1. An organization seeking to be registered as a voluntary
purchasing group:
(a) Must be incorporated as a Nevada corporation not for profit for
the purpose of securing health benefits for its members and their
eligible employees and dependents;
(b) Shall file articles of incorporation with the Secretary of
State and provide a copy of the articles to the Commissioner in such a
form as the Commissioner may require; and
(c) Must apply to the Commissioner for and obtain a certificate of
registration to operate as a voluntary purchasing group.
2. The contents of the application must be established by the
Commissioner and include at least:
(a) The name of the voluntary purchasing group and any agent for
service of process;
(b) Provisions to govern the business and affairs of the group,
including the management and organizational structure;
(c) An affidavit by an officer of the organization that the group
is in compliance with the requirements of NRS 689C.490 to 689C.600 , inclusive; and
(d) The names of managing personnel of the voluntary purchasing
group.
(Added to NRS by 1995, 2680)
1. The application must be accompanied by a fee in an amount to be
established by the Commissioner by regulation to cover the direct costs
of examining the qualifications of an applicant.
2. The Commissioner shall respond to each application for a
certificate of registration within 30 days after receipt. The
Commissioner shall either approve the application or shall inform the
organization of specific changes to the application necessary to permit
approval.
(Added to NRS by 1995, 2680)
1. Before the issuance of a certificate of registration, each
voluntary purchasing group shall, to the satisfaction of the Commissioner:
(a) Establish the conditions of membership in the group and require
as a condition of membership that all employers include all their
eligible employees. The group may not differentiate among classes of
membership on the basis of the kind of employment, race, religion, sex,
education, health or income. The group shall set reasonable fees for
membership which will finance all reasonable and necessary costs incurred
in administering the group.
(b) Provide to members of the group and their eligible employees
information meeting the requirements of NRS 689C.440 regarding any proposed contracts.
2. In addition to the information required pursuant to subsection
1, a voluntary purchasing group shall provide annually to members of the
group information regarding available benefits and carriers.
(Added to NRS by 1995, 2680)
A voluntary
purchasing group shall:
1. File any reports required by the Commissioner; and
2. Pay a renewal fee established by the Commissioner by regulation
to recover the direct costs to the Division to determine annually that a
voluntary purchasing group is in compliance with NRS 689C.490 to 689C.600 , inclusive.
(Added to NRS by 1995, 2680)
A voluntary purchasing group shall:
1. Establish administrative and accounting procedures for the
operation of the group and the provision of services to members, prepare
an annual budget and annual operational fiscal reports;
2. Provide for internal and independent audits; and
3. Maintain all records, reports and other information of the
group and may contract with qualified third-party administrators,
licensed insurance agents or brokers as needed.
(Added to NRS by 1995, 2681)
A voluntary purchasing group shall offer to collect premiums
for contracts offered through the purchasing group and maintain a trust
account for the deposit of premiums collected to be paid to carriers for
coverage offered through the purchasing group. A voluntary purchasing
group is a fiduciary with respect to any premiums so collected.
(Added to NRS by 1995, 2681)
A voluntary purchasing group shall post a
bond for the benefit of members of the group and their eligible employees
and dependents, or deposit a certificate of deposit or securities, in
such a manner and amount as the Commissioner establishes by regulation.
(Added to NRS by 1995, 2681)
No person who organizes a voluntary
purchasing group may acquire or attempt to acquire a financial interest
in the group’s business for a period of 3 years after organization of the
group.
(Added to NRS by 1995, 2681)
A voluntary purchasing group shall
not perform any activity included in the definition of transacting
insurance in this state as defined in NRS 679A.130 , perform any activity for which it is
subject to regulation pursuant to NRS 685B.120 or establish or otherwise engage in the
activities of a health maintenance organization as provided in chapter
695C of NRS.
(Added to NRS by 1995, 2681)
The
Commissioner may deny, revoke or suspend a certificate of registration of
any voluntary purchasing group found to be in violation of NRS 689C.490
to 689C.600 , inclusive.
(Added to NRS by 1995, 2681)
The Commissioner shall adopt such
regulations as are needed to carry out the requirements of NRS 689C.490
to 689C.600 , inclusive.
(Added to NRS by 1995, 2681)
REINSURANCE
General Provisions
As used in NRS 689C.610 to 689C.980 , inclusive, unless the context otherwise
requires, the words and terms defined in NRS 689C.620 to 689C.730 , inclusive, have the meanings ascribed to
them in those sections.
(Added to NRS by 1997, 2929; A 1999, 2814 )
“Board” means the Board of
Directors of the Program of Reinsurance established pursuant to NRS
689C.750 .
(Added to NRS by 1997, 2929)
“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, 2929)
“Committee” means the Committee
on Health Benefit Plans that is created pursuant to NRS 689C.960 .
(Added to NRS by 1997, 2929)
“Eligible person” has the
meaning ascribed to it in NRS 689A.515 .
(Added to NRS by 1997, 2929)
“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, 2929)
“Individual health benefit plan” means:
1. A health benefit plan, other than a converted policy or a plan
for coverage of a bona fide association, for individuals and their
dependents; and
2. A certificate issued to an individual that evidences coverage
under a policy or contract issued to a trust, an association or 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 eligible person 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, 2929)
“Individual
reinsuring carrier” means an individual carrier that has elected to
reinsure eligible persons in the Program of Reinsurance.
(Added to NRS by 1997, 2929)
“Individual risk-assuming carrier” means an individual carrier that has
elected to act as a risk-assuming carrier.
(Added to NRS by 1997, 2929)
“Plan of operation”
means the plan of operation of the Program of Reinsurance.
(Added to NRS by 1997, 2929)
“Program of
Reinsurance” means the Program of Reinsurance for Small Employers and
Eligible Persons created pursuant to NRS 689C.740 .
(Added to NRS by 1997, 2929)
“Reinsuring carrier”
means a small employer carrier participating in the Program of
Reinsurance.
(Added to NRS by 1997, 2929)
“Risk-assuming
carrier” means a small employer carrier that has elected to act as a
risk-assuming carrier.
(Added to NRS by 1997, 2930)
Program of Reinsurance for Small Employers and Eligible Persons
There is hereby created a nonprofit entity
to be known as the Program of Reinsurance for Small Employers and
Eligible Persons.
(Added to NRS by 1997, 2930)
1. The Board of Directors of the Program of Reinsurance is hereby
created. The Board consists of:
(a) Eight members to be appointed by the Commissioner as follows:
(1) Six persons who represent carriers that provide health
insurance coverage to small employers pursuant to the provisions of this
chapter or to individuals pursuant to chapter 689A of NRS, or to both small employers and
individuals; and
(2) Two persons who represent small employers and eligible
persons; and
(b) The Commissioner, or his designated representative, who is an
ex officio, nonvoting member of the Board.
2. Members of the Board serve without compensation except that,
while engaged in the business of the Board, each member is entitled to
receive the per diem allowance or travel expenses provided for state
officers and employees generally, to be paid from the proceeds of the
assessments received by the Program of Reinsurance as an administrative
expense of the Program of Reinsurance.
3. After the initial term, the term of each appointed member is 3
years. Members may be reappointed. A member may be removed from the Board
by the Commissioner for good cause shown.
4. At the expiration of the term of a member of the Board, or if
the member resigns or is otherwise unable to complete his term, the
Commissioner shall appoint a replacement not later than 30 days after the
vacancy occurs. All vacancies on the Board must be filled in the same
manner of appointment as the member who created the vacancy.
(Added to NRS by 1997, 2930)
1. The Board shall meet:
(a) Until a plan of operation, other than a temporary plan of
operation, has been approved by the Commissioner, twice a year;
(b) Once a plan of operation has been so approved, once a year; and
(c) At such other times as the Commissioner deems necessary.
2. The Board shall elect from its membership a Chairman who shall
serve for a term of 2 years. Any vacancy occurring in this position must
be filled by election of the members of the Board for the remainder of
the unexpired term.
(Added to NRS by 1997, 2930)
1. Not later than 120 days after the initial appointment of the
Board, the Board shall submit to the Commissioner a plan of operation
that ensures the fair, reasonable and equitable administration of the
Program of Reinsurance. Once a plan of operation has been approved by the
Commissioner, the Board may amend the plan of operation as needed,
subject to the approval of the Commissioner.
2. The Commissioner shall, after notice and a hearing, approve a
plan of operation and any amendment to the plan of operation submitted
for his approval if he determines that the plan or amendment is suitable
to:
(a) Ensure the fair, reasonable and equitable administration of the
Program of Reinsurance; and
(b) Provide for the sharing of the gains and losses of the Program
of Reinsurance on an equitable basis in accordance with the provisions of
NRS 689C.610 to 689C.980 , inclusive.
3. If the Board fails to submit a suitable plan of operation
within 120 days after its appointment or if the Commissioner determines
in accordance with subsection 2 that the plan of operation as submitted
is not suitable, the Commissioner may, after notice and a hearing, adopt
and carry out a temporary plan of operation which is effective only until
the approval of a plan of operation submitted by the Board.
4. Before approving a plan of operation submitted by the Board,
the Commissioner may amend the plan if he determines that such an
amendment is necessary to ensure that the plan is suitable pursuant to
subsection 2.
5. A plan of operation becomes effective upon the written approval
of the Commissioner.
(Added to NRS by 1997, 2930)
A plan of operation and a temporary plan of operation must:
1. Establish procedures for the handling and accounting of the
assets of the Program of Reinsurance and for an annual fiscal reporting
to the Commissioner.
2. Establish procedures for selecting an administering carrier and
set forth the powers and duties of the administering carrier.
3. Establish procedures for reinsuring risks pursuant to the
Program of Reinsurance.
4. Establish procedures for collecting assessments to pay claims
and administrative expenses incurred or estimated to be incurred by the
Program of Reinsurance.
5. Establish a methodology for applying the minimum amount of
claims and the maximum liability of the reinsuring or individual
reinsuring carrier as set forth in NRS 689C.800 .
6. Provide for any additional matters necessary to carry out and
administer the Program of Reinsurance.
(Added to NRS by 1997, 2931)
Notwithstanding any provision of this title to the contrary, the
Program of Reinsurance shall be deemed to have the general powers and
authority granted under the laws of this state to insurance companies and
health maintenance organizations licensed to transact business in this
state, except that the Program of Reinsurance shall not issue any health
benefit plans directly to small employers or individuals, or both. The
Program of Reinsurance may:
1. With the approval of the Commissioner, enter into such
contracts as are necessary to carry out the provisions of this chapter
and NRS 689A.470 to 689A.740 , inclusive, including entering into
contracts with similar programs of reinsurance of other states for the
joint performance of common functions, or with persons or other
organizations for the performance of administrative functions, relating
to programs of reinsurance.
2. Take any legal action necessary or proper to recover
assessments and penalties for or on behalf of the Program of Reinsurance,
or to avoid the payment of improper claims against the Program of
Reinsurance.
3. Sue or be sued by a reinsuring carrier or an individual
reinsuring carrier relating to the carrier’s participation in the Program
of Reinsurance.
4. Define the health benefit plans for which reinsurance will be
provided and issue reinsurance policies, in accordance with the
requirements of this chapter and NRS 689A.470 to 689A.740 , inclusive.
5. Establish rules, conditions and procedures for reinsuring risks
under the Program of Reinsurance.
6. Establish actuarial functions as appropriate for the operation
of the Program of Reinsurance.
7. Make assessments in accordance with the provisions of NRS
689C.840 , 689C.850 and 689C.870 and make advance interim assessments as may
be reasonable and necessary to pay for any organizational and interim
operating expenses. Any interim assessment must be credited as an offset
against any assessments due after the close of the fiscal year.
8. Appoint appropriate legal, actuarial and other committees as
necessary to provide technical assistance in the operation of the Program
of Reinsurance, design of policies and other similar contract of
insurance, and any other function within the authority of the Program of
Reinsurance.
