without
limitation, reducing the reimbursement of the provider of health care; or
(e) Offer or pay any type of material inducement, bonus or other
financial incentive to a provider of health care to deny, reduce,
withhold, limit or delay any of the services listed in subsection 1 to an
insured.
3. Except as otherwise provided in subsection 5, a policy subject
to the provisions of this chapter that is delivered, issued for delivery
or renewed on or after October 1, 1999, has the legal effect of including
the coverage required by subsection 1, and any provision of the policy or
the renewal which is in conflict with this section is void.
4. The provisions of this section do not:
(a) Require an insurer to provide coverage for fertility drugs.
(b) Prohibit an insurer from requiring an insured to pay a
deductible, copayment or coinsurance for the coverage required by
paragraphs (a) and (b) of subsection 1 that is the same as the insured is
required to pay for other prescription drugs covered by the policy.
5. An insurer which offers or issues a policy of health insurance
and which is affiliated with a religious organization is not required to
provide the coverage required by paragraph (a) of subsection 1 if the
insurer objects on religious grounds. Such an insurer shall, before the
issuance of a policy of health insurance and before the renewal of such a
policy, provide to the prospective insured, written notice of the
coverage that the insurer refuses to provide pursuant to this subsection.
6. As used in this section, “provider of health care” has the
meaning ascribed to it in NRS 629.031 .
(Added to NRS by 1999, 1995 )
1. Except as otherwise provided in subsection 5, an insurer that
offers or issues a policy of health insurance which provides coverage for
outpatient care shall include in the policy coverage for any health care
service related to contraceptives or hormone replacement therapy.
2. An insurer that offers or issues a policy of health insurance
that provides coverage for outpatient care shall not:
(a) Require an insured to pay a higher deductible, copayment or
coinsurance or require a longer waiting period or other condition for
coverage for outpatient care related to contraceptives or hormone
replacement therapy than is required for other outpatient care covered by
the policy;
(b) Refuse to issue a policy of health insurance or cancel a policy
of health insurance solely because the person applying for or covered by
the policy uses or may use in the future any of the services listed in
subsection 1;
(c) Offer or pay any type of material inducement or financial
incentive to an insured to discourage the insured from accessing any of
the services listed in subsection 1;
(d) Penalize a provider of health care who provides any of the
services listed in subsection 1 to an insured, including, without
limitation, reducing the reimbursement of the provider of health care; or
(e) Offer or pay any type of material inducement, bonus or other
financial incentive to a provider of health care to deny, reduce,
withhold, limit or delay any of the services listed in subsection 1 to an
insured.
3. Except as otherwise provided in subsection 5, a policy subject
to the provisions of this chapter that is delivered, issued for delivery
or renewed on or after October 1, 1999, has the legal effect of including
the coverage required by subsection 1, and any provision of the policy or
the renewal which is in conflict with this section is void.
4. The provisions of this section do not prohibit an insurer from
requiring an insured to pay a deductible, copayment or coinsurance for
the coverage required by subsection 1 that is the same as the insured is
required to pay for other outpatient care covered by the policy.
5. An insurer which offers or issues such a policy of health
insurance and which is affiliated with a religious organization is not
required to provide the coverage for health care service related to
contraceptives required by this section if the insurer objects on
religious grounds. Such an insurer shall, before the issuance of a policy
of health insurance and before the renewal of such a policy, provide to
the prospective insured written notice of the coverage that the insurer
refuses to provide pursuant to this subsection.
6. As used in this section, “provider of health care” has the
meaning ascribed to it in NRS 629.031 .
(Added to NRS by 1999, 1996 )
1. No health insurance policy may be delivered or issued for
delivery in this state if it contains any exclusion, reduction or other
limitation of coverage relating to complications of pregnancy, unless the
provision applies generally to all benefits payable under the policy.
2. As used in this section, the term “complications of pregnancy”
includes any condition which requires hospital confinement for medical
treatment and:
(a) If the pregnancy is not terminated, is caused by an injury or
sickness not directly related to the pregnancy or by acute nephritis,
nephrosis, cardiac decompensation, missed abortion or similar medically
diagnosed conditions; or
(b) If the pregnancy is terminated, results in nonelective cesarean
section, ectopic pregnancy or spontaneous termination.
3. A policy subject to the provisions of this chapter which is
delivered or issued for delivery on or after July 1, 1977, has the legal
effect of including the coverage required by this section, and any
provision of the policy which is in conflict with this section is void.
(Added to NRS by 1977, 415)
1. A policy of health insurance must provide coverage for:
(a) Enteral formulas for use at home that are prescribed or ordered
by a physician as medically necessary for the treatment of inherited
metabolic diseases characterized by deficient metabolism, or
malabsorption originating from congenital defects or defects arising
shortly after birth, of amino acid, organic acid, carbohydrate or fat; and
(b) At least $2,500 per year for special food products which are
prescribed or ordered by a physician as medically necessary for the
treatment of a person described in paragraph (a).
2. The coverage required by subsection 1 must be provided whether
or not the condition existed when the policy was purchased.
3. A policy subject to the provisions of this chapter that is
delivered, issued for delivery or renewed on or after January 1, 1998,
has the legal effect of including the coverage required by this section,
and any provision of the policy or the renewal which is in conflict with
this section is void.
4. As used in this section:
(a) “Inherited metabolic disease” means a disease caused by an
inherited abnormality of the body chemistry of a person.
(b) “Special food product” means a food product that is specially
formulated to have less than one gram of protein per serving and is
intended to be consumed under the direction of a physician for the
dietary treatment of an inherited metabolic disease. The term does not
include a food that is naturally low in protein.
(Added to NRS by 1997, 1526)
1. Except as otherwise provided in this subsection, an individual
health benefit plan issued pursuant to this chapter that includes
coverage for maternity care and pediatric care for newborn infants may
not restrict benefits for any length of stay in a hospital in connection
with childbirth for a mother or newborn infant covered by the plan to:
(a) Less than 48 hours after a normal vaginal delivery; and
(b) Less than 96 hours after a cesarean section.
Ê If a different length of stay is provided in the guidelines established
by the American College of Obstetricians and Gynecologists, or its
successor organization, and the American Academy of Pediatrics, or its
successor organization, the individual health benefit plan may follow
such guidelines in lieu of following the length of stay set forth above.
The provisions of this subsection do not apply to any individual health
benefit plan in any case in which the decision to discharge the mother or
newborn infant before the expiration of the minimum length of stay set
forth in this subsection is made by the attending physician of the mother
or newborn infant.
2. Nothing in this section requires a mother to:
(a) Deliver her baby in a hospital; or
(b) Stay in a hospital for a fixed period following the birth of
her child.
3. An individual health benefit plan that offers coverage for
maternity care and pediatric care of newborn infants may not:
(a) Deny a mother or her newborn infant coverage or continued
coverage under the terms of the plan or coverage if the sole purpose of
the denial of coverage or continued coverage is to avoid the requirements
of this section;
(b) Provide monetary payments or rebates to a mother to encourage
her to accept less than the minimum protection available pursuant to this
section;
(c) Penalize, or otherwise reduce or limit, the reimbursement of an
attending provider of health care because he provided care to a mother or
newborn infant in accordance with the provisions of this section;
(d) Provide incentives of any kind to an attending physician to
induce him to provide care to a mother or newborn infant in a manner that
is inconsistent with the provisions of this section; or
(e) Except as otherwise provided in subsection 4, restrict benefits
for any portion of a hospital stay required pursuant to the provisions of
this section in a manner that is less favorable than the benefits
provided for any preceding portion of that stay.
4. Nothing in this section:
(a) Prohibits an individual health benefit plan from imposing a
deductible, coinsurance or other mechanism for sharing costs relating to
benefits for hospital stays in connection with childbirth for a mother or
newborn child covered by the plan, except that such coinsurance or other
mechanism for sharing costs for any portion of a hospital stay required
by this section may not be greater than the coinsurance or other
mechanism for any preceding portion of that stay.
(b) Prohibits an arrangement for payment between an individual
health benefit plan and a provider of health care that uses capitation or
other financial incentives, if the arrangement is designed to provide
services efficiently and consistently in the best interest of the mother
and her newborn infant.
(c) Prevents an individual health benefit plan from negotiating
with a provider of health care concerning the level and type of
reimbursement to be provided in accordance with this section.
(Added to NRS by 1997, 2898)
1. No policy of health insurance that provides coverage for
hospital, medical or surgical expenses may be delivered or issued for
delivery in this state unless the policy includes coverage for the
management and treatment of diabetes, including, without limitation,
coverage for the self-management of diabetes.
2. An insurer who delivers or issues for delivery a policy
specified in subsection 1:
(a) Shall include in the disclosure required pursuant to NRS
689A.390 notice to each policyholder
and subscriber under the policy of the availability of the benefits
required by this section.
(b) Shall provide the coverage required by this section subject to
the same deductible, copayment, coinsurance and other such conditions for
coverage that are required under the policy.
3. A policy of health insurance subject to the provisions of this
chapter that is delivered, issued for delivery or renewed on or after
January 1, 1998, has the legal effect of including the coverage required
by this section, and any provision of the policy that conflicts with this
section is void.
4. As used in this section:
(a) “Coverage for the management and treatment of diabetes”
includes coverage for medication, equipment, supplies and appliances that
are medically necessary for the treatment of diabetes.
(b) “Coverage for the self-management of diabetes” includes:
(1) The training and education provided to an insured person
after he is initially diagnosed with diabetes which is medically
necessary for the care and management of diabetes, including, without
limitation, counseling in nutrition and the proper use of equipment and
supplies for the treatment of diabetes;
(2) Training and education which is medically necessary as a
result of a subsequent diagnosis that indicates a significant change in
the symptoms or condition of the insured person and which requires
modification of his program of self-management of diabetes; and
(3) Training and education which is medically necessary
because of the development of new techniques and treatment for diabetes.
(c) “Diabetes” includes type I, type II and gestational diabetes.
(Added to NRS by 1997, 742)
1. All individual health insurance policies providing family
coverage on an expense-incurred basis must as to family members’ coverage
provide that the health benefits applicable for children are payable with
respect to:
(a) A newly born child of the insured from the moment of birth;
(b) An adopted child from the date the adoption becomes effective,
if the child was not placed in the home before adoption; and
(c) A child placed with the insured for the purpose of adoption
from the moment of placement as certified by the public or private agency
making the placement. The coverage of such a child ceases if the adoption
proceedings are terminated as certified by the public or private agency
making the placement.
Ê The policies must provide the coverage specified in subsection 3 and
must not exclude premature births.
2. The policy or contract may require that notification of:
(a) The birth of a newly born child;
(b) The effective date of adoption of a child; or
(c) The date of placement of a child for adoption,
Ê and payments of the required premium or fees, if any, must be furnished
to the insurer within 31 days after the date of birth, adoption or
placement for adoption in order to have the coverage continue beyond the
31-day period.
3. The coverage for newly born and adopted children and children
placed for adoption consists of coverage of injury or sickness, including
the necessary care and treatment of medically diagnosed congenital
defects and birth abnormalities and, within the limits of the policy,
necessary transportation costs from place of birth to the nearest
specialized treatment center under major medical policies, and with
respect to basic policies to the extent such costs are charged by the
treatment center.
(Added to NRS by 1975, 1109; A 1989, 739)
1. Any health insurance policy delivered or issued for delivery
after November 1, 1973, which provides for the termination of coverage on
a dependent child of a policyholder when such child attains a
contractually specified limiting age shall also provide that such
coverage shall not terminate when the dependent child reaches such age if
such child is and continues to be:
(a) Incapable of self-sustaining employment due to a physical
handicap or mental retardation; and
(b) Dependent on the policyholder for support and maintenance.
2. Proof of such child’s incapacity and dependency shall be
furnished to the insurer by the policyholder within 31 days after such
child attains the specified limiting age and as often as the insurer may
thereafter require, but no more than once a year beginning 2 years after
such child attains the specified limiting age.
(Added to NRS by 1973, 546)
1. Notwithstanding any provisions of this Title to the contrary, a
policy of health insurance delivered or issued for delivery in this state
pursuant to this chapter must provide coverage for the treatment of
conditions relating to severe mental illness.
2. The coverage required by this section:
(a) Must provide:
(1) Benefits for at least 40 days of hospitalization as an
inpatient per policy year and 40 visits for treatment as an outpatient
per policy year, excluding visits for the management of medication; and
(2) That two visits for partial or respite care, or a
combination thereof, may be substituted for each 1 day of hospitalization
not used by the insured. In no event is the policy required to provide
coverage for more than 40 days of hospitalization as an inpatient per
policy year.
(b) Is not required to provide benefits for psychosocial
rehabilitation or care received as a custodial inpatient.
3. Any deductibles and copayments required to be paid for the
coverage required by this section must not be greater than 150 percent of
the out-of-pocket expenses required to be paid for medical and surgical
benefits provided pursuant to the policy of health insurance.
4. The provisions of this section do not apply to a policy of
health insurance if, at the end of the policy year, the premiums charged
for that policy, or a standard grouping of policies, increase by more
than 2 percent as a result of providing the coverage required by this
section and the insurer obtains an exemption from the Commissioner
pursuant to subsection 5.
