As used in this chapter, unless the
context otherwise requires, the words and terms defined in NRS 695F.020
to 695F.070 , inclusive, have the meanings ascribed to
them in those sections.
(Added to NRS by 1991, 1113; A 1995, 2439)
“Enrollee” means a person,
including his dependents, who is entitled to a limited health service
pursuant to a contract with a person authorized to provide or arrange for
that service pursuant to this chapter.
(Added to NRS by 1991, 1113)
“Evidence of
coverage” means any certificate, agreement or contract issued to an
enrollee which sets forth the coverage he is entitled to receive.
(Added to NRS by 1991, 1113)
“Limited health
service” means:
1. Chiropractic, dental, hospital, medical, optometric,
pharmaceutical, podiatric or surgical care;
2. Treatment relating to mental health or the abuse of drugs or
alcohol; or
3. Such other care or treatment as may be determined by the
Commissioner to be a limited health service.
(Added to NRS by 1991, 1113; A 1993, 2402)
“Medicaid” means a program
established in any state pursuant to Title XIX of the Social Security Act
(42 U.S.C. §§ 1396 et seq.) to provide assistance for part or all of the
cost of medical care rendered on behalf of indigent persons.
(Added to NRS by 1995, 2437)
“Order for
medical coverage” means an order of a court or administrative tribunal to
provide medical coverage to a child pursuant to the provisions of 42
U.S.C. § 1396g-1.
(Added to NRS by 1995, 2437)
1. “Prepaid limited health service organization” means any person
who, in return for a prepayment, agrees to provide or arrange for the
provision of one or more limited health services to enrollees.
2. The term does not include:
(a) A person otherwise authorized pursuant to the laws of this
state to provide a limited health service on a prepayment basis or any
other basis or to indemnify for any limited health service;
(b) A person who complies with the requirements of NRS 695F.130
; or
(c) A provider who provides or arranges for the provision of a
limited health service pursuant to a contract with a prepaid limited
health service organization or person described in paragraph (a) or (b).
(Added to NRS by 1991, 1113)
“Provider” means any physician,
dentist or any other person who is licensed or otherwise authorized in
this state to provide a limited health service.
(Added to NRS by 1991, 1114)
“Subscriber” means a person
whose employment or other status, except for family dependency, is the
basis for his entitlement to receive a limited health service pursuant to
a contract with a person authorized to provide or arrange for that
service pursuant to this chapter.
(Added to NRS by 1991, 1114)
Except as
otherwise provided in this chapter or in specific provisions of this
title, the provisions of this title are not applicable to any prepaid
limited health service organization granted a certificate of authority
pursuant to this chapter. This section does not apply to an insurer
licensed and regulated pursuant to this title except with respect to its
activities as a prepaid limited health service organization authorized
and regulated pursuant to this chapter.
(Added to NRS by 1991, 1114)
[Effective through
June 30, 2006.] Prepaid limited health service organizations are subject
to the provisions of this chapter and to the following provisions, to the
extent reasonably applicable:
1. NRS 687B.310 to 687B.420
, inclusive, concerning cancellation
and nonrenewal of policies.
2. NRS 687B.122 to 687B.128
, inclusive, concerning readability of
policies.
3. The requirements of NRS 679B.152 .
4. The fees imposed pursuant to NRS 449.465 .
5. NRS 686A.010 to 686A.310
, inclusive, concerning trade
practices and frauds.
6. The assessment imposed pursuant to NRS 679B.700 .
7. Chapter 683A of NRS.
8. To the extent applicable, the provisions of NRS 689B.340 to 689B.590 , inclusive, and chapter 689C of NRS relating to the portability and
availability of health insurance.
9. NRS 689A.035 , 689A.410
and 689A.413 .
10. NRS 680B.025 to 680B.039
, inclusive, concerning premium tax,
premium tax rate, annual report and estimated quarterly tax payments. For
the purposes of this subsection, unless the context otherwise requires
that a section apply only to insurers, any reference in those sections to
“insurer” must be replaced by a reference to “prepaid limited health
service organization.”
11. Chapter 692C of NRS, concerning
holding companies.
12. NRS 689A.637 , concerning
health centers.