9. Borrow money to effect the purposes of the Program of
Reinsurance. Any note or other evidence of indebtedness of the Program of
Reinsurance not in default shall be deemed to be legal investments for
carriers and may be carried as admitted assets.
(Added to NRS by 1997, 2931)
1. The Program of Reinsurance must reinsure:
(a) For a basic or standard health benefit plan, the level of
coverage provided; and
(b) For any other plan, up to the level of coverage provided in a
basic or standard health benefit plan.
2. A reinsuring carrier may reinsure a small employer within 60
days after the beginning of coverage of the small employer under a health
benefit plan, or for an eligible employee or his dependent, within 60
days after the beginning of coverage of the employee or dependent under a
health benefit plan. An individual reinsuring carrier may reinsure an
eligible person or his dependent within 60 days after the effective date
of coverage of the person or dependent under a health benefit plan.
3. The Program of Reinsurance may not reimburse a reinsuring
carrier or an individual reinsuring carrier for a claim of a reinsured
eligible employee or eligible person, or a dependent of such an employee
or person, as appropriate, until the reinsuring or individual reinsuring
carrier has incurred in a calendar year the minimum amount of claims of
the eligible employee, eligible person or dependent of benefits covered
by the Program of Reinsurance. After the amount of claims of the eligible
employee, eligible person or dependent is equal to or greater than the
required minimum amount, the reinsuring or individual reinsuring carrier
is liable for 10 percent of the next $50,000 of payments of benefits that
are paid during that calendar year and the Program of Reinsurance must
reinsure the remainder of the benefit payments. The total liability of a
carrier in a calendar year pursuant to this subsection may not exceed the
maximum liability established by the Board.
4. For the purposes of subsection 3, the Board shall establish:
(a) The minimum amount of claims, which must be in an amount that
is equal to or greater than $5,000, that must be incurred before the
Program of Reinsurance will reimburse the reinsuring or individual
reinsuring carrier.
(b) The maximum liability of a reinsuring or individual reinsuring
carrier, which must be in an amount that is equal to or greater than
$10,000.
Ê The Board shall annually adjust the minimum amount of claims and the
maximum liability of a reinsuring or individual reinsuring carrier to
reflect increases in the costs and utilization within the standard market
for health benefit plans within this state. Unless the Board proposes and
the Commissioner approves a factor that would provide for a lower
adjustment, the adjustments must not be less than the annual change in
the component for medical care of the Consumer Price Index for All Urban
Consumers of the United States Department of Labor, Bureau of Labor
Statistics.
5. A reinsuring carrier that provides health insurance coverage to
small employers may terminate reinsurance with the Program of Reinsurance
for a reinsured employee or dependent, and an individual reinsuring
carrier may terminate reinsurance with the Program of Reinsurance for an
eligible person or dependent, on the anniversary date of the health
benefit plan.
6. The premium rates charged for reinsurance by the Program of
Reinsurance to a health maintenance organization that is federally
qualified pursuant to 42 U.S.C. §§ 300 et seq. and is subject to
requirements limiting the amount of risk that may be ceded to a Program
of Reinsurance that are more restrictive than the amounts set forth in
subsection 5 must be reduced to reflect that portion of the risk above
the amount determined pursuant to this section, if any, that may not be
ceded to the Program of Reinsurance.
7. A reinsuring carrier or an individual reinsuring carrier
purchasing reinsurance pursuant to this chapter or NRS 689A.470 to 689A.740 , inclusive, shall apply its techniques for
handling managed care and claims, including utilization review,
individual case management, preferred provider provisions and other
provisions or methods of operating relating to managed care, to the
health benefit plans that are being reinsured pursuant to the Program of
Reinsurance in a manner that is consistent with the business of the
carrier that is not reinsured.
8. Nothing in this section prohibits a reinsuring carrier or an
individual reinsuring carrier from terminating the coverage of a small
employer or an eligible person on the grounds described in paragraph (c)
of subsection 1 of NRS 687B.320 .
9. The plan of operation must provide that:
(a) A reinsuring carrier may reinsure a small employer or an
eligible employee or his dependent if coverage is written on or after
July 1, 1997; and
(b) An individual reinsuring carrier may reinsure an eligible
person or his dependent if coverage is written on or after January 1,
1998.
(Added to NRS by 1997, 2932)
1. The plan of operation must include a methodology for
determining premium rates to be charged by the Program of Reinsurance for
Reinsuring Small Employers and Eligible Persons pursuant to NRS 689C.610
to 689C.980 , inclusive. The methodology must:
(a) Include a system for the classification of small employers
which reflects the types of case characteristics commonly used by
carriers that provide health insurance coverage to small employers
pursuant to the provisions of this chapter; and
(b) Provide for the development of initial base premium rates for
reinsurance to be used pursuant to subsection 2 to determine the premium
rates for the Program of Reinsurance. The Board shall establish such base
rates, subject to the approval of the Commissioner, at levels that
reasonably approximate the gross premiums charged to small employers by
small employer carriers, to eligible employees and their dependents by
small employer carriers, or to eligible persons by individual carriers,
as appropriate, for health benefit plans with benefits similar to the
standard health benefit plan, as adjusted to reflect the minimum amount
of claims and the maximum liability established pursuant to NRS 689C.800
.
2. Premiums for the Program of Reinsurance:
(a) For an entire small employer group, must be at a rate that is
at least 1 1/2 times the base premium rate established pursuant to
subsection 1.
(b) For an eligible employee and his dependent, must be at a rate
that is at least five times the base premium rate established pursuant to
subsection 1.
(c) For an eligible person, must be at a rate that is at least 1
1/2 times the base premium rate established pursuant to subsection 1.
3. The Board shall periodically review the methodology established
pursuant to this section, including the system of classification and any
rating factors, to ensure that the methodology reasonably reflects the
claims experience of the Program of Reinsurance. The Board may, subject
to the approval of the Commissioner, change the methodology as needed.
4. The Board may adjust the factor by which the base premium rate
must be multiplied pursuant to this section to determine the premium
rates to be charged for the Program of Reinsurance to reflect the use of
effective measures of cost containment and any arrangements for managed
care.
(Added to NRS by 1997, 2933)
1. If a health benefit plan for a small employer, an eligible
employee or an eligible person is entirely or partially reinsured with
the Program of Reinsurance, the premiums charged to the small employer,
eligible employee or eligible person for any rating period during which
such coverage is entirely or partially reinsured must meet the
requirements for premium rates set forth in NRS 689A.680 to 689A.700 , inclusive, or as established in accordance
with NRS 689C.230 , as appropriate.
2. As used in this section, “rating period” means the calendar
period for which premium rates established by a carrier subject to this
section and NRS 689C.810 are assumed
to be in effect.
(Added to NRS by 1997, 2934)
On or before March 1 of each year, the Board
shall determine, separately account for and report to the Commissioner
the net loss of the Program of Reinsurance for the previous calendar
year, including administrative expenses and incurred losses for that
year. Such a determination and accounting must take into account any
investment income and other appropriate gains and losses for reinsured
small employers and eligible employees and their dependents and for
reinsured eligible persons.
(Added to NRS by 1997, 2934)
1. Any net loss from reinsuring small employers and eligible
employees and their dependents must be recouped by assessments against
reinsuring carriers.
2. As part of the plan of operation, the Board shall establish a
formula pursuant to which assessments may be made against reinsuring
carriers to recover the net loss. The formula must be based on:
(a) The share of each reinsuring carrier of the total premiums
earned by all reinsuring carriers during the preceding calendar year from
existing health benefit plans delivered or issued for delivery to small
employers in this state; and
(b) The share of each reinsuring carrier of the premiums earned by
all reinsuring carriers in the preceding calendar year from newly issued
health benefit plans delivered or issued for delivery during that year to
small employers in this state.
3. An assessment made against a reinsuring carrier pursuant to
this section must not be less than 50 percent nor more than 150 percent
of an amount equal to the proportion of the total premium earned by the
reinsuring carrier during the preceding calendar year from health benefit
plans delivered or issued for delivery to small employers in this state
to the total premiums earned by all such carriers in the preceding
calendar year for such health benefit plans.
4. The Board may, with the approval of the Commissioner, change
the formula for determining assessments against reinsuring carriers
established pursuant to this section as necessary. The Board may provide
that, during any transitional period, the shares of the assessment base
attributable to the total premiums and to the premiums of the previous
year may vary.
5. Subject to the approval of the Commissioner, the Board shall
adjust the formula for assessing reinsuring carriers that are approved
health maintenance organizations which are federally qualified under 42
U.S.C. §§ 300 et seq., to the extent that any restrictions are placed on
such reinsuring carriers that are not imposed on other small employer
carriers.
6. In determining the amount of net loss pursuant to this section,
the Board shall include any expenses incurred by the Program of
Reinsurance in providing such reinsurance.
(Added to NRS by 1997, 2935)
1. Any net loss from reinsuring individual eligible persons and
their dependents must be recouped by assessments against individual
reinsuring carriers.
2. As part of the plan of operation, the Board shall establish a
formula pursuant to which assessments may be made against individual
reinsuring carriers to recover the net loss. The formula must be based on:
(a) The share of each individual reinsuring carrier of the total
premiums earned by all individual reinsuring carriers during the
preceding calendar year from existing health benefit plans delivered or
issued for delivery to individuals in this state; and
(b) The share of each individual reinsuring carrier of the premiums
earned by all individual reinsuring carriers in the preceding calendar
year from newly issued health benefit plans delivered or issued for
delivery during that year to individuals in this state.
3. An assessment made against an individual reinsuring carrier
pursuant to this section must not be less than 50 percent nor more than
150 percent of an amount equal to the proportion of the total premium
earned by the individual reinsuring carrier during the preceding calendar
year from health benefit plans delivered or issued for delivery to
individuals in this state to the total premiums earned by all such
carriers in the preceding calendar year for such health benefit plans.
4. The Board may, with the approval of the Commissioner, change
the formula for determining assessments against individual reinsuring
carriers established pursuant to this section as necessary. The Board may
provide that, during any transitional period, the shares of the
assessment base attributable to the total premiums and to the premiums of
the previous year may vary.
5. Subject to the approval of the Commissioner, the Board shall
adjust the formula for assessing individual reinsuring carriers that are
approved health maintenance organizations which are federally qualified
under 42 U.S.C. §§ 300 et seq., to the extent that any restrictions are
placed on such individual reinsuring carriers that are not imposed on
other individual carriers.
6. In determining the amount of net loss pursuant to this section,
the Board shall include any expenses incurred by the Program of
Reinsurance in providing such reinsurance.
(Added to NRS by 1997, 2935)
1. On or before March 1 of each year, the Board shall determine,
separately account for and file with the Commissioner an estimate of the
assessments needed to fund the losses incurred by the Program of
Reinsurance in the previous calendar year for:
(a) Reinsured small employer groups, eligible employees and the
dependents of such employees; and
(b) Reinsured eligible persons.
2. If the Board determines that the amount of the assessments
against reinsuring carriers needed to fund the losses incurred by the
Program of Reinsurance in the previous calendar year will exceed 5
percent of the total premiums earned in the previous calendar year from
health benefit plans delivered or issued for delivery in this state by
reinsuring carriers and individual reinsuring carriers, the Board shall
evaluate the operation of the Program of Reinsurance and report its
findings, including any recommendations for changes to the plan of
operation, to the Commissioner not later than 90 days after the end of
the calendar year in which the losses were incurred. The evaluation must
include an estimate of future assessments and administrative costs of the
Program of Reinsurance, the appropriateness of the premium charged, the
level of retention of insurers under the Program of Reinsurance and the
costs of coverage for small employers. If the Board fails to file the
report timely with the Commissioner, the Commissioner may evaluate the
operations of the Program of Reinsurance and make such amendments to the
plan of operation as he determines to be necessary to reduce future
losses and assessments.
(Added to NRS by 1997, 2936)
1. If, in each of 2 consecutive years, the Board determines that
the amount of the assessment needed exceeds 5 percent of the total
premiums earned in the previous calendar year from health benefit plans
delivered or issued for delivery to small employers by reinsuring
carriers, the Program of Reinsurance is eligible for additional funding
pursuant to this section.