5. To obtain the exemption required by subsection 4, an insurer
must submit to the Commissioner a written request therefor that is signed
by an actuary and sets forth the reasons and actuarial assumptions upon
which the request is based. To determine whether an exemption may be
granted, the Commissioner shall subtract from the amount of premiums
charged during the policy year the amount of premiums charged during the
period immediately preceding the policy year and the amount of any
increase in the premiums charged that is attributable to factors that are
unrelated to providing the coverage required by this section. The
Commissioner shall verify the information within 30 days after receiving
the request. The request shall be deemed approved if the Commissioner
does not deny the request within that time.
6. The provisions of this section do not:
(a) Limit the provision of specialized services covered by Medicaid
for persons with conditions relating to mental health or substance abuse.
(b) Supersede any provision of federal law, any federal or state
policy relating to Medicaid, or the terms and conditions imposed on any
Medicaid waiver granted to this state with respect to the provisions of
services to persons with conditions relating to mental health or
substance abuse.
7. A policy of health insurance subject to the provisions of this
chapter which is delivered, issued for delivery or renewed on or after
January 1, 2000, has the legal effect of including the coverage required
by this section, and any provision of the policy or the renewal which is
in conflict with this section is void, unless the policy is otherwise
exempt from the provisions of this section pursuant to subsection 4.
8. As used in this section, “severe mental illness” means any of
the following mental illnesses that are biologically based and for which
diagnostic criteria are prescribed in the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, published by the American
Psychiatric Association:
(a) Schizophrenia.
(b) Schizoaffective disorder.
(c) Bipolar disorder.
(d) Major depressive disorders.
(e) Panic disorder.
(f) Obsessive-compulsive disorder.
(Added to NRS by 1999, 3100 )
1. The benefits provided by a policy for health insurance for
treatment of the abuse of alcohol or drugs must consist of:
(a) Treatment for withdrawal from the physiological effect of
alcohol or drugs, with a minimum benefit of $1,500 per calendar year.
(b) Treatment for a patient admitted to a facility, with a minimum
benefit of $9,000 per calendar year.
(c) Counseling for a person, group or family who is not admitted to
a facility, with a minimum benefit of $2,500 per calendar year.
2. These benefits must be paid in the same manner as benefits for
any other illness covered by a similar policy are paid.
3. The insured person is entitled to these benefits if treatment
is received in any:
(a) Facility for the treatment of abuse of alcohol or drugs which
is certified by the Health Division of the Department of Health and Human
Services.
(b) Hospital or other medical facility or facility for the
dependent which is licensed by the Health Division of the Department of
Health and Human Services, accredited by the Joint Commission on
Accreditation of Healthcare Organizations and provides a program for the
treatment of abuse of alcohol or drugs as part of its accredited
activities.
(Added to NRS by 1979, 1176; A 1983, 2036; 1985, 1569, 1773; 1993,
1918; 1997, 1301; 1999, 1888 ; 2001, 438 )
1. Except as otherwise provided in this section, no policy of
health insurance may be delivered or issued for delivery in this state if
it contains an exclusion of coverage of treatment of the
temporomandibular joint whether by specific language in the policy or by
a claims settlement practice. A policy may exclude coverage of those
methods of treatment which are recognized as dental procedures,
including, but not limited to, the extraction of teeth and the
application of orthodontic devices and splints.
2. The insurer may limit its liability on the treatment of the
temporomandibular joint to:
(a) No more than 50 percent of the usual and customary charges for
such treatment actually received by an insured, but in no case more than
50 percent of the maximum benefits provided by the policy for such
treatment; and
(b) Treatment which is medically necessary.
3. Any provision of a policy subject to the provisions of this
chapter and issued or delivered on or after January 1, 1990, which is in
conflict with this section is void.
(Added to NRS by 1989, 2137)
REIMBURSEMENT FOR CERTAIN MEDICALLY RELATED TREATMENT AND SERVICES
If any policy of health insurance
provides coverage for acupuncture performed by a physician, the insured
is entitled to reimbursement for acupuncture performed by a person who is
licensed pursuant to chapter 634A of NRS.
(Added to NRS by 1991, 1133)
If any policy of
health insurance provides coverage for treatment of an illness which is
within the authorized scope of the practice of a qualified psychologist,
the insured is entitled to reimbursement for treatments by a psychologist
who is licensed pursuant to chapter 641 of
NRS.
(Added to NRS by 1979, 367; A 1989, 1553)
If any policy of health insurance provides coverage for treatment of an
illness which is within the authorized scope of the practice of a
licensed marriage and family therapist, the insured is entitled to
reimbursement for treatment by a marriage and family therapist who is
licensed pursuant to chapter 641A of NRS.
(Added to NRS by 1987, 2133)
If
any policy of health insurance provides coverage for treatment of an
illness which is within the authorized scope of the practice of a
licensed associate in social work, social worker, independent social
worker or clinical social worker, the insured is entitled to
reimbursement for treatment by an associate in social work, social
worker, independent social worker or clinical social worker who is
licensed pursuant to chapter 641B of NRS.
(Added to NRS by 1987, 1123)
1. If any policy of health insurance provides coverage for
treatment of an illness which is within the authorized scope of practice
of a qualified chiropractor, the insured is entitled to reimbursement for
treatments by a chiropractor who is licensed pursuant to chapter 634
of NRS.
2. The terms of the policy must not limit:
(a) Coverage for treatments by a chiropractor to a number less than
for treatments by other physicians.
(b) Reimbursement for treatments by a chiropractor to an amount
less than that reimbursed for similar treatments by other physicians.
(Added to NRS by 1981, 930; A 1983, 327)
1. If any policy of health insurance provides coverage for
services which are within the authorized scope of practice of a
registered nurse who is authorized pursuant to chapter 632 of NRS to perform additional acts in an emergency or
under other special conditions as prescribed by the State Board of
Nursing, and which are reimbursed when provided by another provider of
health care, the insured is entitled to reimbursement for services
provided by such a registered nurse.
2. The terms of the policy must not limit:
(a) Coverage for services provided by such a registered nurse to a
number of occasions less than for services provided by another provider
of health care.
(b) Reimbursement for services provided by such a registered nurse
to an amount less than that reimbursed for similar services provided by
another provider of health care.
3. An insurer is not required to pay for services provided by such
a registered nurse which duplicate services provided by another provider
of health care.
(Added to NRS by 1985, 1446)
1. Except as otherwise provided in subsection 3, every policy of
health insurance amended, delivered or issued for delivery in this State
after October 1, 1989, that provides coverage for medical transportation,
must contain a provision for the direct reimbursement of a provider of
medical transportation for covered services if that provider does not
receive reimbursement from any other source.
2. The insured or the provider may submit the claim for
reimbursement. The provider shall not demand payment from the insured
until after that reimbursement has been granted or denied.
3. Subsection 1 does not apply to any agreement between an insurer
and a provider of medical transportation for the direct payment by the
insurer for the provider’s services.
(Added to NRS by 1989, 1273)
MISCELLANEOUS PROVISIONS
There shall be a provision
as follows:
Entire Contract; Changes: This policy, including the endorsements
and the attached papers, if any, constitutes the entire contract of
insurance. No change in this policy shall be valid until approved by an
executive officer of the insurer and unless such approval is endorsed
hereon or attached hereto. No agent has authority to change this policy
or to waive any of its provisions.
(Added to NRS by 1971, 1753)
There shall be a
provision as follows:
Time Limit on Certain Defenses:
1. After 3 years from the date of issue of this policy no
misstatements, except fraudulent misstatements, made by the applicant in
the application for such policy shall be used to void the policy or to
deny a claim for loss incurred or disability (as defined in the policy)
commencing after the expiration of such 3-year period.
The foregoing policy provision shall not be so construed as to affect any
legal requirement for avoidance of a policy or denial of a claim during
such initial 3-year period, nor to limit the application of NRS 689A.200
to 689A.230 , inclusive, in the event of misstatement
with respect to age or occupation or other insurance. A policy which the
insured has the right to continue in force subject to its terms by the
timely payment of the premium until at least age 50 or, in the case of a
policy issued after age 44, for at least 5 years from its date of issue,
may contain in lieu of the foregoing the following provision (from which
the clause in parentheses may be omitted at the insurer’s option):
“Incontestable: After this policy has been in force for a period of three
years during the lifetime of the insured (excluding any period during
which the insured is disabled), it shall become incontestable as to the
statements contained in the application.”
2. No claim for loss incurred or disability (as defined in the
policy) commencing after 3 years from the date of issue of this policy
shall be reduced or denied on the ground that a disease or physical
condition not excluded from coverage by name or specific description
effective on the date of loss had existed prior to the effective date of
coverage of this policy.
(Added to NRS by 1971, 1753)
There shall be a provision as follows:
Grace Period: A grace period of ..... (insert a number not less
than “7” for weekly premium policies, “10” for monthly premium policies
and “31” for all other policies) days will be granted for the payment of
each premium falling due after the first premium, during which grace
period the policy shall continue in force.
A policy in which the insurer reserves the right to refuse any renewal
shall have, at the beginning of the above provision:
Unless not less than 30 days prior to the premium due date the
company has delivered to the insured or has mailed to his last address as
shown by the records of the insurer written notice of its intention not
to renew this policy beyond the period for which the premium has been
accepted.
(Added to NRS by 1971, 1754)
1. There shall be a provision as follows:
Reinstatement: If any renewal premium be not paid within the time
granted the insured for payment, a subsequent acceptance of premium by
the insurer or by any agent duly authorized by the insurer to accept such
premium, without requiring in connection therewith an application for
reinstatement, shall reinstate the policy; provided, however, that if the
insurer or such agent requires an application for reinstatement and
issues a conditional receipt for the premium tendered, the policy will be
reinstated upon approval of such application by the insurer or, lacking
such approval, upon the 45th day following the date of such conditional
receipt unless the insurer has previously notified the insured in writing
of its disapproval of such application. The reinstated policy shall cover
only loss resulting from such accidental injury as may be sustained after
the date of reinstatement and loss due to such sickness as may begin more
than 10 days after such date. In all other respects the insured and
insurer shall have the same rights thereunder as they had under the
policy immediately before the due date of the defaulted premium, subject
to any provisions endorsed herein or attached hereto in connection with
the reinstatement. Any premium accepted in connection with a
reinstatement shall be applied to a period for which premium has not been
previously paid, but not to any period more than 60 days prior to the
date of reinstatement.
2. The last sentence of subsection 1 may be omitted from any
policy which the insured has the right to continue in force subject to
its terms by the timely payment of premiums:
(a) Until at least age 50; or
(b) In the case of a policy issued after age 44, for at least 5
years from its date of issue.
3. Pursuant to the last sentence in subsection 1, the insurer
shall apply the premium accepted in such manner as to place the policy
currently in force, exclusive of any applicable grace period, but not in
any event to any period more than 60 days prior to the date of
reinstatement.
(Added to NRS by 1971, 1754)
1. There shall be a provision as follows:
Notice of Claim: Written notice of claim must be given to the
insurer within 20 days after the occurrence or commencement of any loss
covered by the policy, or as soon thereafter as is reasonably possible.
Notice given by or on behalf of the insured or the beneficiary to the
insurer at ................ (insert the location of such office as the
insurer may designate for the purpose), or to any authorized agent of the
insurer, with information sufficient to identify the insured, shall be
deemed notice to the insurer.
2. In a policy providing a loss-of-time benefit which may be
payable for at least 2 years, an insurer may at its option insert the
following between the first and second sentence of subsection 1:
Subject to the qualifications set forth below, if the insured
suffers loss of time on account of disability for which indemnity may be
payable for at least 2 years, he shall, at least once in every 6 months
after having given notice of the claim, give to the insurer notice of
continuance of said disability, except in the event of legal incapacity.
The period of 6 months following any filing of proof by the insured or
any payment by the insurer on account of such claim or any denial of
liability in whole or in part by the insurer shall be excluded in
applying this provision. Delay in the giving of such notice shall not
impair the insured’s right to any indemnity which would otherwise have
accrued during the period of 6 months preceding the date on which such
notice is actually given.
(Added to NRS by 1971, 1755)
There shall be a
provision as follows:
Claim Forms: The insurer, upon receipt of a notice of claim, will
furnish to the claimant such forms as are usually furnished by it for
filing proofs of loss. If such forms are not furnished within 15 days
after the giving of such notice the claimant shall be deemed to have
complied with the requirements of this policy as to proof of loss upon
submitting, within the time fixed in the policy for filing proofs of
loss, written proof covering the occurrence, the character and the extent
of the loss for which claim is made.
(Added to NRS by 1971, 1756)
Every
insurer under a health insurance contract and every state agency for its
records shall accept from:
1. A hospital the Uniform Billing and Claims Forms established by
the American Hospital Association in lieu of its individual billing and
claims forms.
2. An individual who is licensed to practice one of the health
professions regulated by Title 54 of NRS such uniform health insurance
claims forms as the Commissioner shall prescribe, except in those cases
where the Commissioner has excused uniform reporting.