(Added to NRS by 1991, 1121; A 1993, 2402; 1997, 1097, 2960, 2962,
3036; 1999, 631 , 1652 ; 2001, 480 , 1924 )
[Effective July 1,
2006.] Prepaid limited health service organizations are subject to the
provisions of this chapter and to the following provisions, to the extent
reasonably applicable:
1. NRS 687B.310 to 687B.420
, inclusive, concerning cancellation
and nonrenewal of policies.
2. NRS 687B.122 to 687B.128
, inclusive, concerning readability of
policies.
3. The requirements of NRS 679B.152 .
4. The fees imposed pursuant to NRS 449.465 .
5. NRS 686A.010 to 686A.310
, inclusive, concerning trade
practices and frauds.
6. The assessment imposed pursuant to NRS 679B.700 .
7. Chapter 683A of NRS.
8. To the extent applicable, the provisions of NRS 689B.340 to 689B.590 , inclusive, and chapter 689C of NRS relating to the portability and
availability of health insurance.
9. NRS 689A.035 , 689A.410
, 689A.413 and 689A.415 .
10. NRS 680B.025 to 680B.039
, inclusive, concerning premium tax,
premium tax rate, annual report and estimated quarterly tax payments. For
the purposes of this subsection, unless the context otherwise requires
that a section apply only to insurers, any reference in those sections to
“insurer” must be replaced by a reference to “prepaid limited health
service organization.”
11. Chapter 692C of NRS, concerning
holding companies.
12. NRS 689A.637 , concerning
health centers.
(Added to NRS by 1991, 1121; A 1993, 2402; 1997, 1097, 2960, 2962,
3036; 1999, 631 , 1652 ; 2001, 480 , 1924 ; 2005, 2346 , effective July 1, 2006)
CERTIFICATE OF AUTHORITY
A person shall not operate a
prepaid limited health service organization in this state unless he has
been issued a certificate of authority by the Commissioner pursuant to
this chapter.
(Added to NRS by 1991, 1114)
An application for a
certificate of authority to operate a prepaid limited health service
organization must be filed with the Commissioner on a form prescribed by
him. The application must be verified by an officer or authorized
representative of the applicant and include:
1. A copy of the applicant’s basic organizational document,
including any articles of incorporation, articles of association,
partnership agreement, trust agreement or any other applicable document
or amendment thereto.
2. A copy of the bylaws, rules and regulations or similar
documents, if any, which regulate the conduct of the internal affairs of
the applicant.
3. A list of the names, addresses, official positions and
biographical information of the persons responsible for conducting the
applicant’s affairs, including, but not limited to:
(a) The members of the board of directors;
(b) The members of the board of trustees;
(c) The members of the executive committee or other governing board
or committee;
(d) The principal officers;
(e) Any person owning or having the right to acquire 10 percent or
more of the voting securities of the applicant; and
(f) If the applicant is a partnership or association, the partners
or members of that partnership or association.
4. A statement generally describing the applicant, its facilities,
employees and the limited health service or services to be offered.
5. A copy of any contract made or to be made between the applicant
and any provider concerning the provision of a limited health service to
enrollees.
6. A copy of any contract made, or to be made between the
applicant and any person described in subsection 3 of this section.
7. A copy of any contract made or to be made between the applicant
and any person for the performance on the applicant’s behalf of any
functions, including, but not limited to, marketing, administration,
enrollment, management of investments and subcontracting for the
provision of a limited health service to enrollees.
8. A copy of the form of any group contract which is to be issued
to employers, unions, trustees or other organizations.
9. A copy of any form for evidence of coverage to be issued to
subscribers.
10. A copy of the applicant’s most recent financial statements
which have been audited by an independent certified public accountant. If
the financial affairs of the parent company of the applicant are audited
by an independent certified public accountant and the financial affairs
of the applicant are not audited, the applicant must submit a copy of the
most recently audited financial statement of the parent company which was
certified by an independent certified public accountant and the
consolidating financial statements of the applicant, unless the
Commissioner determines that additional or more recent financial
information is required.
11. A copy of the applicant’s financial plan, including a 3-year
projection of the anticipated operating results, a statement of the
sources of working capital and any other sources of funding and any plan
for contingencies.
12. A schedule of the rates and charges for the limited health
service.