2. If, in each of 2 consecutive years, the Board determines that
the amount of the assessment needed exceeds 5 percent of the total
premiums earned in the previous calendar year from health benefit plans
delivered or issued for delivery to individuals by individual reinsuring
carriers, the Program of Reinsurance is eligible for additional funding
pursuant to this section.
3. To raise the additional funding, the Board shall establish a
formula pursuant to which additional assessments may be made on all
carriers that offer a health benefit plan or provide stop-loss coverage
for a health benefit plan which is an employer-sponsored plan or a plan
established pursuant to the Labor-Management Relations Act, 1947, as
amended. The total additional assessments on all such carriers combined
may not exceed one-half of 1 percent of the total premiums earned from
all health benefit plans and stop-loss coverage issued in this state in
the previous calendar year.
(Added to NRS by 1997, 2936; A 1999, 2814 )
1. If the amount of the assessments exceeds the net losses of the
Program of Reinsurance from reinsuring small employers and eligible
employees, the excess amount must be retained by the Board and used to
offset future losses or to reduce the premiums of the reinsuring carriers.
2. If the amount of the assessments exceeds the net losses of the
Program of Reinsurance from reinsuring eligible persons, the excess
amount must be retained by the Board and used to offset future losses or
to reduce the premiums of the individual reinsuring carriers.
3. As used in this section, “future losses” includes reserves for
claims that have been incurred, but have not yet been reported.
(Added to NRS by 1997, 2937)
1. Each assessment against a reinsuring carrier and individual
reinsuring carrier must be determined annually by the Board based on
annual statements and such other reports deemed relevant by the Board and
filed by the reinsuring carriers with the Board.
2. The plan of operation must provide for the imposition of an
interest penalty for late payment of assessments.
3. A reinsuring or individual reinsuring carrier may seek from the
Commissioner a deferment of any part of an assessment imposed by the
Board pursuant to NRS 689C.840 . The
Commissioner may defer any part of the assessment if he determines that
the payment of the assessment would place the carrier in a financially
impaired condition. If any amount of an assessment against a carrier is
deferred pursuant to this subsection, the amount so deferred must be
assessed against the other participating carriers in a manner consistent
with NRS 689C.840 . A carrier
receiving a deferment pursuant to this subsection remains liable to the
Program of Reinsurance for the amount deferred and shall not reinsure any
small employers, eligible employees or eligible persons with the Program
of Reinsurance until the deferred assessment is paid.
(Added to NRS by 1997, 2937)
1. The Board shall issue to each insurer paying an assessment
under NRS 689C.870 a certificate of
contribution, in a form prescribed by the Commissioner, for the amount so
paid. All outstanding certificates are of equal dignity and priority
without reference to the amounts or dates of issue. A member insurer may
show a certificate of contribution as an asset in its financial statement
in such form, for such amount, if any, and for such period as the
Commissioner may approve.
2. A carrier may offset against its liability for premium tax to
this state, accrued with respect to business transacted in a calendar
year, an amount equal to 20 percent of the amount certified pursuant to
subsection 1 in each of the 5 calendar years following the year in which
the assessment was paid. If an insurer ceases to transact business, it
may offset all uncredited assessments against its liability for premium
tax for the year in which it ceases to transact business.
(Added to NRS by 1997, 2937)
Subject to the approval of the
Commissioner, the Board shall adjust the formula for assessing carriers
that are approved health maintenance organizations which are federally
qualified under 42 U.S.C. §§ 300 et seq., to the extent that any
restrictions are placed on such carriers that are not imposed on other
carriers.
(Added to NRS by 1997, 2938)
Except as otherwise provided in NRS 689C.790
, neither participation in the Program
of Reinsurance as a reinsuring carrier or individual reinsuring carrier,
the establishment of rates, forms or procedures, nor any other joint or
collective action required by NRS 689C.610 to 689C.980 , inclusive, may be the basis of any legal
action, civil liability or penalty against the Program of Reinsurance or
any of the participating reinsuring carriers and individual reinsuring
carriers, either jointly or separately.
(Added to NRS by 1997, 2938)
As part of the plan of operation, the Board shall develop
standards that set forth the manner and levels of compensation that may
be paid to producers for the sale of basic and standard health benefit
plans issued in accordance with the Program of Reinsurance. In
establishing such standards, the Board shall consider:
1. The need to ensure the broad availability of coverages;
2. The objectives of the Program of Reinsurance;
3. The time and effort expended in placing the coverage;
4. The need to provide on-going service to small employers,
eligible employees and eligible persons;
5. The level of compensation currently used in the industry; and
6. The overall cost of coverage to small employers, eligible
employees and eligible persons selecting such coverage.
(Added to NRS by 1997, 2938)
The Commissioner may, by regulation, prescribe
standards for determining whether a policy issued as a stop-loss policy
is a health benefit plan for the purposes of this chapter.
(Added to NRS by 1997, 2938)
Notwithstanding any specific statute to the contrary, a statute that
requires the coverage of a specific health care service or benefit, or
the reimbursement, utilization or inclusion of a specific category of
licensed health care practitioner, is not applicable to a basic health
benefit plan delivered or issued for delivery to small employers or
eligible persons in this state pursuant to this chapter or chapter 689A
of NRS.
(Added to NRS by 1997, 2940)
No member, agent or employee of the
Board may be held liable in a civil action for any act that he performs
in good faith in the execution of his duties pursuant to the provisions
of this chapter.
(Added to NRS by 1999, 2810 )
Committee on Health Benefit Plans
1. The Committee on Health Benefit Plans is hereby created
consisting of eight members. The Commissioner shall appoint to the
Committee representatives of carriers, small employers and eligible
employees, eligible persons, health care providers, producers and
third-party administrators.
2. Members of the Committee serve without compensation, but while
engaged in the business of the Committee, each member is entitled to
receive the per diem allowance or travel expenses provided for state
officers and employees generally, to be paid from the proceeds of the
assessments received by the Program of Reinsurance as an administrative
expense of the Program of Reinsurance.
3. After the initial term, the term of each appointed member is 3
years. Members may be reappointed. A member may be removed from the
Committee by the Commissioner for good cause shown.
4. At the expiration of the term of a member, or if the member
resigns or is otherwise unable to complete his term, the Commissioner
shall appoint a replacement not later than 30 days after the vacancy
occurs.
(Added to NRS by 1997, 2938)
1. The Committee shall meet:
(a) Until a plan of operation, other than a temporary plan of
operation, has been approved by the Commissioner, twice a year;
(b) Once a plan of operation has been so approved, once a year; and
(c) At such other times as the Commissioner deems necessary.
2. The Committee shall elect from its membership a Chairman who
shall serve for a term of 2 years. Any vacancy occurring in this position
must be filled by election of the members of the Committee for the
remainder of the unexpired term.
3. The Committee shall:
(a) Recommend to the Board the form and level of coverages to be
made available by small employers pursuant to NRS 689C.156 , 689C.1565 , 689C.157 and 689C.190 , and by individual carriers pursuant to NRS
689A.680 to 689A.700 , inclusive.
(b) Recommend to the Board levels for benefits and cost sharing,
exclusions and limitations for a basic health benefit plan and a standard
health benefit plan.
(c) Design a basic health benefit plan and a standard health
benefit plan that are consistent with the basic method of operation and
the benefit plans of health maintenance organizations authorized to
transact insurance in this state, including any restrictions imposed by
federal law.
4. The basic and standard health benefit plans recommended by the
Committee may include features for the containment of costs, including:
(a) Utilization review of health care services, including a review
of the medical necessity of hospital and physician services;
(b) Case management;
(c) Selective contracting with hospitals, physicians and other
providers of health care;
(d) Reasonable benefit differentials applicable to providers that
participate and providers that do not participate in arrangements using a
provision for a restricted network; and
(e) Other provisions relating to managed care.
5. The Committee shall submit its recommendations for a basic and
a standard health benefit plan to the Commissioner not later than 120
days after the date on which the Committee is appointed.
6. As used in this section, “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 health care providers
that have entered into a contractual arrangement with the carrier to
provide health care services to persons covered by the plan.
(Added to NRS by 1997, 2939)
1. At least once every 3 years, the Board, in consultation with
the Committee, shall study and submit a report to the Commissioner
concerning the effectiveness of NRS 689C.610 to 689C.980 , inclusive.
2. The report:
(a) Must analyze the effectiveness of NRS 689C.610 to 689C.980 , inclusive, in promoting the stability of
rates, the availability of products and the affordability of coverage;
(b) May contain recommendations for actions to improve the overall
effectiveness, efficiency and fairness of the marketplace for health
insurance for small employers and individuals;
(c) Must address the issue of whether carriers and producers are
fairly and actively marketing or issuing health benefit plans to small
employers in accordance with the provisions of this chapter and to
individuals in accordance with NRS 689A.470 to 689A.740 , inclusive; and
(d) May contain recommendations for the regulation of the
marketplace for health insurance for small employers and individuals and
other regulatory standards or actions.
(Added to NRS by 1997, 2940)
Except as otherwise provided in this
chapter, as used in this chapter, unless the context otherwise requires,
the words and terms defined in NRS 689C.017 to 689C.106 , inclusive, have the meanings ascribed to
them in those sections.
(Added to NRS by 1995, 978; A 1997, 1096, 2940)
“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, 2916)
“Affiliation period”
means a period, not to exceed 60 days for new enrollees and 90 days for
late enrollees, during which no premiums may be collected from, and
coverage issued would not become effective for, a small employer or an
eligible employee or his dependent, if the affiliation period is applied
uniformly and without regard to any health status-related factors.
(Added to NRS by 1997, 2916)
“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, 2916)
“Bona fide
association” has the meaning ascribed to it in NRS 689A.485 .
(Added to NRS by 1997, 2916)
“Carrier” means any person who
provides health insurance in this state, including a fraternal benefit
society, a health maintenance organization, a nonprofit hospital and
health service corporation, a health insurance company and any other
person providing a plan of health insurance or health benefits subject to
this title.
(Added to NRS by 1995, 978)
“Characteristics” means
demographic or other information concerning a small employer that is
considered by a carrier in the determination of premium rates for the
small employer, except claim experience, health status and duration of
coverage.
(Added to NRS by 1995, 978)
“Class of business”
means all or a distinct grouping of small employers as shown in the
records of a carrier serving small employers.
(Added to NRS by 1995, 978)
“Control” has the meaning
ascribed to it in NRS 692C.050 .
(Added to NRS by 1997, 2916)
“Converted policy” means
a basic or standard health benefit plan issued in accordance with NRS
689C.610 to 689C.980 , inclusive.
(Added to NRS by 1997, 2916)
“Creditable coverage”
means health benefits or coverage provided to a person 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 federal regulations
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, 2916; A 1999, 2240 , 2811 )
“Dependent” means a spouse or:
1. An unmarried child under 19 years of age;
2. An unmarried child who is a full-time student under 24 years of
age and who is financially dependent upon the parent; or
3. An unmarried child of any age who is medically certified as
disabled and dependent upon the parent,
Ê who the parent claimed as his dependent on the form for income tax
returns which he filed with the Internal Revenue Service for the previous
fiscal year.
(Added to NRS by 1995, 978)
“Eligible employee”
means a permanent employee who has a regular working week of 30 or more
hours. The term includes a sole proprietor or a partner of a partnership,
if the sole proprietor or partner is included as an employee under a
health benefit plan of a small employer.
(Added to NRS by 1995, 978)
“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, 2917)
“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, 2917)
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, 2917)
1. “Health benefit plan” means a policy or certificate for
hospital or medical expenses, a contract for dental, hospital or medical
services, or a health care plan of a health maintenance organization
available for use, offered or sold to a small employer. Except as
otherwise provided in this section, the term includes short-term and
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) Coverage under a short-term health insurance policy;
(i) Coverage under a blanket student accident and health insurance
policy; and
(j) Other similar insurance coverage specified in federal
regulations issued pursuant to the Health Insurance Portability and
Accountability Act of 1996, Public Law 104-191, under which benefits for
medical care are secondary or incidental to other insurance benefits.