(Added to NRS by 1975, 897)
There
shall be a provision as follows:
Proofs of Loss: Written proof of loss must be furnished to the
insurer at its office in case of claim for loss for which this policy
provides any periodic payment contingent upon continuing loss within 90
days after the termination of the period for which the insurer is liable
and in case of claim for any other loss within 90 days after the date of
such loss. Failure to furnish such proof within the time required shall
not invalidate nor reduce any claim if it was not reasonably possible to
give proof within such time, provided such proof is furnished as soon as
reasonably possible and in no event, except in the absence of legal
capacity, later than 1 year from the time proof is otherwise required.
(Added to NRS by 1971, 1756)
There shall be a
provision as follows:
Time of Payment of Claims: Indemnities payable under this policy
for any loss, other than loss for which this policy provides any periodic
payment, will be paid immediately upon receipt of due written proof of
such loss. Subject to due written proof of loss, all accrued indemnities
for loss for which this policy provides periodic payment will be paid
................ (insert period for payment which must not be less
frequently than monthly) and any balance remaining unpaid upon the
termination of liability will be paid immediately upon receipt of due
written proof.
(Added to NRS by 1971, 1756)
1. There shall be a provision as follows:
Payment of Claims: Indemnity for loss of life will be payable in
accordance with the beneficiary designation and the provisions respecting
such payment which may be prescribed herein and effective at the time of
payment. If no such designation or provision is then effective, such
indemnity shall be payable to the estate of the insured. Any other
accrued indemnities unpaid at the insured’s death may, at the option of
the insurer, be paid either to such beneficiary or to such estate. All
other indemnities will be payable to the insured.
2. The following provisions, or either of them, may be included
with the provision in subsection 1 at the option of the insurer:
If any indemnity of this policy shall be payable to the estate of
the insured, or to an insured or beneficiary who is a minor or otherwise
not competent to give a valid release, the insurer may pay such
indemnity, up to an amount not exceeding $..... (insert an amount which
shall not exceed $1,000), to any relative by blood or connection by
marriage of the insured or beneficiary who is deemed by the insurer to be
equitably entitled thereto. Any payment made by the insurer in good faith
pursuant to this provision shall fully discharge the insurer to the
extent of such payment.
Subject to any written direction of the insured in the application
or otherwise all or a portion of any indemnities provided by this policy
on account of hospital, nursing, medical or surgical services may, at the
insurer’s option and unless the insured requests otherwise in writing not
later than the time of filing proofs of such loss, be paid directly to
the hospital or person rendering such services; but it is not required
that the service be rendered by a particular hospital or person.
(Added to NRS by 1971, 1756)
1. A person insured under a policy of health insurance may assign
his right to benefits to the provider of health care who provided the
services covered by the policy. The insurer shall pay all or the part of
the benefits assigned by the insured to the person designated by him. A
payment made pursuant to this subsection discharges the insurer’s
obligation to pay those benefits.
2. If the insured makes an assignment under this section, but the
insurer after receiving a copy of the assignment pays the benefits to the
insured, the insurer shall also pay those benefits to the provider of
health care who received the assignment as soon as the insurer receives
notice of the incorrect payment.
3. For the purpose of this section, “provider of health care” has
the meaning ascribed to it in NRS 629.031 .
(Added to NRS by 1983, 879)
There shall be a
provision as follows:
Physical Examinations and Autopsy: The insurer at its own expense
shall have the right and opportunity to examine the person of the insured
when and as often as it may reasonably require during the pendency of a
claim hereunder and to make an autopsy in case of death where it is not
forbidden by law.
(Added to NRS by 1971, 1757)
There shall be a provision as follows:
Legal Actions: No action at law or in equity shall be brought to
recover on this policy prior to the expiration of 60 days after written
proof of loss has been furnished in accordance with the requirements of
this policy. No such action shall be brought after the expiration of 3
years after the time written proof of loss is required to be furnished.
(Added to NRS by 1971, 1757)
1. There shall be a provision as follows:
Change of Beneficiary: Unless the insured makes an irrevocable
designation of beneficiary, the right to change of beneficiary is
reserved to the insured and the consent of the beneficiary or
beneficiaries shall not be requisite to surrender or assignment of this
policy or to any change of beneficiary or beneficiaries, or to any other
changes in this policy.
2. The first clause of the provision set forth in subsection 1,
relating to the irrevocable designation of beneficiary, may be omitted at
the insurer’s option.
(Added to NRS by 1971, 1757)
1. Except as to nonrenewable accident policies and individual
credit health insurance policies, every individual health insurance
policy shall contain a provision therein or in a separate rider attached
thereto when delivered, stating in substance that the person to whom the
policy is issued shall be permitted to return the policy within 10 days
of its delivery to such person and to have a refund of the premium paid
if after examination of the policy the purchaser is not satisfied with it
for any reason. The provision shall be set forth in the policy under an
appropriate caption, and if not so printed on the face page of the policy
adequate notice of the provision shall be printed or stamped
conspicuously on the face page.
2. The policy may be so returned to the insurer at its home or
branch office or to the agent through whom it was applied for, and
thereupon shall be void as from the beginning and as if the policy had
not been issued.
(Added to NRS by 1971, 1758)
[Effective through June 30,
2006.] Except as provided in NRS 689A.040 , no such policy delivered or issued for
delivery to any person in this State may contain provisions respecting
the matters set forth in NRS 689A.190
to 689A.280 , inclusive, unless the
provisions are in the words in which the provisions appear in the
applicable section, except that the insurer may, at its option, use in
lieu of any such provision a corresponding provision of different wording
approved by the Commissioner which is not less favorable in any respect
to the insured or the beneficiary. Any such provision contained in the
policy must be preceded individually by the appropriate caption or, at
the option of the insurer, by such appropriate individual or group
captions or subcaptions as the Commissioner may approve.
(Added to NRS by 1971, 1758; A 1985, 1060)
[Effective July 1, 2006.]
Except as otherwise provided in NRS 689A.040 , no such policy delivered or issued for
delivery to any person in this State may contain provisions respecting
the matters set forth in NRS 689A.190
to 689A.270 , inclusive, unless the
provisions are in the words in which the provisions appear in the
applicable section, except that the insurer may, at its option, use in
lieu of any such provision a corresponding provision of different wording
approved by the Commissioner which is not less favorable in any respect
to the insured or the beneficiary. Any such provision contained in the
policy must be preceded individually by the appropriate caption or, at
the option of the insurer, by such appropriate individual or group
captions or subcaptions as the Commissioner may approve.
(Added to NRS by 1971, 1758; A 1985, 1060; 2005, 2343 , effective July 1, 2006)
Any health insurance
policy may contain a provision for payment not exceeding $500 as an
extended disability benefit upon the insured’s death from any cause,
which benefit shall not be construed as life insurance.
(Added to NRS by 1971, 1758)
There may be a provision as
follows:
Change of Occupation: If the insured be injured or contracts
sickness after having changed his occupation to one classified by the
insurer as more hazardous than that stated in this policy or while doing
for compensation anything pertaining to an occupation so classified, the
insurer will pay only such portion of the indemnities provided in this
policy as the premium paid would have purchased at the rates and within
the limits fixed by the insurer for such more hazardous occupation. If
the insured changes his occupation to one classified by the insurer as
less hazardous than that stated in this policy, the insurer, upon receipt
of proof of such change of occupation, will reduce the premium rate
accordingly, and will return the excess pro rata unearned premium from
the date of change of occupation or from the policy anniversary date
immediately preceding receipt of such proof, whichever is the more
recent. In applying this provision, the classification of occupational
risk and the premium rates shall be such as have been last filed by the
insurer prior to the occurrence of the loss for which the insurer is
liable or prior to date of proof of change in occupation with the state
official having supervision of insurance in the state where the insured
resided at the time this policy was issued; but if such filing was not
required, then the classification of occupational risk and the premium
rates shall be those last made effective by the insurer in such state
prior to the occurrence of the loss or prior to the date of proof of
change in occupation.
(Added to NRS by 1971, 1758)
There may be a provision as
follows:
Misstatement of Age: If the age of the insured has been misstated,
all amounts payable under this policy shall be such as the premium paid
would have purchased at the correct age.
(Added to NRS by 1971, 1759)
There may be
a provision as follows:
If an accident or sickness or accident and sickness policy or
policies previously issued by the insurer to the insured be in force
concurrently herewith, making the aggregate indemnity for
................ (insert type of coverage or coverages) in excess of
$..... (insert maximum limit of indemnity or indemnities), the excess
shall be void and all premiums paid for such excess shall be returned to
the insured or to his estate.
Or, in lieu thereof:
Insurance effective at any one time on the insured under this
policy and like policy or policies in this insurer is limited to the one
policy elected by the insured, his beneficiary or his estate, as the case
may be, and the insurer will return all premiums paid for all other such
policies.
(Added to NRS by 1971, 1759)
1. There may be a provision as follows:
Coordination of Benefits: If, with respect to a person covered
under this policy, benefits for allowable expense incurred during a claim
determination period under this policy, together with benefits for
allowable expense during such period under all other valid coverage
(without giving effect to this provision or to any “coordination of
benefits provision” applying to such other valid coverage), exceed the
total of such person’s allowable expense during such period, this insurer
shall be liable only for such proportionate amount of the benefits for
allowable expense under this policy during such period as (a) the total
allowable expense during such period bears to (b) the total amount of
benefits payable during such period for such expense under this policy
and all other valid coverage (without giving effect to this provision or
to any “coordination of benefits provision” applying to such other valid
coverage) less in both (a) and (b) any amount of benefits for allowable
expense payable under other valid coverage which does not contain a
“coordination of benefits provision.” In no event shall this provision
operate to increase the amount of benefits for allowable expense payable
under this policy with respect to a person covered under this policy
above the amount which would have been paid in the absence of this
provision. This insurer may pay benefits to any insurer providing other
valid coverage in the event of overpayment by such insurer. Any such
payment shall discharge the liability of this insurer as fully as if the
payment had been made directly to the insured, his assignee or his
beneficiary. If this insurer pays benefits to the insured, his assignee
or his beneficiary, in excess of the amount which would have been payable
if the existence of other valid coverage had been disclosed, this insurer
shall have a right of action against the insured, his assignee or his
beneficiary to recover the amount which would not have been paid had
there been a disclosure of the existence of the other valid coverage. The
amount of other valid coverage which is on a provision of service basis
shall be computed as the amount the services rendered would have cost in
the absence of such coverage.
For the purposes of this provision:
(1) “Allowable expense” means 100 percent of any necessary,
reasonable and customary item of expense which is covered, in whole or in
part, as a hospital, surgical, medical or major medical expense under
this policy or under any other valid coverage.
(2) “Claim determination period” with respect to any covered
person means the initial period of ..... (insert period of not less than
30 days) and each successive period of a like number of days, during
which allowable expense covered under this policy is incurred on account
of such person. The first such period begins on the date when the first
such expense is incurred, and successive periods shall begin when such
expense is incurred after expiration of a prior period.
or, in lieu thereof:
(2) “Claim determination period” with respect to any covered
person means each ..... (insert calendar or policy period of not less
than a month) during which allowable expense covered under this policy is
incurred on account of such person.
(3) “Coordination of benefits provision” means this provision and
any other provision which may reduce an insurer’s liability because of
the existence of benefits under other valid coverage.
2. The foregoing policy provisions may be inserted in all policies
providing hospital, surgical, medical or major medical benefits for which
the application includes a question as to other coverages subject to this
provision. If the policy provision stated in subsection 1 is included in
a policy which also contains the policy provision stated in NRS 689A.240
, there shall be added to the caption
of the provision stated in subsection 1 of the phrase “expense-incurred
benefits.” The insurer may make this provision applicable to either or
both:
(a) Other valid coverage with other insurers; and
(b) Other valid coverage with the same insurer.
Ê The insurer shall include in this provision a definition of “other
valid coverage” approved as to form by the Commissioner. Such term may
include hospital, surgical, medical or major medical benefits provided by
individual or family-type coverage, government programs or workmen’s
compensation. Such term shall not include any group insurance, automobile
medical payments or third party liability coverage. The insurer shall not
include a subrogation clause in the policy. The insurer may require, as
part of the proof of claim, the information necessary to administer this
provision.
3. If by application of any of the foregoing provisions the
insurer effects a material reduction of benefits otherwise payable under
the policy, the insurer shall refund to the insured any premium unearned
on the policy by reason of such reduction of coverage during the policy
year current and that next preceding at the time the loss commenced,
subject to the insurer’s right to provide in the policy that no such
reduction of benefits or refund will be made unless the unearned premium
to be so refunded amounts to $5 or such larger sum as the insurer may so
specify.