3. 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, the term does not include the following
benefits:
(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. 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, the term does not include:
(a) Coverage that is only for a specified disease or illness; and
(b) Hospital indemnity or other fixed indemnity insurance.
5. If offered as a separate policy, certificate or contract of
insurance, the term does not include:
(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 1995, 978; A 1997, 2940; 1999, 2811 )
“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, 2918)
“Network plan” means a
health benefit plan offered by a health carrier under which the financing
and delivery of medical care, including items and services paid for as
medical care, are 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, 2918)
“Open enrollment” means
the period designated for enrollment in a health benefit plan.
(Added to NRS by 1997, 2918)
“Plan for coverage of a bona fide association” has the meaning
ascribed to it in NRS 689A.570 .
(Added to NRS by 1997, 2918)
“Plan sponsor” has the
meaning ascribed to it in section 3(16)(B) of the Employee Retirement
Income Security Act of 1974, as that section existed on July 16, 1997.
(Added to NRS by 1997, 2918)
“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 immediately 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, 2918)
“Producer” means an agent or
broker licensed pursuant to this title.
(Added to NRS by 1997, 2918)
“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, 2918)
“Rating period” means the
period for which premium rates established by a carrier are assumed to be
in effect.
(Added to NRS by 1995, 979)
“Risk-assuming
carrier” means a small employer carrier that has elected to act as a
risk-assuming carrier.
(Added to NRS by 1997, 2918)
1. “Small employer” means, with respect to a calendar year and a
plan year, an employer who employed on business days during the preceding
calendar year an average of at least 2 employees, but not more than 50
employees, who have a normal workweek of 30 hours or more, and who
employs at least 2 employees on the first day of the plan year. For the
purposes of determining the number of eligible employees, organizations
which are affiliated or which are eligible to file a combined tax return
for the purposes of taxation constitute one employer.
2. For the purposes of this section, organizations are
“affiliated” if one directly, or indirectly, through one or more
intermediaries, controls or is controlled by, or is under common control
with, the other, as determined pursuant to the provisions of NRS 692C.050
.
(Added to NRS by 1995, 979; A 1997, 2941; 1999, 2812 )
“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, 2918)
Supplemental
coverage is not a health benefit plan if:
1. The carrier files on or before March 1 of each year a
certification with the Commissioner that contains:
(a) A statement from the 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 in
cases where 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, 1996, the carrier files
with the Commissioner the information and statement required in
subsection 1 at least 30 days before the date the policy or certificate
is issued or delivered in this state.
(Added to NRS by 1995, 979)
“Waiting period” means the
period established by a plan of health insurance that must pass before a
person who is an eligible participant or beneficiary in a plan is covered
for benefits under the terms of the plan. The term includes the period
from the date a person submits an application to an individual carrier
for coverage under a health benefit plan until the first day of coverage
under that health benefit plan.
(Added to NRS by 1997, 2919; A 1999, 2813 )
The provisions of this chapter apply
to health benefit plans that provide coverage to the employees of small
employers in this state and to carriers that offer those health benefit
plans if:
1. A portion of the premium or benefits are paid by or on behalf
of the small employer;
2. An eligible employee or his dependent is reimbursed for a
portion of the premium, whether by wage adjustments or otherwise, by or
on behalf of the small employer; or
3. The health benefit plan is considered by the small employer or
any of his eligible employees or dependents as part of a plan or program
for the purposes of section 106, 125 or 162 of the Internal Revenue Code,
26 U.S.C. § 106, 125 or 162.
(Added to NRS by 1999, 2810 )
1. For the purposes of this chapter, and except as otherwise
provided in subsection 2, two or more carriers which are affiliated
companies or which are eligible to file a consolidated tax return shall
be deemed to be one carrier, and any restrictions or limitations imposed
by the provisions of this chapter apply as if the health benefit plans
delivered or issued for delivery to small employers in this state by such
carriers were issued by one carrier.
2. An affiliated 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 carrier for the purposes of this chapter.
3. Unless otherwise authorized by the Commissioner, a carrier
shall not enter into any ceding arrangement with respect to a health
benefit plan delivered or issued for delivery to a small employer in this
state if, as a result of the ceding arrangement, the ceding carrier
retains less than 30 percent of the insurance obligation or risk for that
health benefit plan.
(Added to NRS by 1997, 2919)
For the purposes of this chapter:
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 a 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 the provisions of subsection 2, as an employee welfare benefit plan
that 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, 2919)
1. If an employer was not in existence throughout the entire
preceding calendar year, the determination of whether the employer is a
small or large employer must be based on the average number of employees
reasonably expected to be employed on business days in the current
calendar year.
2. Except as otherwise provided by specific statute, the
provisions of this chapter that apply to a small employer at the time
that a carrier issues a health benefit plan to the small employer
pursuant to the provisions of this chapter continue to apply at least
until the plan anniversary following the date on which the small employer
no longer meets the requirements of being a small employer.
(Added to NRS by 1997, 2919)
1. An employee welfare benefit plan for providing benefits for
employees of more than one employer under which health insurance coverage
is provided to small employers must comply with the provisions of this
chapter and with NRS 679B.139 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, 2928)
1. A health benefit plan offered by a carrier pursuant to this
chapter must include coverage of basic medical and hospital care.
2. In addition to the coverage required by subsection 1, a carrier
may offer additional coverage for an additional cost upon the approval of
the Commissioner.
(Added to NRS by 1995, 979)
1. A carrier serving small employers shall apply rating factors,
including characteristics, consistently with respect to all small
employers in a class of business. Rating factors must produce premiums
for identical groups that differ only by the amounts attributable to the
design of the plans and the terms of the coverage and do not reflect
differences based on the nature of the groups that will select particular
health benefit plans. As used in this subsection, “premium” means all
money paid by a small employer and eligible employees to a carrier as a
condition of receiving coverage from a carrier, including any fees or
other contributions associated with the health benefit plan.
2. A carrier serving small employers shall treat all health
benefit plans issued or renewed in the same calendar month as having the
same rating period, if the terms of coverage provided in the plans are
the same.
(Added to NRS by 1995, 979)
1. For the purposes of determining rates charged for health
benefit plans, a health benefit plan that contains a provision for a
restricted network is not similar coverage to a health benefit plan that
does not contain such a provision if the restriction of benefits results
in material differences in cost of claims.
2. As used in this section, “provision for a restricted network”
means any provision of a group health benefit plan that conditions the
payment of benefits, in whole or in part, on the use of providers of
health care who have entered into a contractual arrangement with the
carrier to provide health care to persons covered by the plan.
(Added to NRS by 1995, 980)
A carrier 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, 2137 )
In determining the rating
factors for establishing the premiums for a health benefit plan, a
carrier serving small employers shall not use characteristics other than
age, sex, industry, geographic area, composition of family, size of group
and the amount contributed by the employer to the cost of coverage
without the prior approval of the Commissioner.
(Added to NRS by 1995, 980)
The Commissioner may adopt regulations
to carry out the provisions of NRS 689C.107 to 689C.145 , inclusive, 689C.156 to 689C.159 , inclusive, 689C.165 , 689C.183 , 689C.187 , 689C.191 to 689C.198 , inclusive, 689C.203 , 689C.207 , 689C.265 , 689C.283 , 689C.287 , 689C.325 , 689C.342 to 689C.348 , inclusive, 689C.355 and 689C.610 to 689C.980 , inclusive, and to ensure that rating
practices used by carriers serving small employers are consistent with
those sections, including regulations that:
1. Ensure that differences in rates charged for health benefit
plans by such carriers are reasonable and reflect only differences in the
designs of the plans, the terms of the coverage, the amount contributed
by the employers to the cost of coverage and differences based on the
rating factors established by the carrier.
2. Prescribe the manner in which characteristics may be used by
such carriers.
(Added to NRS by 1995, 980; A 1997, 2942)
1. As a condition of transacting business in this State with small
employers, a carrier shall actively market to a small employer each
health benefit plan which is actively marketed in this State by the
carrier to any small employer in this State. The health insurance plans
marketed pursuant to this section by the carrier must include, without
limitation, a basic health benefit plan and a standard health benefit
plan. A carrier shall be deemed to be actively marketing a health benefit
plan when it makes available any of its plans to a small employer that is
not currently receiving coverage under a health benefit plan issued by
that carrier.
2. A carrier shall issue to a small employer any health benefit
plan marketed in accordance with this section if the eligible small
employer 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 689C.015 to 689C.355 , inclusive, and 689C.610 to 689C.980 , inclusive, except that a carrier is not
required to issue a health benefit plan to a self-employed person who is
covered by, or is eligible for coverage under, a health benefit plan
offered by another employer.
3. If a health benefit plan marketed pursuant to this section
provides, delivers, arranges for, pays for or reimburses any cost of
health care services through managed care, the carrier shall provide a
system for resolving any complaints of an employee concerning those
health care services that complies with the provisions of NRS 695G.200
to 695G.310 , inclusive.
(Added to NRS by 1997, 2920; A 2003, 775 )
1. A carrier is not required to provide coverage to small
employers pursuant to NRS 689C.156 :
(a) During any period in which the Commissioner determines that
requiring the carrier to provide such coverage would place the carrier in
a financially impaired condition.
(b) If the carrier elects not to offer any new coverage to any
small employers in this State. A carrier that elects not to offer new
coverage in accordance with this paragraph may maintain its existing
policies issued to small employers in this State, subject to the
requirements of NRS 689C.310 and
689C.320 .
2. A 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 small
employers in this State for 5 years after the date of the notification.
(Added to NRS by 1997, 2920)
1. Each carrier shall file with the Commissioner, 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 carrier. A health
benefit plan filed pursuant to this section may not be offered by a
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 a carrier on the ground that the plan
does not meet the requirements of NRS 689C.015 to 689C.355 , inclusive, and 689C.610 to 689C.980 , inclusive.
(Added to NRS by 1997, 2920)
For the
purposes of providing coverage under a health benefit plan pursuant to
the provisions of this chapter, a producer may only market association
memberships to small employers and eligible employees, accept
applications for such membership or sign up such members in a bona fide
association if the small employers and eligible employees being marketed
are actively engaged in, or directly related to, the bona fide
association.
(Added to NRS by 1997, 2919)
The provisions of
NRS 689C.156 , 689C.157 and 689C.190 do not apply to health benefit plans offered
by a carrier if the carrier makes the health benefit plan available in
the small employer market only through a bona fide association.
(Added to NRS by 1997, 2921)
The requirements used by a
carrier serving small employers to determine whether to provide coverage
to a small employer, including, without limitation, standards for medical
underwriting, requirements for minimum participation of eligible
employees and minimum employer’s contributions, must be applied uniformly
among all small employers with the same number of eligible employees
applying for coverage or receiving coverage from the carrier.
(Added to NRS by 1995, 980)
Except as otherwise provided in
NRS 689C.170 and 689C.180 , a carrier shall not modify a health benefit
plan with respect to a small employer or any eligible employee or
dependent of an eligible employee, through riders or endorsements, or
otherwise, to restrict or exclude coverage or benefits for specific
diseases, medical conditions or services otherwise covered by the plan.
(Added to NRS by 1997, 2921)
1. Except as otherwise provided in this section, a health benefit
plan 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 carrier 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 carrier 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 plan 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 plan.
3. Any provision of a health benefit plan 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, 859 ; A 2003, 2299 )
1. A carrier serving small employers may vary the application of
requirements for minimum participation of eligible employees and minimum
employer’s contributions only by the size of the small employer’s group.
2. In applying requirements for minimum participation with respect
to a small employer, a carrier shall not consider employees or dependents
who have creditable coverage when determining whether the applicable
percentage of participation is met, but may consider employees or
dependents who have coverage under another health benefit plan that is
sponsored by the employer.
3. A carrier shall not deny an application for coverage solely
because the applicant works in a certain industry.
4. After a small employer has been accepted for coverage, a
carrier shall not increase any requirement for minimum employee
participation or modify any requirement for minimum employer contribution
applicable to the small employer.
(Added to NRS by 1995, 980; A 1997, 2942)
1. If a carrier serving small employers offers coverage to a small
employer, the carrier shall offer the same coverage to all of the
eligible employees of the small employer and their dependents. A carrier
shall not offer coverage to only certain members of a small employer’s
group or to only part of the group, but may exclude an otherwise eligible
employee, or his dependent, who requests enrollment in a health benefit
plan after the end of the initial period during which the employee or
dependent is entitled to enroll under the terms of the plan, if the
initial period is at least 30 days.
2. A carrier shall not exclude an eligible employee or dependent
if:
(a) The employee or dependent:
(1) Was covered under other creditable coverage at the time
of the initial period for enrollment;
(2) Lost coverage under the other creditable coverage as a
result of termination of employment or eligibility, the involuntary
termination of the creditable coverage, the death of a spouse or divorce;
and
(3) Requests enrollment within 30 days after termination of
the other creditable coverage;
(b) The employee is employed by an employer that offers multiple
health benefit plans and elects a different plan during an open period
for enrollment; or
(c) A court has ordered that coverage be provided for a dependent
under a covered employee’s health benefit plan and the request for
enrollment is made within 30 days after issuance of the court order.
(Added to NRS by 1995, 981; A 1997, 2942)
A health benefit plan and a carrier offering such a plan shall permit an
employee or a dependent of an employee covered by the health benefit plan
who is eligible, but not enrolled, for coverage in connection with the
health benefit plan to enroll for coverage under the terms of the health
benefit plan if:
1. The employee or dependent was covered under a different health
benefit plan or had other health insurance coverage at the time coverage
was previously offered to the employee or dependent;
2. The employee stated in writing at that time that the other
coverage was the reason for declining enrollment, but only if the plan
sponsor or carrier required such a written statement and informed the
employee of that requirement and the consequences of the requirement; and
3. The employee or his dependent:
(a) Was covered under any provision of the Consolidated Omnibus
Budget Reconciliation Act of 1985 relating to the continuation of
coverage and such continuation of coverage was exhausted; or
(b) Was not covered under such a provision and his insurance
coverage was lost as a result of cessation of contributions by his
employer, termination of employment or eligibility, reduction in the
number of hours of employment, or the death of, or divorce or legal
separation from, a covered spouse.
(Added to NRS by 1997, 2921)
1. A health benefit plan and a carrier of such a plan that makes
coverage available to the dependent of a covered employee shall permit
the employee to enroll a dependent after the close of a period of open
enrollment if:
(a) The employee is a participant in the health benefit plan, or
has met any waiting period applicable to becoming a participant and is
eligible to be enrolled under the plan, except for a failure to enroll
during a previous period of open enrollment; and
(b) The person to be enrolled became a dependent of the employee
through marriage, birth, adoption or placement for adoption.
2. The health benefit plan or carrier shall provide a period of
special enrollment for the enrollment of a dependent of an employee
pursuant to this section. Such a period must be not less than 30 days and
must begin on:
(a) The date specified by the health benefit plan or carrier for
the period of special enrollment; or
(b) The date of the marriage, birth, adoption or placement for
adoption, as appropriate.
3. If an employee seeks to enroll a dependent during the first 30
days of the period for special enrollment provided pursuant to subsection
2, the coverage of the dependent becomes effective:
(a) In the case of a marriage, not later than the first day of the
first month beginning after the date on which the completed request for
enrollment is received;
(b) In the case of a birth, on the date of the birth; and
(c) In the case of an adoption or placement for adoption, on the
date of the adoption or the placement for adoption.
4. In the case of a birth, an adoption or a placement for adoption
of a child of an employee, the spouse of the employee may be enrolled as
a dependent pursuant to this section if the spouse is otherwise eligible
for coverage under the health benefit plan.
(Added to NRS by 1997, 2922)
1. Except as otherwise provided in this section, a carrier serving
small employers that issues a health benefit plan shall not deny, exclude
or limit a benefit for a preexisting condition:
(a) For more than 12 months after the effective date of coverage if
the employee enrolls through open enrollment or after the first day of
the waiting period for such enrollment, whichever is earlier; or
(b) For more than 18 months after the effective date of coverage
for a late enrollee. A carrier may not define a preexisting condition in
its health benefit plan more restrictively than that term is defined in
NRS 689C.082 .
2. The period of any exclusion for a preexisting condition imposed
by a health benefit plan on a person to be insured in accordance with the
provisions of this chapter must be reduced by the aggregate period of
creditable coverage of that person, if the creditable coverage was
continuous to a date not more than 63 days before the effective date of
the new coverage. The period of continuous coverage must not include:
(a) Any waiting period for the effective date of the new coverage
applied by the employer or the carrier; or
(b) Any affiliation period, not to exceed 60 days for a new
enrollee and 90 days for a late enrollee, required before becoming
eligible to enroll in the health benefit plan.
3. A health maintenance organization authorized to transact
insurance pursuant to chapter 695C of NRS
that does not restrict coverage for a preexisting condition may require
an affiliation period before coverage becomes effective under a plan of
insurance if the affiliation period applies uniformly to all employees
and without regard to any health status-related factors. During the
affiliation period, the carrier shall not collect any premiums for
coverage of the employee.
4. A carrier that restricts coverage for preexisting conditions
shall not impose an affiliation period.
5. A carrier shall not impose any exclusion for a preexisting
condition:
(a) Relating to pregnancy.
(b) In the case of a person who, as of the last day of the 30-day
period beginning on the date of his birth, is covered under creditable
coverage.
(c) In the case of a child who is adopted or placed for adoption
before attaining the age of 18 years and who, as of the last day of the
30-day period beginning on the date of adoption or placement for
adoption, whichever is earlier, is covered under creditable coverage. The
provisions of this paragraph do not apply to coverage before the date of
adoption or placement for adoption.
(d) In the case of a condition for which medical advice, diagnosis,
care or treatment was recommended or received for the first time while
the covered person held creditable coverage, and the medical advice,
diagnosis, care or treatment was a covered benefit under the plan, if the
creditable coverage was continuous to a date not more than 90 days before
the effective date of the new coverage.
Ê The provisions of paragraphs (b) and (c) do not apply to a person after
the end of the first 63-day period during all of which the person was not
covered under any creditable coverage.
6. As used in this section, “late enrollee” means an eligible
employee, or his dependent, who requests enrollment in a health benefit
plan of a small employer following the initial period of enrollment, if
the initial period of enrollment is at least 30 days, during which the
person is entitled to enroll under the terms of the health benefit plan.
The term does not include an eligible employee or his dependent if:
(a) The employee or dependent:
(1) Was covered under creditable coverage at the time of the
initial enrollment;
(2) Lost coverage under creditable coverage as a result of
cessation of employer contribution, termination of employment or
eligibility, reduction in the number of hours of employment, involuntary
termination of creditable coverage, or the death of, or divorce or legal
separation from, a covered spouse; and
(3) Requests enrollment not later than 30 days after the
date on which his creditable coverage was terminated or on which the
change in conditions that gave rise to the termination of the coverage
occurred.
(b) The person enrolls during the open enrollment period, as
provided in the contract or as otherwise provided by specific statute.
(c) The person is employed by an employer which offers multiple
health benefit plans and the person elected a different plan during an
open enrollment period.
(d) A court has ordered coverage to be provided to the spouse or a
minor or dependent child of an employee under a health benefit plan of
the employee and a request for enrollment is made within 30 days after
the issuance of the court order.
(e) The person changes status from not being an eligible employee
to being an eligible employee and requests enrollment, subject to any
waiting period, within 30 days after the change in status.
(f) The person has continued coverage in accordance with the
Consolidated Omnibus Budget Reconciliation Act of 1985 and such coverage
has been exhausted.
(Added to NRS by 1995, 981; A 1997, 2943)
1. In determining the applicable creditable coverage of a person
for the purposes of NRS 689C.190 , a
period of creditable coverage must not be included if, after the
expiration of that period but before the enrollment date, there was a
63-day period during all of which the person was not covered under any
creditable coverage. To establish a period of creditable coverage, an
eligible employee must present any certificates of coverage provided to
him in accordance with NRS 689C.192
and such other evidence of coverage as required by regulations adopted by
the Commissioner. For the purposes of this subsection, any waiting period
for coverage or an affiliation period must not be considered in
determining the applicable period of creditable coverage.
2. In determining the period of creditable coverage of a person
for the purposes of NRS 689C.190 , a
carrier shall include each applicable period of creditable coverage
without regard to the specific benefits covered during that period,
except that the carrier may elect to include applicable periods of
creditable coverage based on coverage of specific benefits as specified
by the United States Department of Health and Human Services by
regulation, if such an election is made on a uniform basis for all
participants and beneficiaries of the health benefit plan or coverage.
Pursuant to such an election, the carrier shall include each applicable
period of creditable coverage with respect to any class or category of
benefits if any level of benefits is covered within that class or
category, as specified by those regulations.
3. Regardless of whether coverage is actually provided, if a
carrier elects in accordance with subsection 2 to determine creditable
coverage based on specified benefits, a statement that such an election
has been made and a description of the effect of the election must be:
(a) Included prominently in any disclosure statement concerning the
health benefit plan; and
(b) Provided to each eligible employee at the time of enrollment in
the health benefit plan.
(Added to NRS by 1997, 2926)
1. For the purposes of determining the period of creditable
coverage of a person accumulated under a health benefit plan or group
health insurance, the insurer shall provide written certification of
coverage on a form prescribed by the Commissioner to the person which
certifies the length of:
(a) The period of creditable coverage that the person accumulated
under the plan and any coverage 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; and
(b) Any waiting and affiliation period imposed on the person
pursuant to that coverage.
2. The certification of coverage must be provided to the person
who was insured:
(a) At the time that he ceases to be covered under the plan, if he
does not otherwise become 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 he becomes covered under such a provision, at the time that
he ceases to be covered by that provision; and
(c) Upon request, if the request is made not later than 24 months
after the date on which he ceased to be covered as described in
paragraphs (a) and (b).
(Added to NRS by 1997, 2927)
1. A carrier shall not place any restriction on a small employer
or an eligible employee or his dependent as a condition of being a
participant in or a beneficiary of a health benefit plan that is
inconsistent with NRS 689C.015 to
689C.355 , inclusive.
2. A carrier that offers health insurance coverage to small
employers pursuant to this chapter shall not establish rules of
eligibility, including, but not limited to, rules which define applicable
waiting periods, for the initial or continued enrollment under a health
benefit plan offered by the carrier that are based on the following
factors relating to the eligible employee or his dependent:
(a) Health status.
(b) Medical condition, including physical and mental illnesses, or
both.
(c) Claims experience.
(d) Receipt of health care.
(e) Medical history.
(f) Genetic information.
(g) Evidence of insurability, including conditions which arise out
of acts of domestic violence.
(h) Disability.
3. Except as otherwise provided in NRS 689C.190 , the provisions of subsection 1 do not:
(a) Require a carrier to provide particular benefits other than
those that would otherwise be provided under the terms of the health
benefit plan or coverage; or
(b) Prevent a carrier from establishing limitations or restrictions
on the amount, level, extent or nature of the benefits or coverage for
similarly situated persons.
4. As a condition of enrollment or continued enrollment under a
health benefit plan, a carrier shall not require any person to pay a
premium or contribution that is greater than the premium or contribution
for a similarly situated person covered by similar coverage on the basis
of any factor described in subsection 2 in relation to the person or his
dependent.
5. Nothing in this section:
(a) Restricts the amount that a small employer may be charged for
coverage by a carrier;
(b) Prevents a carrier from establishing premium discounts or
rebates or from modifying otherwise applicable copayments or deductibles
in return for adherence by the insured person to programs of health
promotion and disease prevention; or
(c) Precludes a carrier from establishing rules relating to
employer contribution or group participation when offering health
insurance coverage to small employers in this State.