(Added to NRS by 1971, 1760)
1. There may be a provision as follows:
Relation of Earnings to Insurance: After the loss-of-time benefit
of this policy has been payable for 90 days, such benefit will be
adjusted, as provided below, if the total amount of unadjusted
loss-of-time benefits provided in all valid loss-of-time coverage upon
the insured should exceed ..... percent of the insured’s earned income;
provided, however, that if the information contained in the application
discloses that the total amount of loss-of-time benefits under this
policy and under all other valid loss-of-time coverage expected to be
effective upon the insured in accordance with the application for this
policy exceeded ..... percent of the insured’s earned income at the time
of such application, such higher percentage will be used in place of
..... percent. Such adjusted loss-of-time benefit under this policy for
any month shall be only such proportion of the loss-of-time benefit
otherwise payable under this policy as (a) the product of the insured’s
earned income and ..... percent (or, if higher the alternative percentage
described at the end of the first sentence of this provision) bears to
(b) the total amount of loss-of-time benefits payable for such month
under this policy and all other valid loss-of-time coverage on the
insured (without giving effect to the “overinsurance provision” in this
or any other coverage) less in both (a) and (b) any amount of
loss-of-time benefits payable under other valid loss-of-time coverage
which does not contain an “overinsurance provision.” In making such
computation, all benefits and earnings shall be converted to a consistent
(insert “weekly” if the loss-of-time benefit of this policy is payable
weekly, “monthly” if such benefit is payable monthly, etc.) basis. If the
numerator of the foregoing ratio is zero or is negative, no benefit shall
be payable under this policy. In no event shall this provision (1)
operate to reduce the total combined amount of loss-of-time benefits for
such month payable under this policy and all other valid loss-of-time
coverage below the lesser of $300 and the total combined amount of
loss-of-time benefits determined without giving effect to any
“coordination of benefits provision,” nor (2) operate to increase the
amount of benefits payable under this policy above the amount which would
have been paid in the absence of this provision, nor (3) take into
account or operate to reduce any benefit other than the loss-of-time
benefit.
For purposes of this provision:
(A) “Earned income,” except where otherwise specified, means the
greater of the monthly earnings of the insured at the time disability
commences and his average monthly earnings for a period of 2 years
immediately preceding the commencement of such disability, and shall not
include any investment income or any other income not derived from the
insured’s vocational activities.
(B) “Coordination of benefits provision” includes this provision
and any other provision with respect to any loss-of-time coverage which
may have the effect of reducing an insurer’s liability if the total
amount of loss-of-time benefits under all coverage exceeds a stated
relationship to the insured’s earnings.
2. If the policy provision stated in subsection 1 is included in a
policy which also contains the policy provision stated in NRS 689A.230
, there shall be added to the caption
of the provision stated in subsection 1 the phrase “loss-of-time
benefits.”
3. The foregoing provision may be included only in a policy which
provides a loss-of-time benefit which may be payable for at least 52
weeks, which is issued on the basis of selective underwriting of each
individual application, and for which the application includes a question
designed to elicit information necessary either to determine the ratio of
the total loss-of-time benefits of the insured to the insured’s earned
income or to determine that such ratio does not exceed the percentage of
earnings, not less than 60 percent selected by the insurer and inserted
in lieu of the blank factor above. The insurer may require, as part of
the proof of claim, the information necessary to administer this
provision. If the application indicates that other loss-of-time coverage
is to be discontinued, the amount of such other coverage shall be
excluded in computing the alternative percentage in the first sentence of
the overinsurance provision. The policy shall include a definition of
“valid loss-of-time coverage,” approved as to form by the Commissioner,
which definition shall not include group insurance, benefits provided by
union welfare plans, employer or employee benefit plans, workmen’s
compensation or employer’s liability statute or third party liability.
The insurer shall not include a subrogation clause in the policy.
4. If by application of any of the foregoing provisions the
insurer effects a material reduction of benefits otherwise payable under
the policy, the insurer shall refund to the insured any premium unearned
on the policy by reason of such reduction of coverage during the policy
year current and that next preceding at the time the loss commenced,
subject to the insurer’s right to provide in the policy that no such
reduction of benefits or refund will be made unless the unearned premium
to be so refunded amounts to $5 or such larger sum as the insurer may so
specify.
(Added to NRS by 1971, 1761)
There may be a provision as follows:
Unpaid Premium: Upon the payment of a claim under this policy, any
premium then due and unpaid or covered by any note or written order may
be deducted therefrom.
(Added to NRS by 1971, 1763)
There may be a
provision as follows:
Conformity with State Statutes: Any provision of this policy
which, on its effective date is in conflict with the statutes of the
state in which the insured resides on such date is hereby amended to
conform to the minimum requirements of such statutes.
(Added to NRS by 1971, 1763)
There may be a provision as
follows:
Illegal Occupation: The insurer shall not be liable for any loss
to which a contributing cause was the insured’s commission of or attempt
to commit a felony or to which a contributing cause was the insured’s
being engaged in an illegal occupation.
(Added to NRS by 1971, 1763)
[Effective through June
30, 2006.]
1. There may be a provision as follows:
Intoxicants and Narcotics: The insurer is not liable for any loss
sustained or contracted in consequence of the insured’s being intoxicated
or under the influence of any narcotic unless administered on the advice
of a physician.
2. If the insurer includes the provision set forth in subsection
1, he shall also provide that such provision in no way affects benefits
payable for the treatment of alcohol or drug abuse, as required by
subsection 9 of NRS 689A.030 .
(Added to NRS by 1971, 1763; A 1975, 1849; R 2005, 2348 , effective July 1, 2006)
Health insurance policies, other than
accident insurance only policies, in which the insurer reserves the right
to refuse renewal on an individual basis, shall provide in substance in a
provision thereof or in an endorsement thereon or rider attached thereto
that subject to the right to terminate the policy upon nonpayment of
premium when due, such right to refuse renewal may not be exercised so as
to take effect before the renewal date occurring on, or after and
nearest, each policy anniversary (or in the case of lapse and
reinstatement, at the renewal date occurring on, or after and nearest,
each anniversary of the last reinstatement), and that any refusal of
renewal shall be without prejudice to any claim originating while the
policy is in force. (The parenthetic reference to lapse and reinstatement
may be omitted at the insurer’s option.)
(Added to NRS by 1971, 1764)
The provisions which
are the subject of NRS 689A.050 to
689A.290 , inclusive, or any
corresponding provisions which are used in lieu thereof in accordance
with such sections shall be printed in the consecutive order of the
provisions in such sections or, at the option of the insurer, any such
provision may appear as a unit in any part of the policy, with other
provisions to which it may be logically related, provided that the
resulting policy shall not be in whole or in part unintelligible,
uncertain, ambiguous, abstruse or likely to mislead a person to whom the
policy is offered, delivered or issued.
(Added to NRS by 1971, 1764)
The word “insured,” as used in this chapter, shall not be construed as
preventing a person other than the insured with a proper insurable
interest from making application for and owning a policy covering the
insured or from being entitled under such a policy to any indemnities,
benefits and rights provided therein.
(Added to NRS by 1971, 1764)
1. Any policy of a foreign or alien insurer, when delivered or
issued for delivery to any person in this state, may contain any
provision which is not less favorable to the insured or the beneficiary
than the provisions of this chapter and which is prescribed or required
by the law of the state or country under which the insurer is organized.
2. Any policy of a domestic insurer may, when issued for delivery
in any other state or country, contain any provision permitted or
required by the laws of such other state or country.
(Added to NRS by 1971, 1764)
If
any policy is issued by a domestic insurer for delivery to a person
residing in another state, and if the insurance commissioner or
corresponding public officer of that other state has informed the
Commissioner that the policy is not subject to approval or disapproval by
that officer, the Commissioner may by ruling require that the policy meet
the standards set forth in NRS 689A.030 to 689A.320 , inclusive.
(Added to NRS by 1971, 1765; A 1985, 1447; 1989, 1273; 1997, 743;
1999, 760 , 1997 ; 2003, 1334 , 3355 , 3522 )
1. No policy provision which is not subject to this chapter shall
make a policy, or any portion thereof, less favorable in any respect to
the insured or the beneficiary than the provisions thereof which are
subject to this chapter.
2. A policy delivered or issued for delivery to any person in this
state in violation of this chapter shall be held valid but shall be
construed as provided in this chapter. When any provision in a policy
subject to this chapter is in conflict with any provision of this
chapter, the rights, duties and obligations of the insurer, the insured
and the beneficiary shall be governed by the provisions of this chapter.
(Added to NRS by 1971, 1765)
If any such policy contains a provision
establishing, as an age limit or otherwise, a date after which the
coverage provided by the policy will not be effective, and if such date
falls within a period for which a premium is accepted by the insurer or
if the insurer accepts a premium after such date, the coverage provided
by the policy will continue in force subject to any right of termination
until the end of the period for which the premium has been accepted. If
the age of the insured has been misstated and if, according to the
correct age of the insured, the coverage provided by the policy would not
have become effective, or would have ceased prior to the acceptance of
such premium or premiums, then the liability of the insurer shall be
limited to the refund of all premiums paid for the period not covered by
the policy.
(Added to NRS by 1971, 1765)
Each insurer issuing individual
health insurance policies for delivery in this state shall, before use
thereof, file with the Commissioner its premium rates and classification
of risks pertaining to such policies. The insurer shall adhere to its
rates and classifications as filed with the Commissioner. The insurer may
change such filings from time to time as it deems proper.
(Added to NRS by 1971, 1765)
1. Health insurance on a franchise plan is hereby declared to be
that form of health insurance issued to:
(a) Three or more employees of any corporation, copartnership or
individual employer or any governmental corporation, agency or department
thereof; or
(b) Ten or more members, employees or employees of members of any
trade or professional association or of a labor union or of any other
association having had an active existence for at least 2 years where
such association or union has a constitution or bylaws and is formed in
good faith for purposes other than that of obtaining insurance,
Ê where such persons with or without their dependents, are issued the
same form of an individual policy varying only as to amounts and kinds of
coverage applied for by such persons under an arrangement whereby the
premiums on such policies may be paid to the insurer periodically by the
employer, with or without payroll deductions, or by the insured, or the
association or union for its members, or by some designated person acting
on behalf of such employer or association or union. The term “employees”
as used in this section shall be deemed to include the officers, managers
and employees and retired employees of the employer and the individual
proprietor or partners if the employer is an individual proprietor or
partnership.
2. Each policy issued under this section shall provide that the
coverage shall terminate when the insured individual no longer qualifies
for such policy under this section; but the policy may provide that it
may be continued in force or be replaced with another policy if the
premium, benefits and other relevant factors of the continued or
replacement policy are the same as those of a similar individual policy
not issued under or pursuant to this section.
(Added to NRS by 1971, 1765)
As used in
any policy of health insurance delivered, issued for delivery or used in
this state, unless otherwise provided in the policy or in an endorsement
thereon or in a rider attached thereto:
1. “Accidental death” means death by accident exclusively and
independently of all other causes.
2. “Confinement to house” or “house confinement” includes the
activities of a convalescent not able to be gainfully employed.
3. “Medical or surgical services” includes also services within
the scope of his license rendered by any person while duly licensed by
the State of Nevada under any of the following chapters of NRS: 631
(dentistry); 633 (osteopathic medicine); 634 (chiropractic); 634A
(Oriental medicine); 635 (podiatry); or 636 (optometry). No policy of
health insurance may provide that the insured does not have the option of
selecting any licensee provided for in this subsection to perform any
medical or surgical services covered by a policy of insurance if the
service is within the scope of his license.
4. “Total disability” means inability to perform the duties of any
gainful occupation for which the insured is reasonably fitted by
training, experience and accomplishment.
(Added to NRS by 1971, 1766; A 1971, 1953; 1975, 240; 1977, 966)
1. The Commissioner shall adopt regulations which require an
insurer to file with the Commissioner, for his approval, a disclosure
summarizing the coverage provided by each policy of health insurance
offered by the insurer. The disclosure must include:
(a) Any significant exception, reduction or limitation that applies
to the policy; and
(b) Any other information,
Ê that the Commissioner finds necessary to provide for full and fair
disclosure of the provisions of the policy.
2. The disclosure must be written in language which is easily
understood and must include a statement that the disclosure is a summary
of the policy only, and that the policy itself should be read to
determine the governing contractual provisions.
3. The Commissioner shall not approve any proposed disclosure
submitted to him pursuant to this section which does not comply with the
requirements of this section and the applicable regulations.
(Added to NRS by 1989, 1248)
An insurer shall provide each person to whom it offers a
policy of health insurance with a copy of the disclosure approved for
that policy pursuant to NRS 689A.390
before the policy is issued. An insurer shall not offer a policy of
health insurance unless the disclosure for that policy has been approved
by the Commissioner.
(Added to NRS by 1989, 1249)
1. An insurer that offers or issues a policy of health insurance
which provides coverage for prescription drugs shall include with any
summary, certificate or evidence of that coverage provided to an insured,
notice of whether a formulary is used and, if so, of the opportunity to
secure information regarding the formulary from the insurer pursuant to
subsection 2. The notice required by this subsection must:
(a) Be in a language that is easily understood and in a format that
is easy to understand;
(b) Include an explanation of what a formulary is; and
(c) If a formulary is used, include:
(1) An explanation of:
(I) How often the contents of the formulary are
reviewed; and
(II) The procedure and criteria for determining which
prescription drugs are included in and excluded from the formulary; and
(2) The telephone number of the insurer for making a request
for information regarding the formulary pursuant to subsection 2.