6. As used in this section:
(a) “Contribution” means the minimum employer contribution toward
the premium for enrollment of participants and beneficiaries in a health
benefit plan.
(b) “Group participation” means the minimum number of participants
or beneficiaries that must be enrolled in a health benefit plan in
relation to a specified percentage or number of eligible persons or
employees of the employer.
(Added to NRS by 1997, 2925)
1. Except as otherwise provided in this subsection, a 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 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 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. A 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 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 a health benefit plan or carrier 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 a health benefit
plan or carrier 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 a health benefit plan or carrier 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, 2924)
An insurer shall not
deny a claim, refuse to issue a health benefit plan or cancel a health
benefit plan 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 benefit plan 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, 1096)
[Effective July 1, 2006.]
1. Except as otherwise provided in subsection 2, a carrier shall
not:
(a) Deny a claim under a health benefit plan 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 participation under a health benefit plan 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 participation under a health benefit plan 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 a carrier from
enforcing a provision included in a health benefit plan 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 participation in a health benefit plan solely because of
such a claim; or
(c) Refuse participation in a health benefit plan to an eligible
applicant solely because of such a claim.
(Added to NRS by 2005, 2344 , effective July 1, 2006)
1. Except as otherwise provided in subsection 2, a carrier serving
small employers 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 a carrier
serving small employers 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, 1460)
A
carrier serving small employers is not required to accept applications
from or offer coverage to:
1. A small employer if the employer is not physically located in
the carrier’s established geographic area; or
2. An employee if the employee does not work or reside within the
carrier’s established geographic area.
(Added to NRS by 1995, 982; A 1997, 2946)
1. A denial by a carrier of an application for coverage from a
small employer must be in writing and must state the reason for the
denial.
2. The Commissioner may adopt regulations that set forth standards
to provide for the fair marketing and broad availability of health
benefit plans to small employers in this state.
(Added to NRS by 1997, 2924)
The Commissioner may adopt regulations to require a carrier, as a
condition of transacting insurance with small employers in this state
after July 16, 1997, to reissue a health benefit plan to any small
employer whose health benefit plan has been terminated or not renewed by
the 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 small employers.
(Added to NRS by 1997, 2924)
1. Except as otherwise provided in subsection 3, a carrier shall
not increase the premium rate charged to a small employer for a new
rating period by a percentage greater than the sum of:
(a) The percentage of change in the premium rate for new business
for the policy under which the small employer is covered, measured from
the first day of the previous rating period to the first day of the new
rating period;
(b) An adjustment, not to exceed 15 percent annually, adjusted pro
rata for rating periods of less than 1 year, on account of the claim
experience, health status, or duration of coverage of the employees or
dependents of the small employer as determined from the carrier’s rate
manual for the class of business; and
(c) Any adjustment on account of change in coverage or change in
the characteristics of the small employer as determined from the
carrier’s rate manual for the class of business.
2. If the carrier no longer issues new policies for that class of
business, the carrier shall use the percentage of change in the premium
rate for new business for the class of business which is most similar to
the closed class of business and for which the carrier is issuing new
policies.
3. In the case of health benefit plans delivered or issued for
delivery before January 1, 1996, for groups with not fewer than 2
employees and not more than 25 employees, or before July 1, 1997, for
groups with not fewer than 26 employees and not more than 50 employees, a
premium rate for a rating period may exceed the ranges set forth in NRS
689C.230 for a period of 3 years
following that date. In that case, the percentage of increase in the
premium rate charged to a small employer for a new rating period may not
exceed the sum of:
(a) The percentage of change in the premium rate for new business
measured from the first day of the previous rating period to the first
day of the new rating period. In the case of a health benefit plan into
which the carrier is no longer enrolling new small employers, the carrier
shall use the percentage of change in the base premium rate if that
change does not exceed, on a percentage basis, the change in the premium
rate for new business for the most similar health benefit plan into which
the carrier is actively enrolling new small employers.
(b) Any adjustment on account of change in coverage or change in
the characteristics of the small employer as determined from the
carrier’s rate manual for the class of business.
(Added to NRS by 1995, 983; A 1997, 2946; 1999, 2813 )
A
carrier serving small employers shall not charge adjustments in rates for
claim experience, health status and duration of coverage to individual
employees or dependents. Any such adjustment must be applied uniformly to
the rates charged for all employees and dependents of a small employer.
(Added to NRS by 1995, 984)
1. The index rate for a rating period for any class of business
may not exceed the index rate for any other class of business by more
than 20 percent.
2. For a class of business, the premium rates charged during a
rating period to small employers with similar characteristics for the
same or similar coverage, or the rates that could be charged to such
employers under the rating system for that class of business, may not
vary, because of health status-related factors, from the index rate by
more than 30 percent.
3. As used in this section:
(a) “Base premium rate” means, for each class of business as to a
rating period, the lowest premium rate charged or that could have been
charged under a rating system for that class of business by the carrier
to small employers with similar characteristics for health benefit plans
subject to regulation by the Commissioner.
(b) “Index rate” means, for each class of business as to a rating
period for small employers with similar characteristics, the arithmetic
average of the applicable base premium rate and the corresponding highest
premium rate.
(Added to NRS by 1995, 984; A 1997, 2947)
A
carrier serving small employers may utilize industry classifications as a
rating factor in establishing premium rates, but the highest rate factor
associated with any industry classification may not exceed the lowest
rate factor associated with any industry classification by more than 20
percent.
(Added to NRS by 1995, 984; A 1995, 989)
A carrier serving small employers
shall make the information and documents described in NRS 689C.210 to 689C.240 , inclusive, available to the Commissioner
upon request. Except in cases of violations of NRS 689C.015 to 689C.355 , inclusive, the information 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 carrier or as ordered by a court of competent jurisdiction.
(Added to NRS by 1995, 984)
1. Except as otherwise provided in subsection 2, a carrier serving
small employers may establish no more than nine separate classes of
business, and each class must reflect substantial differences in expected
claim experience or administrative costs related to the following:
(a) The use of more than one type of system for the marketing and
sale of health benefit plans to small employers;
(b) The acquisition of a class of business from another carrier
serving small employers; or
(c) The provision of coverage to one or more groups that meet the
requirements of NRS 689B.026 .
2. The Commissioner may approve the establishment of additional
classes of business upon application by a carrier and a finding by the
Commissioner that this action would enhance the efficiency and fairness
of the market for health insurance for small employers.
3. The Commissioner may adopt regulations to provide for a period
of transition for a carrier serving small employers to comply with
subsection 1 if the carrier acquires an additional class of business from
another carrier serving small employers.
4. A carrier shall not transfer a small employer involuntarily
into or out of a class of business. A carrier shall not offer to transfer
a small employer into or out of a class of business unless the offer is
to transfer all small employers in the class of business without regard
to characteristics, claim experience, health status or duration of
coverage.
(Added to NRS by 1995, 984)
A carrier may modify the health
insurance coverage for a product offered to small employers pursuant to a
group health plan if, for coverage that is available in that market other
than through one or more bona fide associations, the modification is
consistent with the provisions of this title and is effective on a
uniform basis among such group health plans.
(Added to NRS by 1997, 2927)
1. The Commissioner shall adopt regulations which require a
carrier to file with the Commissioner, for his approval, a disclosure
offered by the carrier to a small employer. The disclosure must include:
(a) Any significant exception, reduction or limitation that applies
to the policy;
(b) Any restrictions on payments for emergency care, including,
without limitation, related definitions of an emergency and medical
necessity;
(c) The provision of the health benefit plan concerning the
carrier’s right to change premium rates and the characteristics, other
than claim experience, that affect changes in premium rates;
(d) The provisions relating to renewability of policies and
contracts;
(e) The provisions relating to any preexisting condition; and
(f) Any other information that the Commissioner finds necessary to
provide for full and fair disclosure of the provisions of a policy or
contract of insurance issued pursuant to this chapter.
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.
4. The carrier shall make available to a small employer or a
producer acting on behalf of a small employer, upon request, a copy of
the disclosure approved by the Commissioner pursuant to this section for
policies of health insurance for which that employer may be eligible.
(Added to NRS by 1995, 985; A 1997, 2947; 1999, 2814 )
A carrier shall provide to
a small employer to whom it has offered a health benefit plan a copy of
the disclosure approved for that plan pursuant to NRS 689C.270 before any policy or contract of insurance
under a health benefit plan is issued. A carrier shall not offer a health
benefit plan to a small employer unless the disclosure for the plan has
been approved by the Commissioner.
(Added to NRS by 1995, 985)
1. A carrier that offers or issues a health benefit plan 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 carrier 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 carrier for making a request
for information regarding the formulary pursuant to subsection 2.
2. If a carrier offers or issues a health benefit plan which
provides coverage for prescription drugs and a formulary is used, the
carrier 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 carrier 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, 858 )
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 small employer market, each carrier shall
elect to operate as either a risk-assuming carrier or a reinsuring
carrier and shall notify the Commissioner of its election.
2. The initial election of a carrier to act as a risk-assuming or
reinsuring carrier is effective on the 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 a 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 a risk-assuming or
reinsuring carrier is effective.
3. A carrier may apply to the Commissioner, in a manner prescribed
by the Commissioner by regulation, to change its status as a
risk-assuming or reinsuring carrier.
4. A 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 small employer health
benefit plan with the Program of Reinsurance.
(b) Shall pay a prorated assessment based upon business issued as a
reinsuring carrier for any portion of the year that the business was
reinsured.
5. As used in this section:
(a) “Plan of operation” means the plan of operation of the Program
of Reinsurance established pursuant to NRS 689C.610 to 689C.980 , inclusive.
(b) “Reinsuring carrier” means a carrier participating in the
Program of Reinsurance established pursuant to NRS 689C.610 to 689C.980 , inclusive.
(Added to NRS by 1997, 2922)
1. The Commissioner may suspend the election of a carrier to act
as a risk-assuming carrier if the Commissioner finds that:
(a) The financial condition of the carrier will no longer support
the assumption of risk from issuing coverage to small employers in
compliance with NRS 689C.156 and
689C.190 without the protection
afforded by the Program of Reinsurance;
(b) The carrier has failed to market its health benefit plans
fairly to all small employers in this state or in its established
geographic service area, as applicable; or
(c) The carrier has failed to provide coverage to eligible small
employers as required pursuant to NRS 689C.156 and 689C.190 .
2. A carrier that elects to be a risk-assuming carrier is subject
to:
(a) The provisions of NRS 689C.156 , relating to the availability of coverage;
and
(b) The provisions of NRS 689C.260 , relating to classes of businesses.
(Added to NRS by 1997, 2923)
The Commissioner may suspend for a specified period the
application of paragraph (a) of subsection 1 and of subsection 2 of NRS
689C.210 as to the premium rates
applicable to one or more small employers included within a class of
business of a carrier serving small employers for one or more rating
periods upon application by the carrier and a finding by the Commissioner
that the suspension:
1. Is reasonable in light of the financial condition of the
carrier; or
2. Would enhance the efficiency and fairness of the market for
health insurance for small employers.
(Added to NRS by 1995, 985)
1. Each carrier serving small employers shall file with the
Commissioner annually, on or before March 15, an actuarial certification
that the carrier is in compliance with the provisions of NRS 689C.210
to 689C.260 , inclusive, and that the rating methods of
the carrier are actuarially sound. The certification must be made in a
form and manner, and contain the information, specified by the
Commissioner. A copy of the certification must be retained by the carrier
at its principal place of business.
2. As used in this section, “actuarial certification” means a
written statement by a member of the American Academy of Actuaries or
other person acceptable to the Commissioner, based upon the certifier’s
examination of the appropriate records of the carrier, including a review
of the actuarial assumptions and methods used by the carrier in
establishing premium rates for health benefit plans.
(Added to NRS by 1995, 985)
1. Except as otherwise provided in subsections 2 and 3, a carrier
shall renew a health benefit plan at the option of the small employer who
purchased the plan.
2. A carrier may refuse to issue or to renew a health benefit plan
if:
(a) The carrier discontinues transacting insurance in this state or
in the geographic area of this state where the employer is located;
(b) The employer fails to pay the premiums or contributions
required by the terms of the plan;
(c) The employer misrepresents any information regarding the
employees covered under the plan or other information regarding
eligibility for coverage under the plan;
(d) The plan sponsor has engaged in an act or practice that
constitutes fraud to obtain or maintain coverage under the plan;
(e) The employer is not in compliance with the minimum requirements
for participation or employer contribution as set forth in the plan; or
(f) The employer fails to comply with any of the provisions of this
chapter.
3. A carrier may require a small employer to exclude a particular
employee or his dependent from coverage under a health benefit plan as a
condition to renewal of the plan if the employee or his dependent commits
fraud upon the carrier or misrepresents a material fact which affects his
coverage under the plan.
4. A carrier shall discontinue the issuance and renewal of
coverage to a small employer if the Commissioner finds that the
continuation of the coverage would not be in the best interests of the
policyholders or certificate holders of the carrier in this state or
would impair the ability of the carrier to meet its contractual
obligations. If the Commissioner makes such a finding, the Commissioner
shall assist the affected small employers in finding replacement coverage.
5. A carrier may discontinue the issuance and renewal of a form of
a product of a health benefit plan offered to small employers pursuant to
this chapter if the Commissioner finds that the form of the product
offered by the carrier is obsolete and is being replaced with comparable
coverage. A form of a product of a health benefit plan may be
discontinued by a carrier pursuant to this subsection only if:
(a) The 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 carrier
notifies the affected small employers pursuant to paragraph (b).
(b) The carrier notifies each affected small employer and the
Commissioner and the chief regulatory officer for insurance in each state
in which any affected small employer is located or eligible employee
resides of the decision of the carrier to discontinue offering the form
of the product. The notice must be made at least 180 days before the date
on which the carrier will discontinue offering the form of the product.
(c) The carrier offers to each affected small employer the option
to purchase any other health benefit plan currently offered by the
carrier to small employers in this state.
(d) In exercising the option to discontinue the particular form of
the product and in offering the option to purchase other coverage
pursuant to paragraph (c), the carrier acts uniformly without regard to
the claims experience of the affected small employers or any health
status-related factor relating to any participant or beneficiary covered
by the discontinued product or any new participant or beneficiary who may
become eligible for such coverage.
6. A carrier may discontinue the issuance and renewal of a health
benefit plan offered to a small employer or an eligible employee pursuant
to this chapter only through a bona fide association if:
(a) The membership of the small employer or eligible employee in
the association was the basis for the provision of coverage;
(b) The membership of the small employer or eligible employee 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 small employer or eligible employee or his dependent.
7. If a 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 carrier in that service area.
(Added to NRS by 1995, 986; A 1997, 2948)
1. A carrier that discontinues transacting insurance in this State
or in a particular geographic area of this State shall:
(a) Notify the Commissioner and the chief regulatory officer for
insurance in each state in which the carrier is licensed to transact
insurance at least 60 days before a notice of cancellation or nonrenewal
is delivered or mailed to the affected small employers pursuant to
paragraph (b).
(b) Notify the Commissioner and each small employer affected not
less than 180 days before the expiration of any policy or contract of
insurance under any health benefit plan issued to a small employer
pursuant to this chapter.
2. A carrier that cancels any health benefit plan because it has
discontinued transacting insurance in this State or in a particular
geographic area of this State:
(a) Shall discontinue the issuance and delivery for issuance of all
health benefit plans pursuant to this chapter in this State and not renew
coverage under any health benefit plan issued to a small employer; and
(b) May not issue any health benefit plans pursuant to this chapter
in this State or in the particular geographic area for 5 years after it
gives notice to the Commissioner pursuant to paragraph (b) of subsection
1.
(Added to NRS by 1995, 986; A 1997, 2949)
A
carrier that offers coverage through a network plan is not required to
offer coverage to or accept any applications for coverage from the
eligible employees of a small employer pursuant to NRS 689C.310 and 689C.320 if:
1. The eligible employees do not reside or work in the established
geographic service area of the network plan.
2. For a small employer whose eligible employees reside or work in
the established geographic service area of the network plan, the carrier
demonstrates to the satisfaction of the Commissioner that the carrier
does not have the capacity to deliver adequate service to additional
small employers and eligible employees because of the existing
obligations of the carrier. If a carrier is authorized by the
Commissioner not to offer coverage pursuant to this subsection, the
carrier shall not thereafter offer coverage to additional small employers
and eligible employees within that established geographic service area
until the carrier demonstrates to the satisfaction of the Commissioner
that it has regained the capacity to deliver adequate service to
additional small employers and eligible employees within that service
area.
(Added to NRS by 1997, 2921)
1. A carrier that offers a network plan shall use its best efforts
to contract with at least one health center in each established
geographic service area to provide health care as a member of the
carrier’s defined set of providers under the network plan if the health
center:
(a) Meets all conditions imposed by the carrier on similarly
situated providers of health care that are members of the carrier’s
defined set of providers, 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 that are members of the carrier’s defined set of
providers.
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, 1923 )
1. Any policy or contract of insurance delivered or issued for
delivery in this state under a health benefit plan which provides for
coverage of benefits under the plan on an expense-incurred basis must
contain a provision that the employee is entitled to have issued to him
by the insurer a policy of health insurance when the employee is no
longer covered by the health benefit plan.
2. The requirement in subsection 1 only applies to a policy or
contract of insurance issued under a health benefit plan if:
(a) The termination of coverage is not because of termination of
the health benefit plan, unless the termination of the health benefit
plan resulted from the failure of the employer to remit the required
premiums;
(b) The termination is not because of failure of the employee to
remit any required contributions;
(c) The employee has been continuously insured under any health
benefit plan of the employer for at least 3 consecutive months
immediately preceding the termination; and
(d) The employee applies in writing for the converted policy and
pays his first premium to the insurer not later than 31 days after the
termination.
(Added to NRS by 1995, 986)
1. Except as otherwise provided in this section, if an employer
who employs less than 20 employees maintains a health benefit plan which
covers those employees, the plan must contain a provision which permits:
(a) An employee to elect to continue identical coverage under the
plan, excluding coverage provided for eye or dental care, if:
(1) His employment is terminated for any reason other than
gross misconduct; or
(2) The number of his working hours is reduced so that he
ceases to be eligible for coverage.
(b) The spouse or dependent child of an employee to elect to
continue coverage, excluding any coverage provided for eye or dental
care, if:
(1) The employee’s employment is terminated for any reason
other than gross misconduct or the number of his working hours is reduced
so that he ceases to be eligible for coverage;
(2) The employee dies;
(3) The employee and his spouse are divorced or legally
separated;
(4) The dependent child ceases to be eligible for coverage
under the terms of the policy; or
(5) The spouse ceases to be eligible for coverage after
becoming eligible for Medicare.
2. The period of continued coverage is limited to:
(a) Eighteen months for an employee.
(b) Thirty-six months for the dependent of an employee.
3. An employee who voluntarily leaves his employment, or the
dependent of that employee, is not eligible to continue coverage pursuant
to this section.
4. An employee or his dependent who has not been covered under a
health benefit plan of the employer for at least 12 consecutive months
before the termination of his coverage is not eligible to continue
coverage pursuant to this section.
5. A provision for continued coverage must include coverage for
any child born to, legally adopted by or placed for adoption with the
employee during the period of continued coverage. Such a child is
eligible for continued coverage only to the end of the period of
continued coverage as established pursuant to subsection 2.
(Added to NRS by 1995, 987; A 1997, 2950)
1. An employee, spouse or dependent child shall notify the
employer that he is eligible to continue his coverage pursuant to NRS
689C.340 not later than 60 days after
he becomes eligible to do so.
2. The employer shall, within 14 days after receipt of
notification pursuant to subsection 1, provide adequate information to
the employee, spouse or dependent child regarding the election to
continue coverage and the premium required to be paid.
3. If the employee, spouse or dependent child elects to continue
coverage, he shall notify the insurer of his election and pay to the
insurer the premium required by NRS 689C.344 within 60 days after receipt of the
information provided pursuant to subsection 2.
(Added to NRS by 1997, 2928)
1. Any person who elects to continue coverage pursuant to NRS
689C.340 shall pay a premium for that
coverage in an amount not to exceed 125 percent of the premium charged to
the employer by the insurer for coverage of that person on the date on
which that person became eligible for continued coverage.
2. If there is a change in the rate charged or benefits provided
under the policy during the time of continued coverage, the premium may
not exceed 125 percent of the new rate charged to the employer.
3. The premiums must be paid to the insurer on a quarterly basis.
4. If the payment of a premium is not received by the insurer
within 30 days after the date on which it is due, continued coverage must
be terminated.
(Added to NRS by 1997, 2928)
If an employer changes his insurer during the period
of a person’s continued coverage, the new insurer shall provide continued
coverage for that person for the remainder of the continuation period in
accordance with the provisions of NRS 689C.344 .
(Added to NRS by 1997, 2928)
Continued coverage pursuant to NRS
689C.340 ceases before the end of the
period provided in that section if:
1. The employer discontinues group health insurance for his
employees;
2. The employee, spouse or dependent child fails to pay the
required premiums;
3. The employee, spouse or dependent child becomes covered under
any other policy of group health insurance;
4. The employee or spouse qualifies for Medicare; or
5. The spouse remarries and becomes eligible for coverage under a
policy of group health insurance of the new spouse.
(Added to NRS by 1997, 2928)
A health
benefit plan which offers a difference of payment between preferred
providers of health care and providers of health care who are not
preferred:
1. May not require a deductible of more than $600 difference per
admission to a facility for inpatient treatment which is not a preferred
provider of health care.
2. May not require a deductible of more than $500 difference per
treatment, other than inpatient treatment at a hospital, by a provider
which is not preferred.
3. May not provide for a difference in percentage rates of payment
for coinsurance of more than 30 percentage points between the payment for
coinsurance required to be paid by the insured to a preferred provider of
health care and the payment for coinsurance required to be paid by the
insured to a provider of health care who is not preferred.
4. Must require that the deductible and payment for coinsurance
paid by the insured to a preferred provider of health care be applied to
the negotiated reduced rates of that provider.
5. Must include for providers of health care who are not preferred
a provision establishing the point at which an insured’s payment for
coinsurance is no longer required to be paid if such a provision is
included for preferred providers of health care. Such provisions must be
based on a calendar year. The point at which an insured’s payment for
coinsurance is no longer required to be paid for providers of health care
who are not preferred must not be greater than twice the amount for
preferred providers of health care, regardless of the method of payment.
6. Must provide that if there is a particular service which a
preferred provider of health care does not provide and the provider of
health care who is treating the insured requests the service and the
insurer determines that the use of the service is necessary for the
health of the insured, the service shall be deemed to be provided by the
preferred provider of health care.
7. Must require the insurer to process a claim of a provider of
health care who is not preferred not later than 30 working days after the
date on which proof of the claim is received.
(Added to NRS by 1995, 987)
1. Except as otherwise provided in this section, a carrier or a
producer shall not, directly or indirectly:
(a) Encourage or direct a small employer to refrain from filing an
application for coverage with the carrier because of the health status,
claims experience, industry, occupation or geographic location of the
small employer.
(b) Encourage or direct a small employer to seek coverage from
another carrier because of the health status, claims experience,
industry, occupation or geographic location of the small employer.
2. The provisions of subsection 1 do not apply to information
provided to a small employer by a carrier or a producer relating to the
established geographic service area or a provision for a restricted
network of the carrier.