2. If an insurer offers or issues a policy of health insurance
which provides coverage for prescription drugs and a formulary is used,
the insurer shall:
(a) Provide to any insured or participating provider of health
care, upon request:
(1) Information regarding whether a specific drug is
included in the formulary.
(2) Access to the most current list of prescription drugs in
the formulary, organized by major therapeutic category, with an
indication of whether any listed drugs are preferred over other listed
drugs. If more than one formulary is maintained, the insurer shall notify
the requester that a choice of formulary lists is available.
(b) Notify each person who requests information regarding the
formulary, that the inclusion of a drug in the formulary does not
guarantee that a provider of health care will prescribe that drug for a
particular medical condition.
(Added to NRS by 2001, 856 )
1. Except as otherwise provided in subsection 2, an insurer shall
approve or deny a claim relating to a policy of health insurance within
30 days after the insurer receives the claim. If the claim is approved,
the insurer shall pay the claim within 30 days after it is approved.
Except as otherwise provided in this section, if the approved claim is
not paid within that period, the insurer shall pay interest on the claim
at a rate of interest equal to the prime rate at the largest bank in
Nevada, as ascertained by the Commissioner of Financial Institutions, on
January 1 or July 1, as the case may be, immediately preceding the date
on which the payment was due, plus 6 percent. The interest must be
calculated from 30 days after the date on which the claim is approved
until the date on which the claim is paid.
2. If the insurer requires additional information to determine
whether to approve or deny the claim, it shall notify the claimant of its
request for the additional information within 20 days after it receives
the claim. The insurer shall notify the provider of health care of all
the specific reasons for the delay in approving or denying the claim. The
insurer shall approve or deny the claim within 30 days after receiving
the additional information. If the claim is approved, the insurer shall
pay the claim within 30 days after it receives the additional
information. If the approved claim is not paid within that period, the
insurer shall pay interest on the claim in the manner prescribed in
subsection 1.
3. An insurer shall not request a claimant to resubmit information
that the claimant has already provided to the insurer, unless the insurer
provides a legitimate reason for the request and the purpose of the
request is not to delay the payment of the claim, harass the claimant or
discourage the filing of claims.
4. An insurer shall not pay only part of a claim that has been
approved and is fully payable.
5. A court shall award costs and reasonable attorney’s fees to the
prevailing party in an action brought pursuant to this section.
6. The payment of interest provided for in this section for the
late payment of an approved claim may be waived only if the payment was
delayed because of an act of God or another cause beyond the control of
the insurer.
7. The Commissioner may require an insurer to provide evidence
which demonstrates that the insurer has substantially complied with the
requirements set forth in this section, including, without limitation,
payment within 30 days of at least 95 percent of approved claims or at
least 90 percent of the total dollar amount for approved claims.
8. If the Commissioner determines that an insurer is not in
substantial compliance with the requirements set forth in this section,
the Commissioner may require the insurer to pay an administrative fine in
an amount to be determined by the Commissioner. Upon a second or
subsequent determination that an insurer is not in substantial compliance
with the requirements set forth in this section, the Commissioner may
suspend or revoke the certificate of authority of the insurer.
(Added to NRS by 1991, 1328; A 1999, 1647 ; 2001, 2729 ; 2003, 3355 )
An insurer shall not
deny a claim, refuse to issue a policy of health insurance or cancel a
policy of health insurance solely because the claim involves an act that
constitutes domestic violence pursuant to NRS 33.018 , or because the person applying for or covered
by the health insurance policy was the victim of such an act of domestic
violence, regardless of whether the insured or applicant contributed to
any loss or injury.
(Added to NRS by 1997, 1095)
[Effective July 1, 2006.]
1. Except as otherwise provided in subsection 2, an insurer shall
not:
(a) Deny a claim under a policy of health insurance solely because
the claim involves an injury sustained by an insured as a consequence of
being intoxicated or under the influence of a controlled substance.
(b) Cancel a policy of health insurance solely because an insured
has made a claim involving an injury sustained by the insured as a
consequence of being intoxicated or under the influence of a controlled
substance.
(c) Refuse to issue a policy of health insurance to an eligible
applicant solely because the applicant has made a claim involving an
injury sustained by the applicant as a consequence of being intoxicated
or under the influence of a controlled substance.
2. The provisions of this section do not prohibit an insurer from
enforcing a provision included in a policy of health insurance pursuant
to NRS 689A.270 to:
(a) Deny a claim which involves an injury to which a contributing
cause was the insured’s commission of or attempt to commit a felony;
(b) Cancel a policy of health insurance solely because of such a
claim; or
(c) Refuse to issue a policy of health insurance to an eligible
applicant solely because of such a claim.
(Added to NRS by 2005, 2343 , effective July 1, 2006)
1. Except as otherwise provided in subsection 2, an insurer who
provides health insurance shall not:
(a) Require an insured person or any member of his family to take a
genetic test;
(b) Require an insured person to disclose whether he or any member
of his family has taken a genetic test or any genetic information of the
insured person or a member of his family; or
(c) Determine the rates or any other aspect of the coverage or
benefits for health care provided to an insured person based on:
(1) Whether the insured person or any member of his family
has taken a genetic test; or
(2) Any genetic information of the insured person or any
member of his family.
2. The provisions of this section do not apply to an insurer who
issues a policy of health insurance that provides coverage for long-term
care or disability income.
3. As used in this section:
(a) “Genetic information” means any information that is obtained
from a genetic test.
(b) “Genetic test” means a test, including a laboratory test that
uses deoxyribonucleic acid extracted from the cells of a person or a
diagnostic test, to determine the presence of abnormalities or
deficiencies, including carrier status, that:
(1) Are linked to physical or mental disorders or
impairments; or
(2) Indicate a susceptibility to illness, disease,
impairment or any other disorder, whether physical or mental.
(Added to NRS by 1997, 1459)
An insurer may, subject to
regulation by the Commissioner, offer a policy of health insurance that
has a high deductible and is in compliance with 26 U.S.C. § 223 for the
purposes of establishing a health savings account.
(Added to NRS by 2005, 2136 )
ELIGIBILITY FOR COVERAGE
As used in NRS 689A.420 to 689A.460 , inclusive, unless the context otherwise
requires:
1. “Medicaid” means a program established in any state pursuant to
Title XIX of the Social Security Act (42 U.S.C. §§ 1396 et seq.) to
provide assistance for part or all of the cost of medical care rendered
on behalf of indigent persons.
2. “Order for medical coverage” means an order of a court or
administrative tribunal to provide coverage under a policy of health
insurance to a child pursuant to the provisions of 42 U.S.C. § 1396g-1.
(Added to NRS by 1995, 2427)
1. An insurer shall not, when considering eligibility for coverage
or making payments under a policy of health insurance, consider the
availability of, or eligibility of a person for, medical assistance under
Medicaid.
2. To the extent that payment has been made by Medicaid for health
care, an insurer, group health plan as defined in section 607(1) of the
Employee Retirement Income Security Act of 1974 (29 U.S.C.A. § 1167(1)),
service benefit plan, health maintenance organization or other
organization that has issued a policy of health insurance:
(a) Shall treat Medicaid as having a valid and enforceable
assignment of an insured’s benefits regardless of any exclusion of
Medicaid or the absence of a written assignment; and
(b) May, as otherwise allowed by the policy, evidence of coverage
or contract and applicable law or regulation concerning subrogation, seek
to enforce any right of a recipient of Medicaid to reimbursement against
any other liable party if:
(1) It is so authorized pursuant to a contract with Medicaid
for managed care; or
(2) It has reimbursed Medicaid in full for the health care
provided by Medicaid to its insured.
3. If a state agency is assigned any rights of a person who is:
(a) Eligible for medical assistance under Medicaid; and
(b) Covered by a policy of health insurance,
Ê the insurer that issued the policy shall not impose any requirements
upon the state agency except requirements it imposes upon the agents or
assignees of other persons covered by the policy.
(Added to NRS by 1995, 2427)
An insurer shall
not deny the enrollment of a child pursuant to an order for medical
coverage, under a policy of health insurance pursuant to which a parent
of the child is insured, on the ground that the child:
1. Was born out of wedlock;
2. Has not been claimed as a dependent on the parent’s federal
income tax return; or
3. Does not reside with the parent or within the insurer’s
geographic area of service.
(Added to NRS by 1995, 2427)
If a child has coverage
under a policy of health insurance pursuant to which a noncustodial
parent of the child is insured, the insurer issuing that policy shall:
1. Provide to the custodial parent such information as necessary
for the child to obtain any benefits under that coverage.
2. Allow the custodial parent or, with the approval of the
custodial parent, a provider of health care to submit claims for covered
services without the approval of the noncustodial parent.
3. Make payments on claims submitted pursuant to subsection 2
directly to the custodial parent, the provider of health care or an
agency of this or another state responsible for the administration of
Medicaid.
(Added to NRS by 1995, 2428)
If a parent is required
by an order for medical coverage to provide coverage under a policy of
health insurance for a child and the parent is eligible for coverage of
members of his family under a policy of health insurance, the insurer
that issued the policy:
1. Shall, if the child is otherwise eligible for that coverage,
allow the parent to enroll the child in that coverage without regard to
any restrictions upon periods for enrollment.
2. Shall, if:
(a) The child is otherwise eligible for that coverage; and
(b) The parent is enrolled in that coverage but fails to apply for
enrollment of the child,
Ê enroll the child in that coverage upon application by the other parent
of the child, or by an agency of this or another state responsible for
the administration of Medicaid or a state program for the enforcement of
child support established pursuant to 42 U.S.C. §§ 651 et seq., without
regard to any restrictions upon periods for enrollment.
3. Shall not terminate the enrollment of the child in that
coverage or otherwise eliminate that coverage of the child unless the
insurer has written proof that:
(a) The order for medical coverage is no longer in effect; or
(b) The child is or will be enrolled in comparable coverage through
another insurer on or before the effective date of the termination of
enrollment or elimination of coverage.
(Added to NRS by 1995, 2428)
PORTABILITY AND ACCOUNTABILITY
General Provisions
As used in NRS 689A.470 to 689A.740 , inclusive, unless the context otherwise
requires, the words and terms defined in NRS 689A.475 to 689A.605 , inclusive, have the meanings ascribed to
them in those sections.
(Added to NRS by 1997, 2883; A 2001, 1922 ; 2005, 2136 )
“Affiliated” means any entity
or person who directly, or indirectly through one or more intermediaries,
controls or is controlled by or is under common control with a specified
entity or person.
(Added to NRS by 1997, 2883)
“Basic health
benefit plan” means the basic health benefit plan developed pursuant to
NRS 689C.610 to 689C.980 , inclusive.
(Added to NRS by 1997, 2883)
“Bona fide
association” means, with respect to health insurance coverage offered in
this state, an association that:
1. Has been actively in existence for at least 5 years;
2. Has been formed and maintained in good faith for purposes other
than obtaining insurance;
3. Does not condition membership in the association on any health
status-related factor relating to an individual, including an employee of
an employer or a dependent of an employee;
4. Makes health insurance coverage offered through the association
available to all of its members regardless of any health status-related
factors of the members or other individuals who are eligible for such
health insurance coverage through a member of the association;
5. Does not make health insurance coverage offered through the
association available other than in connection with a member of the
association; and
6. Meets such additional requirements as may be imposed by
specific statute.
(Added to NRS by 1997, 2883)
“Church plan” has the meaning
ascribed to it in section 3(33) of the Employee Retirement Income
Security Act of 1974, as that section existed on July 16, 1997.
(Added to NRS by 1997, 2884)
“Control” has the meaning
ascribed to it in NRS 692C.050 .
(Added to NRS by 1997, 2884)
“Converted policy” means
a basic or standard health benefit plan issued in accordance with NRS
689B.120 to 689B.210 , inclusive, and 689B.590 .
(Added to NRS by 1997, 2884; A 2001, 2219 )
“Creditable coverage”
means, with respect to a person, health benefits or coverage provided
pursuant to:
1. A group health plan;
2. A health benefit plan;
3. Part A or Part B of Title XVIII of the Social Security Act, 42
U.S.C. §§ 1395c et seq., also known as Medicare;
4. Title XIX of the Social Security Act, 42 U.S.C. §§ 1396 et
seq., also known as Medicaid, other than coverage consisting solely of
benefits under section 1928 of that Title, 42 U.S.C. § 1396s;
5. The Civilian Health and Medical Program of Uniformed Services,
CHAMPUS, 10 U.S.C. §§ 1071 et seq.;
6. A medical care program of the Indian Health Service or of a
tribal organization;
7. A state health benefit risk pool;
8. A health plan offered pursuant to the Federal Employees Health
Benefits Program, FEHBP, 5 U.S.C. §§ 8901 et seq.;
9. A public health plan as defined in 45 C.F.R. § 146.113,
authorized by the Public Health Service Act, 42 U.S.C. § 300gg(c)(1)(I);
10. A health benefit plan under section 5(e) of the Peace Corps
Act, 22 U.S.C. § 2504(e);
11. The Children’s Health Insurance Program established pursuant
to 42 U.S.C. §§ 1397aa to 1397jj, inclusive;
12. A short-term health insurance policy; or
13. A blanket student accident and health insurance policy.
(Added to NRS by 1997, 2884; A 1999, 2239 , 2802 )
“Dependent” has the meaning
ascribed to it in NRS 689C.055 .