3. Except as otherwise provided in this subsection, a 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 that is 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 small employer at the time that the health benefit plan is issued to
or renewed by the small employer. The provisions of this subsection do
not apply to any arrangement for compensation that provides payment to a
producer on the basis of percentage of premium, except that the
percentage may not vary because of the health status, claims experience,
industry, occupation or geographic area of the small employer.
4. A 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, occupation or geographic
location of a small employer at the time that the health benefit plan is
issued to or renewed by the small employer placed by the producer with
the carrier.
5. A carrier or producer shall not induce or otherwise encourage a
small employer to separate or otherwise exclude an employee or a
dependent of the employee from health coverage or benefits provided in
connection with the employment of the employee.
6. A violation of any provision of this section by a carrier may
constitute an unfair trade practice for the purposes of chapter 686A
of NRS.
7. 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 a carrier to provide administrative,
marketing or other services related to the offering of a health benefit
plan to small employers in this state.
8. Nothing in this section interferes with the right and
responsibility of a broker to advise and represent the best interests of
a small employer who is seeking health insurance coverage from a small
employer carrier.
(Added to NRS by 1997, 2923)
VOLUNTARY PURCHASING GROUPS
As used in NRS 689C.360 to 689C.600 , inclusive, unless the context otherwise
requires, the words and terms defined in NRS 689C.380 to 689C.420 , inclusive, have the meanings ascribed to
them in those sections.
(Added to NRS by 1995, 2677; A 1997, 2951)
“Contract” means a policy or
certificate for hospital or medical expenses, a contract for dental,
hospital or medical services, or a health care plan of a health
maintenance organization available for use by or offered or sold to a
small employer. The term does not include coverage issued as a supplement
to liability insurance, workers’ compensation or similar insurance,
automobile medical payment insurance, coverage for a specified disease,
hospital confinement indemnity or limited-benefit health insurance.
(Added to NRS by 1995, 2677)
“Dependent” means a spouse, an
unmarried child who has not attained 19 years of age, an unmarried child
who is a full-time student who has not attained 24 years of age and who
is financially dependent upon the parent, and an unmarried child of any
age who is medically certified as disabled and dependent upon the parent.
(Added to NRS by 1995, 2677)
“Voluntary
purchasing group” means the employers and their eligible employees and
dependents who form a group pursuant to NRS 689C.360 to 689C.600 , inclusive, and hold a certificate of
registration issued by the Commission pursuant to NRS 689C.510 .
(Added to NRS by 1995, 2677)
A voluntary
purchasing group and any contract issued to such a group pursuant to NRS
689C.360 to 689C.600 , inclusive, are subject to the provisions of
NRS 689C.015 to 689C.355 , inclusive, to the extent applicable and not
in conflict with the express provisions of NRS 689C.360 to 689C.600 , inclusive.
(Added to NRS by 1997, 2929; A 2001, 860 )
Every insurer, fraternal benefit society,
corporation providing hospital or medical services or health maintenance
organization, whose policies or activities relating to health insurance
are governed by the provisions of chapter 689B , 695A , 695B or 695C of NRS, may
offer contracts to voluntary purchasing groups and, if it does so, shall
comply with the provisions of NRS 689C.360 to 689C.600 , inclusive.
(Added to NRS by 1995, 2677)
1. A carrier serving small employers and a carrier that offers a
contract to a voluntary purchasing group 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 carrier to its insureds.
2. A carrier specified in subsection 1 shall not contract with a
provider of health care to provide health care to an insured unless the
carrier 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 a carrier specified in subsection 1 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 carrier
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 a carrier specified in subsection 1 contracts with a
provider of health care to provide health care to an insured, the carrier
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, 1648 ; A 2001, 2731 ; 2003, 3359 )
1. The Commissioner shall adopt regulations which require a
carrier to file with the Commissioner, for his approval, a disclosure
offered by the carrier to a voluntary purchasing group. The disclosure
must include:
(a) Any significant exception, prior authorization, reduction or
limitation that applies to a contract;
(b) Any restrictions on payments for emergency care, including,
without limitation, related definitions of an emergency and medical
necessity;
(c) Any provision of a contract concerning the carrier’s right to
change premium rates and the characteristics, other than claim
experience, that affect changes in premium rates;
(d) The provisions relating to renewability of contracts;
(e) The provisions relating to any preexisting condition; and
(f) Any other information that the Commissioner finds necessary to
provide for full and fair disclosure of the provisions of a contract.
2. The disclosure must be written in a language which is easily
understood and must include a statement that the disclosure is a summary
of the contract only, and that the contract 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 1995, 2678)
A carrier shall provide to a voluntary purchasing group to
which it has offered a contract a copy of the disclosure approved for
that contract pursuant to NRS 689C.440 before the contract is issued. A carrier
shall not offer a contract to a voluntary purchasing group unless the
disclosure for the contract has been approved by the Commissioner.
(Added to NRS by 1995, 2678)
1. A carrier that offers or issues a contract 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 carrier 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 carrier for making a request
for information regarding the formulary pursuant to subsection 2.
2. If a carrier offers or issues a contract which provides
coverage for prescription drugs and a formulary is used, the carrier
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 carrier 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, 859 )
1. If a carrier offers a contract to a voluntary purchasing group,
the carrier shall offer the same coverage to all of the eligible
employees of the small employers that are members of the voluntary
purchasing group and their dependents. A carrier shall not offer coverage
to only certain members of that group or to only part of that group, but
may exclude an otherwise eligible employee, or his dependent, who
requests enrollment in the contract after the end of the initial period
during which the employee or dependent is entitled to enroll under the
terms of the contract, if the initial period is at least 30 days.
2. A carrier shall not exclude an eligible employee or dependent
if:
(a) The employee or dependent:
(1) Was covered under other creditable coverage at the time
of the initial period for enrollment;
(2) Lost coverage under the other creditable coverage as a
result of termination of employment or eligibility, the involuntary
termination of the creditable coverage, the death of a spouse or divorce;
and
(3) Requests enrollment within 30 days after termination of
the other creditable coverage;
(b) The employee is employed by an employer that offers multiple
contracts and elects a different contract during an open period for
enrollment; or
(c) A court has ordered that coverage be provided for a dependent
under a covered employee’s contract and the request for enrollment is
made within 30 days after issuance of the court order.
(Added to NRS by 1995, 2678; A 1997, 2951)
1. Except as otherwise provided in NRS 689C.360 to 689C.600 , inclusive, a carrier shall renew a contract
as to all insured small employers that are members of a voluntary
purchasing group and their employees and dependents at the request of the
purchaser unless:
(a) Required premiums are not paid;
(b) The insured employer or other purchaser is guilty of fraud or
misrepresentation;
(c) Provisions of the contract are breached;
(d) The number or percentage of employees covered under the
contract is less than the number or percentage of eligible employees
required by the contract;
(e) The employer or purchaser is no longer engaged in the business
in which it was engaged on the effective date of the contract; or
(f) The Commissioner finds that the continuation of the coverage is
not in the best interests of the persons insured under the contract or
would impair the carrier’s ability to meet its contractual obligations.
If nonrenewal occurs as a result of findings pursuant to this subsection,
the Commissioner shall assist affected persons in replacing coverage.
2. A carrier may discontinue issuance and renewal of a form of a
product of a health benefit plan offered to a small employer or
purchasers pursuant to NRS 689C.360
to 689C.600 , inclusive, if the
Commissioner finds that the form of the product offered by the carrier is
obsolete and is being replaced with comparable coverage. A form of a
product of a health benefit plan may be discontinued by a carrier
pursuant to this subsection only if:
(a) The 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 offering and renewing
the form of the product at least 60 days before the carrier notifies the
affected small employers and purchasers pursuant to paragraph (b).
(b) The carrier notifies each affected small employer and
purchaser, and the Commissioner and the chief regulatory officer for
insurance in each state in which any affected small employer is located
or employee resides, of the decision of the carrier to discontinue
offering the form of the product. The notice must be made at least 180
days before the date on which the carrier will discontinue offering the
form of the product.
(c) The carrier offers to each affected small employer and
purchaser the option to purchase any other health benefit plan currently
offered by the carrier to small employers in this state.
(d) In exercising the option to discontinue the particular form of
the product and in offering the option to purchase other coverage
pursuant to paragraph (c), the carrier acts uniformly without regard to
the claim experience of the affected small employers and any health
status-related factor relating to any participant or beneficiary covered
by the discontinued product or any new participant or beneficiary who may
become eligible for such coverage.
3. A carrier may discontinue the issuance and renewal of a health
benefit plan offered to a voluntary purchasing group pursuant to this
chapter only through a bona fide association if:
(a) The membership of the small employer who employs the members of
the voluntary purchasing group or the purchaser in the association was
the basis for the provision of coverage;
(b) The membership of that small employer or the purchaser 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 small employer or the purchaser or his dependent.
(Added to NRS by 1995, 2679; A 1997, 2951)
1. A carrier may cease to renew all contracts covering voluntary
purchasing groups and discontinue issuing and delivering for issuance any
such contracts. The carrier shall provide notice:
(a) At least 60 days before the notice of termination is provided
pursuant to paragraph (b), to the Commissioner and the chief regulatory
officer for insurance of each state in which the carrier is licensed to
transact insurance; and
(b) At least 180 days before termination of coverage to holders of
all affected contracts and to the Commissioner and the chief regulatory
officer for insurance in each state in which an affected insured person
is known to reside.
2. A carrier that exercises its right to cease to renew all
contracts covering voluntary purchasing groups shall not transfer or
otherwise provide coverage to any of the insureds from a nonrenewed
voluntary purchasing group unless the carrier offers to transfer or
provide coverage to all affected employers and eligible employees and
dependents without regard to characteristics of the insured, experience
as to claims, health or duration of coverage.
3. A carrier that decides to terminate its contracts and to
discontinue issuing and delivering for issuance any contracts pursuant to
this section:
(a) Shall discontinue issuance and delivery for issuance all health
benefit plans pursuant to this chapter in this state and, except as
otherwise provided in this section, not renew any such contracts; and
(b) Shall not enter into any new contract with a voluntary
purchasing group for 5 years after the date on which the carrier
terminated its contracts with voluntary purchasing groups.
(Added to NRS by 1995, 2679; A 1997, 2953)
1. Except as otherwise provided in subsection 2, a carrier serving
small employers and a carrier that offers a contract to a voluntary
purchasing group shall approve or deny a claim relating to a policy of
health insurance within 30 days after the carrier receives the claim. If
the claim is approved, the carrier 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 carrier 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 carrier 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 carrier shall notify the provider of health care of all
the specific reasons for the delay in approving or denying the claim. The
carrier shall approve or deny the claim within 30 days after receiving
the additional information. If the claim is approved, the carrier shall
pay the claim within 30 days after it receives the additional
information. If the approved claim is not paid within that period, the
carrier shall pay interest on the claim in the manner prescribed in
subsection 1.
3. A carrier shall not request a claimant to resubmit information
that the claimant has already provided to the carrier, unless the carrier
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. A carrier 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 carrier.
7. The Commissioner may require a carrier to provide evidence
which demonstrates that the carrier 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 a carrier is not in
substantial compliance with the requirements set forth in this section,
the Commissioner may require the carrier to pay an administrative fine in
an amount to be determined by the Commissioner. Upon a second or
subsequent determination that a carrier 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 carrier.
(Added to NRS by 1999, 1648 ; A 2001, 2731 ; 2003, 3359 )
1. A small employer may, in accordance with the provisions of NRS
689C.490 to 689C.600 , inclusive, choose to affiliate voluntarily
with other small employers as a voluntary purchasing group to purchase
health benefits for eligible employees and their dependents.
2. An employer who affiliates with a voluntary purchasing group
shall notify the carrier for that group when the employer has less than 2
or more than 50 employees. The carrier shall:
(a) Upon receiving such a notification, inform the employer of the
provisions of paragraph (b).
(b) If the employer ceases to be a small employer, refuse to renew
the coverage of that employer and his employees and their dependents
under any contract provided through the voluntary purchasing group.
(Added to NRS by 1995, 2679; A 1997, 2953)
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