(Added to NRS by 1997, 2884)
“Eligible person” means:
1. A person:
(a) Who, as of the date on which he seeks coverage pursuant to this
chapter, has an aggregate period of creditable coverage that is 18 months
or more;
(b) Whose most recent prior creditable coverage, other than
coverage under a short-term health insurance policy, was under a group
health plan, governmental plan, church plan or health insurance coverage
offered in connection with any such plan;
(c) Who is not eligible for coverage under a group health plan,
Part A or Part B of Title XVIII of the Social Security Act, 42 U.S.C. §§
1395c et seq., also known as Medicare, a state plan pursuant to Title XIX
of the Social Security Act, 42 U.S.C. §§ 1396 et seq., also known as
Medicaid, or any successor program, and who does not have any other
health insurance coverage;
(d) Whose most recent health insurance coverage within the period
of aggregate creditable coverage was not terminated because of a failure
to pay premiums or fraud;
(e) Who has exhausted his continuation of coverage under the
Consolidation Omnibus Budget Reconciliation Act of 1985, Public Law
99-272, or under a similar state program, if any; and
(f) Who has not had a break of more than 63 consecutive days in his
creditable coverage.
2. A person whose most recent prior creditable coverage was under
a basic or standard health benefit plan and was not renewed by a carrier
who discontinued offering and renewing individual health benefit plans in
this state pursuant to NRS 689A.630 .
3. Notwithstanding the provisions of paragraph (a) of subsection
1, a newborn child or a child placed for adoption, if the child was
enrolled timely and would have otherwise met the requirements of an
eligible person as set forth in subsection 1.
(Added to NRS by 1997, 2884; A 1999, 2803 )
“Established geographic service area” means a geographic area, as
approved by the Commissioner and based on the certificate of authority of
the carrier to transact insurance in this state, within which the carrier
is authorized to provide coverage.
(Added to NRS by 1997, 2885)
“Exclusion for a preexisting condition” means:
1. Any limitation or exclusion of benefits relating to a condition
that was present before the date coverage was first provided, regardless
of whether any medical advice, diagnosis, care or treatment was
recommended or received before that date; or
2. Any exclusion applicable to an individual based on any
information relating to the status of an individual’s health that was
obtained before the date coverage was first provided, including, without
limitation, any identification of a condition resulting from:
(a) A preenrollment questionnaire or physical examination provided
to the individual; or
(b) A review of any medical records relating to the period of
preenrollment.
(Added to NRS by 2005, 2136 )
“Geographic area” means
an area established by the Commissioner for use in adjusting the rates
for a health benefit plan.
(Added to NRS by 1997, 2885)
“Governmental plan” has
the meaning ascribed to it in section 3(32) of the Employee Retirement
Income Security Act of 1974, as that section existed on July 16, 1997,
and any health plan of the Federal Government.
(Added to NRS by 1997, 2885)
1. “Group health plan” means an employee welfare benefit plan, as
defined in section 3(1) of the Employee Retirement Income Security Act of
1974, as that section existed on July 16, 1997, to the extent that the
plan provides medical care to employees or their dependents as defined
under the terms of the plan directly, or through insurance, reimbursement
or otherwise.
2. The term does not include:
(a) Coverage that is only for accident or disability income
insurance, or any combination thereof;
(b) Coverage issued as a supplement to liability insurance;
(c) Liability insurance, including general liability insurance and
automobile liability insurance;
(d) Workers’ compensation or similar insurance;
(e) Coverage for medical payments under a policy of automobile
insurance;
(f) Credit insurance;
(g) Coverage for on-site medical clinics; and
(h) Other similar insurance coverage specified in federal
regulations adopted pursuant to Public Law 104-191 under which benefits
for medical care are secondary or incidental to other insurance benefits.
3. The term does not include the following benefits if the
benefits are provided under a separate policy, certificate or contract of
insurance or are otherwise not an integral part of a health benefit plan:
(a) Limited-scope dental or vision benefits;
(b) Benefits for long-term care, nursing home care, home health
care or community-based care, or any combination thereof; and
(c) Such other similar benefits as are specified in federal
regulations adopted pursuant to Public Law 104-191.
4. The term does not include the following benefits if the
benefits are provided under a separate policy, certificate or contract of
insurance, there is no coordination between the provision of the benefits
and any exclusion of benefits under any group health plan maintained by
the same plan sponsor, and such benefits are paid for a claim without
regard to whether benefits are provided for such a claim under any group
health plan maintained by the same plan sponsor:
(a) Coverage that is only for a specified disease or illness; and
(b) Hospital indemnity or other fixed indemnity insurance.
5. The term does not include any of the following, if offered as a
separate policy, certificate or contract of insurance:
(a) Medicare supplemental health insurance as defined in section
1882(g)(1) of the Social Security Act, as that section existed on July
16, 1997;
(b) Coverage supplemental to the coverage provided pursuant to
chapter 55 of Title 10, United States Code (Civilian Health and Medical
Program of Uniformed Services (CHAMPUS)); and
(c) Similar supplemental coverage provided under a group health
plan.
(Added to NRS by 1997, 2885)
1. “Health benefit plan” means a policy, contract, certificate or
agreement offered by a carrier to provide for, deliver payment for,
arrange for the payment of, pay for or reimburse any of the costs of
health care services. Except as otherwise provided in this section, the
term includes catastrophic health insurance policies and a policy that
pays on a cost-incurred basis.
2. The term does not include:
(a) Coverage that is only for accident or disability income
insurance, or any combination thereof;
(b) Coverage issued as a supplement to liability insurance;
(c) Liability insurance, including general liability insurance and
automobile liability insurance;
(d) Workers’ compensation or similar insurance;
(e) Coverage for medical payments under a policy of automobile
insurance;
(f) Credit insurance;
(g) Coverage for on-site medical clinics;
(h) Other similar insurance coverage specified in federal
regulations issued pursuant to Public Law 104-191 under which benefits
for medical care are secondary or incidental to other insurance benefits;
(i) Coverage under a short-term health insurance policy; and
(j) Coverage under a blanket student accident and health insurance
policy.
3. The term does not include the following benefits if the
benefits are provided under a separate policy, certificate or contract of
insurance or are otherwise not an integral part of a health benefit plan:
(a) Limited-scope dental or vision benefits;
(b) Benefits for long-term care, nursing home care, home health
care or community-based care, or any combination thereof; and
(c) Such other similar benefits as are specified in any federal
regulations adopted pursuant to the Health Insurance Portability and
Accountability Act of 1996, Public Law 104-191.
4. The term does not include the following benefits if the
benefits are provided under a separate policy, certificate or contract of
insurance, there is no coordination between the provision of the benefits
and any exclusion of benefits under any group health plan maintained by
the same plan sponsor, and the benefits are paid for a claim without
regard to whether benefits are provided for such a claim under any group
health plan maintained by the same plan sponsor:
(a) Coverage that is only for a specified disease or illness; and
(b) Hospital indemnity or other fixed indemnity insurance.
5. The term does not include any of the following, if offered as a
separate policy, certificate or contract of insurance:
(a) Medicare supplemental health insurance as defined in section
1882(g)(1) of the Social Security Act, 42 U.S.C. § 1395ss, as that
section existed on July 16, 1997;
(b) Coverage supplemental to the coverage provided pursuant to the
Civilian Health and Medical Program of Uniformed Services, CHAMPUS, 10
U.S.C. §§ 1071 et seq.; and
(c) Similar supplemental coverage provided under a group health
plan.
(Added to NRS by 1997, 2886; A 1999, 2803 )
“Health
status-related factor” means, with regard to a person who is or seeks to
be insured:
1. Health status;
2. Any medical conditions, including physical or mental illness,
or both;
3. Claims experience;
4. Receipt of health care;
5. Medical history;
6. Genetic information;
7. Evidence of insurability, including conditions arising out of
acts of domestic violence; and
8. Disability.
(Added to NRS by 1997, 2887)
“Individual carrier”
means any entity subject to the provisions of this title and the
regulations adopted pursuant thereto, that contracts or offers to
contract to provide for, deliver payment for, arrange for payment of, pay
for, or reimburse any cost of health care services, including a sickness
and accident health service corporation, and any other entity providing a
plan of health insurance, health benefits or health services to
individuals and their dependents in this state.
(Added to NRS by 1997, 2887)
“Individual health benefit plan” means:
1. A health benefit plan for individuals and their dependents,
other than a converted policy or a plan for coverage of a bona fide
association; and
2. A certificate issued to an individual that evidences coverage
under a policy or contract issued to a trust or an association or to any
other similar group of persons, other than a plan for coverage of a bona
fide association, regardless of the situs of delivery of the policy or
contract, if the individual pays the premium and is not being covered
under the policy or contract pursuant to any provision for the
continuation of benefits applicable under federal or state law.
(Added to NRS by 1997, 2887)
“Individual
reinsuring carrier” means an individual carrier that is eligible to
reinsure eligible persons in the Program of Reinsurance established
pursuant to NRS 689C.610 to 689C.980
, inclusive.
(Added to NRS by 1997, 2887)
“Individual risk-assuming carrier” means an individual carrier that has
elected to act as a risk-assuming carrier.
(Added to NRS by 1997, 2888)
“Plan for coverage of a bona fide association” means a health
benefit plan for the members, and their dependents, of a bona fide
association in this state regardless of the situs of delivery of the
policy or contract, if the health benefit plan conforms with NRS 689A.725
.
(Added to NRS by 1997, 2888)
“Plan of operation”
means the plan of operation of the Program of Reinsurance established
pursuant to NRS 689C.610 to 689C.980
, inclusive.
(Added to NRS by 1997, 2888)
“Plan sponsor” has the
meaning ascribed to it in section 3(16)(B) of the Employee Retirement
Security Act of 1974, as that section existed on July 16, 1997.
(Added to NRS by 1997, 2888)
“Preexisting
condition” means a condition, regardless of the cause of the condition,
for which medical advice, diagnosis, care or treatment was recommended or
received during the 6 months preceding the effective date of the new
coverage. The term does not include genetic information in the absence of
a diagnosis of the condition related to such information.
(Added to NRS by 1997, 2888)
“Producer” means an agent or
broker licensed pursuant to this Title.
(Added to NRS by 1997, 2888)
“Program of
Reinsurance” means the Program of Reinsurance for Small Employers and
Eligible Persons established pursuant to NRS 689C.740 .
(Added to NRS by 1997, 2888)
“Provision for a restricted network” means any provision of a health
benefit plan that conditions the payment of benefits, in whole or in
part, on the use of a provider of health care that has entered into a
contractual arrangement with an individual carrier to provide health care
services to individuals covered by the plan.
(Added to NRS by 1997, 2888)
“Standard
health benefit plan” means a standard health benefit plan developed
pursuant to NRS 689C.610 to 689C.980
, inclusive.
(Added to NRS by 1997, 2888)
1. NRS 689A.470 to 689A.740
, inclusive, apply to:
(a) Any health benefit plan that must be made available to eligible
persons; and
(b) Any certificate issued to a trust or an association or other
similar groupings of persons for coverage of eligible persons,
Ê regardless of the location of delivery of the policy or certificate, if
the eligible person pays the premium and is not otherwise covered under
the policy or contract pursuant to any federal or state law relating to
the continuation of benefits.
2. For the purposes of NRS 689A.470 to 689A.740 , inclusive, and except as otherwise provided
in subsection 3, two or more individual carriers which are affiliated
companies or which are eligible to file a consolidated tax return shall
be deemed to be one individual carrier, and any restriction or limitation
imposed by NRS 689A.470 to 689A.740
, inclusive, applies as if all health
benefit plans delivered or issued for delivery to eligible persons in
this State by the affiliated individual carriers were issued by one
individual carrier.
3. An affiliated individual carrier that is a health maintenance
organization having a certificate of authority issued pursuant to the
provisions of chapter 695C of NRS may be
considered a separate individual carrier for the purposes of NRS 689A.470
to 689A.740 , inclusive.
4. Unless otherwise authorized by the Commissioner, an individual
carrier shall not enter into any ceding arrangement with respect to a
health benefit plan delivered or issued for delivery to any eligible
person in this State if the ceding arrangement would result in the ceding
individual carrier retaining less than 30 percent of the insurance
obligations or risks for that health benefit plan.
(Added to NRS by 1997, 2888)
For the purposes of NRS 689A.470 to 689A.740 , inclusive:
1. Any plan, fund or program which would not be, but for section
2721(e) of the Public Health Service Act, as amended by Public Law
104-191, as that section existed on July 16, 1997, an employee welfare
benefit plan and which is established or maintained by a partnership to
the extent that the plan, fund or program provides medical care to
current or former partners in the partnership or to their dependents, as
defined under the terms of the plan, fund or program, directly or through
insurance, reimbursement or otherwise, must be treated, subject to
subsection 2, as an employee welfare benefit plan which is a group health
plan.
2. In the case of a group health plan, a partnership shall be
deemed to be the employer of each partner.
(Added to NRS by 1997, 2889)
A person who meets the requirements to be an eligible person as
set forth in NRS 689A.515 , except
that the person had a break in creditable coverage of more than 63 days,
shall be deemed to be an eligible person and is eligible to obtain health
insurance coverage pursuant to this chapter as an eligible person if the
person seeks that coverage between January 1, 1998, and January 31, 1998,
inclusive.
(Added to NRS by 1997, 2889)
Supplemental coverage is not a health benefit plan if:
1. On or before March 1 of each year, the individual carrier files
a certification with the Commissioner which contains:
(a) A statement from the individual carrier certifying that the
policies or certificates described are being offered and marketed as
supplemental health insurance and not as a substitute for hospital or
medical expense insurance or major medical expense insurance; and
(b) A summary description of each policy or certificate described,
including the average annual premium rates, or range of premium rates for
cases in which premiums vary by age, sex or other factors, charged for
the policies and certificates in this state.
2. In the case of a policy or certificate that is offered for the
first time in this state on or after January 1, 1998, the individual
carrier files with the Commissioner the statement and summary description
required by subsection 1 at least 30 days before the date on which the
policy or certificate is issued or delivered in this state.
(Added to NRS by 1997, 2890)
Individual Carriers
1. Except as otherwise provided in this section, coverage under an
individual health benefit plan must be renewed by the individual carrier
that issued the plan, at the option of the individual, unless:
(a) The individual has failed to pay premiums or contributions in
accordance with the terms of the health benefit plan or the individual
carrier has not received timely premium payments.
(b) The individual has performed an act or a practice that
constitutes fraud or has made an intentional misrepresentation of
material fact under the terms of the coverage.
(c) The individual carrier decides to discontinue offering and
renewing all health benefit plans delivered or issued for delivery in
this state. If the individual carrier decides to discontinue offering and
renewing such plans, the individual carrier shall:
(1) Provide notice of its intention to the Commissioner and
the chief regulatory officer for insurance in each state in which the
individual carrier is licensed to transact insurance at least 60 days
before the date on which notice of cancellation or nonrenewal is
delivered or mailed to the persons covered by the insurance to be
discontinued pursuant to subparagraph (2).
(2) Provide notice of its intention to all persons covered
by the discontinued insurance and to the Commissioner and the chief
regulatory officer for insurance in each state in which such a person is
known to reside. The notice must be made at least 180 days before the
nonrenewal of any health benefit plan by the individual carrier.
(3) Discontinue all health insurance issued or delivered for
issuance for individuals in this state and not renew coverage under any
health benefit plan issued to such individuals.
(d) The Commissioner finds that the continuation of the coverage in
this state by the individual carrier would not be in the best interests
of the policyholders or certificate holders of the individual carrier or
would impair the ability of the individual carrier to meet its
contractual obligations. If the Commissioner makes such a finding, the
Commissioner shall assist the persons covered by the discontinued
insurance in this state in finding replacement coverage.
2. An individual carrier may discontinue the issuance and renewal
of a form of a product of a health benefit plan if the Commissioner finds
that the form of the product offered by the individual carrier is
obsolete and is being replaced with comparable coverage. A form of a
product of a health benefit plan may be discontinued by the individual
carrier pursuant to this subsection only if:
(a) The individual carrier notifies the Commissioner and the chief
regulatory officer for insurance in each state in which it is licensed of
its decision pursuant to this subsection to discontinue the issuance and
renewal of the form of the product at least 60 days before the individual
carrier notifies the persons covered by the discontinued insurance
pursuant to paragraph (b).
(b) The individual carrier notifies each person covered by the
discontinued insurance, the Commissioner and the chief regulatory officer
for insurance in each state in which a person covered by the discontinued
insurance is known to reside of the decision of the individual carrier to
discontinue offering the form of the product. The notice must be made to
persons covered by the discontinued insurance at least 180 days before
the date on which the individual carrier will discontinue offering the
form of the product.
(c) The individual carrier offers to each person covered by the
discontinued insurance the option to purchase any other health benefit
plan currently offered by the individual carrier to individuals in this
state.
(d) In exercising the option to discontinue the form of the product
and in offering the option to purchase other coverage pursuant to
paragraph (c), the individual carrier acts uniformly without regard to
the claim experience of the persons covered by the discontinued insurance
or any health status-related factor relating to those persons or
beneficiaries covered by the discontinued form of the product or any
persons or beneficiaries who may become eligible for such coverage.
3. An individual carrier may discontinue the issuance and renewal
of a health benefit plan that is made available to individuals pursuant
to this chapter only through a bona fide association if:
(a) The membership of the individual in the association was the
basis for the provision of coverage;
(b) The membership of the individual in the association ceases; and
(c) The coverage is terminated pursuant to this subsection
uniformly without regard to any health status-related factor relating to
the covered individual.
4. An individual carrier that elects not to renew a health benefit
plan pursuant to paragraph (c) of subsection 1 shall not write new
business for individuals pursuant to this chapter for 5 years after the
date on which notice is provided to the Commissioner pursuant to
subparagraph (2) of paragraph (c) of subsection 1.
5. If an individual carrier does business in only one established
geographic service area of this state, the provisions of this section
apply only to the operations of the individual carrier in that service
area.
(Added to NRS by 1997, 2890)
1. An individual carrier that offers coverage through a network
plan is not required pursuant to NRS 689A.630 to offer coverage to or accept an
application from an eligible person if the eligible person does not
reside or work in the established geographic service area or in a
geographic area for which the individual carrier is authorized to
transact insurance, provided that the coverage is refused or terminated
uniformly without regard to any health status-related factor of any
eligible person.
2. As used in this section, “network plan” means a health benefit
plan offered by a health carrier under which the financing and delivery
of medical care is provided, in whole or in part, through a defined set
of providers under contract with the carrier. The term does not include
an arrangement for the financing of premiums.
(Added to NRS by 1997, 2892)
1. An individual carrier that offers a health benefit plan that
includes a provision for a restricted network shall use its best efforts
to contract with at least one health center in each established
geographic service area to provide health care services to persons
covered by the plan if the health center:
(a) Meets all conditions imposed by the carrier on similarly
situated providers of health care with which the carrier contracts,
including, without limitation:
(1) Certification for participation in the Medicaid or
Medicare program; and
(2) Requirements relating to the appropriate credentials for
providers of health care; and
(b) Agrees to reasonable reimbursement rates that are generally
consistent with those offered by the carrier to similarly situated
providers of health care with which the carrier contracts.
2. As used in this section, “health center” has the meaning
ascribed to it in 42 U.S.C. § 254b.
(Added to NRS by 2001, 1922 )
1. As a condition of transacting insurance in this State with
individuals, an individual carrier must actively market to eligible
persons each health benefit plan that is actively marketed in this State
by the individual carrier to any individual in this State. The health
insurance plans marketed pursuant to this section by an individual
carrier must include, without limitation, a basic health benefit plan and
a standard health benefit plan.
2. An individual carrier shall issue to an eligible person any
basic or standard individual health benefit plan that it markets in
accordance with subsection 1 if the eligible person applies for the plan
and agrees to make the required premium payments and satisfy the other
reasonable provisions of the health benefit plan that are not
inconsistent with NRS 689A.470 to
689A.740 , inclusive.
(Added to NRS by 1997, 2892)
An individual carrier is not required pursuant to
NRS 689A.640 to offer coverage to or
accept an application for coverage:
1. From an eligible person if he does not reside in the
established geographic service area of the individual carrier.
2. Within an area where the individual carrier reasonably
anticipates, and demonstrates to the satisfaction of the Commissioner,
that the individual carrier does not have the capacity within its
established geographic service area to deliver adequate service to
additional eligible persons because of its obligations to existing
policyholders. If an individual carrier is authorized by the Commissioner
not to offer coverage pursuant to this subsection, the individual carrier
shall not thereafter offer coverage in the applicable area to additional
eligible persons until the individual carrier demonstrates to the
satisfaction of the Commissioner that it has regained the capacity to
deliver adequate service to additional eligible persons in that service
area.
(Added to NRS by 1997, 2893)
1. An individual carrier is not required to provide coverage to
eligible persons pursuant to NRS 689A.640 :
(a) During any period in which the Commissioner determines that
requiring the individual carrier to provide such coverage would place the
individual carrier in a financially impaired condition.
(b) If the individual carrier elects not to offer any new coverage
to any persons in this State. An individual carrier that elects not to
offer new coverage in accordance with this paragraph may maintain its
existing policies issued to persons in this State, subject to the
requirements of NRS 689A.630 .
2. An individual carrier that elects not to offer new coverage
pursuant to paragraph (b) of subsection 1 shall notify the Commissioner
forthwith of that election and shall not thereafter write any new
business to individuals in this State for 5 years after the date of the
notification.
(Added to NRS by 1997, 2893; A 1999, 2805 )
1. Each individual carrier shall file with the Commissioner within
90 days after the date on which a basic health benefit plan and a
standard health benefit plan are approved pursuant to NRS 689C.770 , or for a new individual carrier within 90
days after the date it enters the individual market in this State, in a
format and manner prescribed by the Commissioner, the basic health
benefit plans and the standard health benefit plans to be offered by the
individual carrier. A health benefit plan filed pursuant to this section
may not be offered by an individual carrier until the earlier of:
(a) The date of approval by the Commissioner; or
(b) Thirty days after the date on which the plans are filed, unless
the Commissioner disapproves the use of the plans before the 30-day
period expires.
2. The Commissioner may, at any time, after providing notice and
an opportunity for a hearing, disapprove the continued use of a basic or
standard health benefit plan by the individual carrier on the ground that
the plan does not meet the requirements of NRS 689A.470 to 689A.740 , inclusive, and 689C.610 to 689C.980 , inclusive.
(Added to NRS by 1997, 2892)
An individual carrier shall not:
1. Impose on an eligible person who is covered under a basic or
standard health benefit plan any exclusion because of a preexisting
condition.
2. Modify a health benefit plan, with respect to an eligible
person, through riders, endorsements or otherwise, to restrict or exclude
services otherwise covered by the plan.
(Added to NRS by 1997, 2893; A 1999, 2805 )
Nothing in NRS 689A.640
to 689A.660 , inclusive, requires a health carrier that
offers a health benefit plan only in connection with a group health plan
or through a bona fide association, or both, to offer such health benefit
insurance coverage to individuals.
(Added to NRS by 1997, 2893)
1. Within 30 days after the date on which a plan of operation is
approved by the Commissioner pursuant to NRS 689C.770 , or for a new carrier within 30 days after
the date on which it enters the individual market in this state, an
individual carrier shall elect to operate as either an individual
risk-assuming carrier or an individual reinsuring carrier and shall
notify the Commissioner of its election.
2. The initial election of an individual carrier to act as an
individual risk-assuming or reinsuring carrier is effective on the
individual carrier for 2 years after the date on which it notifies the
Commissioner pursuant to subsection 1. After the initial 2-year period,
such an election is effective for 5 years. The Commissioner may allow an
individual carrier to modify its election at any time for good cause
shown. The Commissioner may waive or modify the period during which the
election of a carrier to operate as an individual risk-assuming or
reinsuring carrier is effective.
3. An individual carrier may apply to the Commissioner, in a
manner prescribed by the Commissioner by regulation, to change its status
as an individual risk-assuming or reinsuring carrier.
4. An individual reinsuring carrier that elects or is subsequently
authorized by the Commissioner to operate as a risk-assuming carrier:
(a) Shall not continue to reinsure any individual health benefit
plan with the Program of Reinsurance.
(b) Shall pay a prorated assessment based upon business issued as
an individual reinsuring carrier for any portion of the year that the
business was reinsured.
(Added to NRS by 1997, 2893)
1. The Commissioner may suspend the election of an individual
carrier to act as an individual risk-assuming carrier, if the
Commissioner finds that:
(a) The financial condition of the individual carrier no longer
supports the assumption of risk from issuing coverage to eligible persons
in compliance with NRS 689A.640 to
689A.660 , inclusive, without the
protection afforded by the Program of Reinsurance;
(b) The individual carrier has failed to market its health benefit
plans fairly to all eligible persons in this state or in its established
geographic service area, as applicable; or
(c) The individual carrier has failed to provide coverage to
eligible persons as required pursuant to NRS 689A.640 to 689A.660 , inclusive.
2. An individual carrier that elects to become an individual
risk-assuming carrier is subject to:
(a) The provisions of NRS 689A.640 to 689A.660 , inclusive, relating to the availability of
coverage; and
(b) The provisions of NRS 689A.680 to 689A.700 , inclusive, relating to premium rates.
(Added to NRS by 1997, 2894)
1. An individual carrier shall develop its rates for its
individual health benefit plans pursuant to NRS 689A.470 to 689A.740 , inclusive, based on rating characteristics.
After any adjustments for rating characteristics and design of benefits,
the rate for any block of business for an individual health benefit plan
written on or after January 1, 2000, must not exceed the rate for any
other block of business for an individual health benefit plan offered by
the individual carrier by more than 50 percent. The rate for a block of
business is equal to the average rate charged to all the insureds in the
block of business. In determining whether the rate of a block of business
complies with the provisions of this subsection, any differences in
rating factors between blocks of business must be considered.
2. In determining the rating factors to establish premium rates
for a health benefit plan, an individual carrier shall not use
characteristics other than age, sex, occupation, geographic area,
composition of the family of the individual and health status.
3. If an individual carrier uses health status as a rating factor
in establishing premium rates, the highest factor associated with any
classification for health status may not exceed the lowest factor by more
than 75 percent.
4. For the purposes of this section, rating characteristics must
not include durational or tier rating, or adverse changes in health
status or claim experience after the policy is issued.
5. As used in this section, “characteristics” means demographic or
other information concerning individuals that is considered by a carrier
in the determination of premium rates for individuals.
(Added to NRS by 1997, 2894; A 1999, 2805 )
1. The amount of change in the rate of a single block of business
of an individual carrier in any 12-month period because of claims
experience or health status-related factors of that block of business,
after adjustment for allowed rating characteristics and design of
benefits, must not exceed the amount of any similar change in the rate of
any other block of business of that individual carrier during the same
period by more than 15 percent.
2. For the purposes of NRS 689A.470 to 689A.740 , inclusive, a health benefit plan that
contains a provision for a restricted network must not be considered to
be a similar design of benefits when compared to a health benefit plan
that does not contain such a provision if the restriction of benefits to
the network providers results in substantial differences in the cost of
claims.
3. An individual carrier shall not transfer an individual or his
dependent covered by an individual health benefit plan issued by the
individual carrier involuntarily into or out of a block of business.
4. If an individual carrier adjusts its premiums for a block of
business to a level that is higher than permitted by requirements
relating to the ratio of losses, as set forth in this Title and the
regulations adopted pursuant thereto, to comply with this section and NRS
689A.680 , the individual carrier
shall make such adjustments on its entire individual health benefit plan
business as needed to meet those requirements.
(Added to NRS by 1997, 2895)
1. As part of its solicitation and sales materials for an
individual health benefit plan, an individual carrier shall disclose, to
the extent reasonable:
(a) The extent to which premium rates for an individual and his
dependent are established or adjusted based upon rating characteristics;
(b) The right of the individual carrier to change premium rates and
the factors, other than claims experience, that may affect changes in
premium rates;
(c) Any provisions in the individual health benefit plan relating
to the renewability of the plan; and
(d) Any provisions in the individual health benefit plan relating
to an exclusion for a preexisting condition.
2. For the purposes of this section, an individual carrier shall
maintain at its principal place of business a complete and detailed
description of its rating practices and underwriting practices, including
information and documentation that demonstrate that its rating methods
and practices are based upon commonly accepted actuarial assumptions and
are in accordance with sound actuarial principles.
3. On or before March 1 of each year, an individual carrier shall
file with the Commissioner an actuarial certification that the individual
carrier is in compliance with NRS 689A.680 to 689A.700 , inclusive, and that the rating methods of
the individual carrier are actuarially sound. The certification must be
in such a form and must contain such information as specified by the
Commissioner. A copy of the certification must be retained by the
individual carrier at its principal place of business.
4. As used in this section, “actuarial certification” means a
written statement signed by a member of the American Academy of Actuaries
or any other person acceptable to the Commissioner that an individual
carrier is in compliance with the provisions of NRS 689A.680 to 689A.700 , inclusive, based upon an examination
conducted by the person which included a review of the appropriate
records and the actuarial assumptions and methods used by the individual
carrier in establishing premium rates for applicable health benefit plans.
(Added to NRS by 1997, 2895)
An individual carrier shall make
the information and documents described in NRS 689A.680 to 689A.700 , inclusive, available to the Commissioner
upon request. Except in cases of violations of the provisions of this
chapter, the information, other than the premium rates charged by the
individual carrier, is proprietary, constitutes a trade secret and is not
subject to disclosure by the Commissioner to persons outside of the
Division except as agreed to by the individual carrier or as ordered by a
court of competent jurisdiction.
(Added to NRS by 1997, 2896)
The Commissioner may
adopt regulations to carry out the provisions of NRS 689A.680 to 689A.700 , inclusive, and to ensure that the practices
used by individual carriers relating to the establishment of rates are
consistent with the purposes of NRS 689A.470 to 689A.740 , inclusive, including, but not limited to,
determining the manner in which geographic areas are designated by all
individual carriers.
(Added to NRS by 1997, 2895)
The Commissioner may adopt regulations to require an individual
carrier, as a condition of transacting business with individuals in this
state after July 16, 1997, to reissue a health benefit plan to any
individual whose health benefit plan has been terminated or not renewed
by the individual carrier after July 1, 1997. The Commissioner may
prescribe such terms for the reissue of coverage as he finds are
reasonable and necessary to provide continuity of coverage to individuals.
(Added to NRS by 1997, 2897)
1. Except as otherwise provided in this section, an individual
carrier or a producer shall not, directly or indirectly:
(a) Encourage or direct an eligible person to refrain from filing
an application for coverage with an individual carrier because of the
health status, claims experience, industry, occupation or geographic
location of the eligible person.
(b) Encourage or direct an eligible person to seek coverage from
another carrier because of the health status, claims experience,
industry, occupation or geographic location of the eligible person.
2. The provisions of subsection 1 do not apply to information
provided to an eligible person by an individual carrier or a producer
relating to the established geographic service area or a provision for a
restricted network of the individual carrier.
3. Except as otherwise provided in this subsection, an individual
carrier shall not, directly or indirectly, enter into any contract,
agreement or arrangement with a producer if the contract, agreement or
arrangement provides for or results in a variation to the compensation
paid to a producer for the sale of a health benefit plan because of the
health status, claims experience, industry, occupation or geographic
location of the individual at the time that the health benefit plan is
issued to or renewed by the individual. The provisions of this subsection
do not apply to any arrangement for compensation that provides payment to
a producer on the basis of a percentage of premiums, except that the
percentage may not vary because of the health status, claims experience,
industry, occupation or geographic area of the individual.
4. An individual carrier shall not terminate, fail to renew, or
limit its contract or agreement of representation with a producer for any
reason related to the health status, claims experience, industry,
occupation or geographic location of an individual at the time that the
health benefit plan is issued to or renewed by the individual placed by
the producer with the individual carrier.
5. A denial by an individual carrier of an application for
coverage from an eligible person must be in writing and must state the
reason for the denial.
6. The Commissioner may adopt regulations that set forth
additional standards to provide for the fair marketing and broad
availability of health benefit plans to eligible persons in this state.
7. A violation of any provision of this section by an individual
carrier may constitute an unfair trade practice for the purposes of
chapter 686A of NRS.
8. The provisions of this section apply to a third-party
administrator if the third-party administrator enters into a contract,
agreement or other arrangement with an individual carrier to provide
administrative, marketing or other services related to the offering of a
health benefit plan to eligible persons in this state.
9. Nothing in this section interferes with the right and
responsibility of a broker to advise and represent the best interests of
an eligible person who is seeking health insurance coverage from an
individual carrier.
(Added to NRS by 1997, 2896)
Individual Health Insurance Coverage
1. An employee welfare benefit plan for providing benefits for
employees of more than one employer under which individual health
insurance coverage is provided must comply with the provisions of NRS
679B.139 and 689A.470 to 689A.740 , inclusive, and the regulations adopted by
the Commissioner pursuant thereto.
2. As used in this section, the term “employee welfare benefit
plan for providing benefits for employees of more than one employer” is
intended to be equivalent to the term “employee welfare benefit plan
which is a multiple employer welfare arrangement” as used in federal
statutes and regulations.
(Added to NRS by 1997, 2890)
1. To determine the period of creditable coverage of a person, a
health insurance issuer offering individual health insurance coverage
shall provide written certification of coverage on a form prescribed by
the Commissioner to the person that certifies:
(a) The period of creditable coverage of the person under the
individual health insurance coverage; and
(b) The date that a substantially completed application was
received by the health insurance issuer from the person for individual
health insurance coverage.
2. The certification of coverage must be provided to the insured:
(a) At the time that the insured ceases to be covered under the
individual health insurance coverage or otherwise becomes covered under
any provision of the Consolidated Omnibus Budget Reconciliation Act of
1985, as that act existed on July 16, 1997, relating to the continuation
of coverage;
(b) If the insured becomes covered under such a provision, at the
time that the insured ceases to be covered by that provision; and
(c) Upon the request of the insured, if the request is made not
later than 24 months after the date on which the insured ceased to be
covered as described in paragraphs (a) and (b).
(Added to NRS by 1997, 2897)
Bona Fide Associations
For the purposes
of NRS 689A.470 to 689A.740 , inclusive, a plan for coverage of a bona
fide association must:
1. Conform with NRS 689A.680
to 689A.700 , inclusive, concerning
rates.
2. Provide for the renewability of coverage for members of the
bona fide association, and their dependents, if such coverage meets the
criteria set forth in NRS 689A.630 .
3. Provide for the availability of coverage for members of the
bona fide association, and their dependents, if such coverage conforms
with NRS 689A.640 , except that the
bona fide association is not required to offer basic and standard health
benefit plan coverage to its members or their dependents.
4. Conform with subsection 1 of NRS 689A.660 , relating to preexisting conditions.
(Added to NRS by 1997, 2889)
For
the purposes of providing coverage under a health benefit plan pursuant
to the provisions of NRS 689A.470 to
689A.740 , inclusive, a producer may
only market association memberships to eligible persons, accept
applications for such membership, or sign up such members in a bona fide
association if the eligible persons being marketed are actively engaged
in, or directly related to, the bona fide association.
(Added to NRS by 1997, 2889)
Miscellaneous Provisions
On or before July 1 of each year, a trustee of a medical
savings account established and maintained in accordance with 26 U.S.C. §
220 shall report to the Commissioner the number of medical savings
accounts administered by the trustee during the previous calendar year.
(Added to NRS by 1997, 2899)
The Commissioner shall adopt
regulations as necessary to carry out the provisions of NRS 689A.470
to 689A.740 , inclusive.
(Added to NRS by 1997, 2896)
SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS
1. Except as otherwise provided in subsection 4, each insurer that
issues a policy of health insurance in this State shall establish a
system for resolving any complaints of an insured concerning health care
services covered under the policy. The system must be approved by the
Commissioner in consultation with the State Board of Health.
2. A system for resolving complaints established pursuant to
subsection 1 must include an initial investigation, a review of the
complaint by a review board and a procedure for appealing a determination
regarding the complaint. The majority of the members on a review board
must be insureds who receive health care services pursuant to a policy of
health insurance issued by the insurer.
3. The Commissioner or the State Board of Health may examine the
system for resolving complaints established pursuant to subsection 1 at
such times as either deems necessary or appropriate.
4. Each insurer that issues a policy of health insurance in this
State that provides, delivers, arranges for, pays for or reimburses any
cost of health care services through managed care shall provide a system
for resolving any complaints of an insured concerning those health care
services that complies with the provisions of NRS 695G.200 to 695G.310 , inclusive.
(Added to NRS by 1997, 307; A 2003, 774 )
1. Each insurer that issues a policy of health insurance in this
State shall submit to the Commissioner and the State Board of Health an
annual report regarding its system for resolving complaints established
pursuant to subsection 1 of NRS 689A.745 on a form prescribed by the Commissioner in
consultation with the State Board of Health which includes, without
limitation:
(a) A description of the procedures used for resolving any
complaints of an insured;
(b) The total number of complaints and appeals handled through the
system for resolving complaints since the last report and a compilation
of the causes underlying the complaints filed;
(c) The current status of each complaint and appeal filed; and
(d) The average amount of time that was needed to resolve a
complaint and an appeal, if any.
2. Each insurer shall maintain records of complaints filed with it
which concern something other than health care services and shall submit
to the Commissioner a report summarizing such complaints at such times
and in such format as the Commissioner may require.
(Added to NRS by 1997, 308; A 2003, 774 )
1. Following approval by the Commissioner, each insurer that
issues a policy of health insurance in this State shall provide written
notice to an insured, in clear and comprehensible language that is
understandable to an ordinary layperson, explaining the right of the
insured to file a written complaint. Such notice must be provided to an
insured:
(a) At the time he receives his evidence of coverage;
(b) Any time that the insurer denies coverage of a health care
service or limits coverage of a health care service to an insured; and
(c) Any other time deemed necessary by the Commissioner.
2. Any time that an insurer denies coverage of a health care
service to an insured, including, without limitation, denying a claim
relating to a policy of health insurance pursuant to NRS 689A.410 , it shall notify the insured in writing
within 10 working days after it denies coverage of the health care
service of:
(a) The reason for denying coverage of the service;
(b) The criteria by which the insurer determines whether to
authorize or deny coverage of the health care service; and
(c) His right to file a written complaint and the procedure for
filing such a complaint.
3. A written notice which is approved by the Commissioner shall be
deemed to be in clear and comprehensible language that is understandable
to an ordinary layperson.
(Added to NRS by 1997, 308; A 1999, 3082 )
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