13. A description of the proposed method of marketing.
14. A statement acknowledging that any process in any legal action
or proceeding against the applicant on a cause of action arising in this
state is valid if lawfully served.
15. A description of the procedure for the resolution of
complaints submitted by enrollees concerning the limited health service
provided by the prepaid limited health service organization.
16. A description of the procedures to be established for quality
assessment and utilization review.
17. A description of the applicant’s plan to comply with the
provisions of NRS 695F.200 .
18. The fee for filing an application for a certificate of
authority.
19. Such other information as the Commissioner may require to make
the determination required by this chapter.
(Added to NRS by 1991, 1114)
1. The Commissioner shall review each application and notify the
applicant of any deficiency contained in the application.
2. The Commissioner shall issue a certificate of authority to an
applicant if:
(a) The applicant has complied with the requirements set forth in
NRS 695F.110 ;
(b) The persons responsible for conducting the applicant’s affairs
are competent, trustworthy and possess good reputations, and have the
appropriate experience, training or education;
(c) The applicant is financially responsible and may reasonably be
expected to carry out its obligations to enrollees and prospective
enrollees; and
(d) The agreements with providers for the limited health service
include the provisions required by NRS 695F.220 .
3. The Commissioner may, when determining whether an applicant
complies with the requirements of paragraph (c) of subsection 2, consider:
(a) The financial soundness of the applicant’s arrangements for the
provision of a limited health service and the schedule of rates,
deductibles, copayments and other charges used in connection therewith;
(b) The adequacy of working capital, any other sources of funding
and any provisions for contingencies;
(c) Any agreement for paying the cost of a limited health service
or for alternative coverage if the prepaid limited health service
organization becomes insolvent; and
(d) The applicant’s manner of compliance with the requirements of
NRS 695F.200 .
(Added to NRS by 1991, 1115)
Any person who is licensed as an
insurer pursuant to chapter 680A of NRS or
issued a certificate of authority pursuant to chapter 695A , 695B or 695C of NRS may submit an application to the
Commissioner for a certificate of authority to provide a limited health
service in this state. The application must include the information
requested by subsections 4, 5, 7, 8, 10, 11, 12 and 15 of NRS 695F.110
and any subsequent material changes
or additions thereto.
(Added to NRS by 1991, 1116)
1. If the Commissioner denies an application for a certificate of
authority of a person who files an application pursuant to NRS 695F.120
or 695F.130 , he shall send a written notice to the
applicant. The notice must include the reason for the denial of the
certificate.
2. The applicant may, within 30 days after it receives the notice,
submit to the Commissioner a written request for a hearing on the matter.
The Commissioner shall hold a hearing within 30 days after he receives
the request.
3. The hearing must be held in the manner set forth in NRS
679B.310 to 679B.370 , inclusive. The decision of the Commissioner
is a final decision for the purpose of judicial review.
(Added to NRS by 1991, 1116)
OPERATION
1. A prepaid limited health service organization shall issue
evidence of coverage to each subscriber. Each evidence of coverage must
contain a clear and complete statement of:
(a) The limited health service which the enrollee is entitled to
receive;
(b) Any limitation of that service, type of service or benefits to
be provided, and exclusions, including any deductible, copayment or other
charges;
(c) Where and in what manner information is available concerning
the location of and manner in which the limited health service may be
obtained; and
(d) The method established for the resolution of complaints
submitted by enrollees concerning the provision of the limited health
service.
2. A prepaid limited health service organization may provide to a
subscriber any amendment to the evidence of coverage in a separate
document.
(Added to NRS by 1991, 1116)
1. A prepaid limited health service organization that offers or
issues evidence of coverage which provides coverage for prescription
drugs shall include with any evidence of that coverage provided to a
subscriber, notice of whether a formulary is used and, if so, of the
opportunity to secure information regarding the formulary from the
organization 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 organization for making a
request for information regarding the formulary pursuant to subsection 2.
2. If a prepaid limited health service organization offers or
issues evidence of coverage which provides coverage for prescription
drugs and a formulary is used, the organization shall:
(a) Provide to any enrollee 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 organization 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, 864 )
1. Except as otherwise provided in this section, evidence of
coverage 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 prepaid
limited health service organization for a medical condition of an
enrollee and the enrollee’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 enrollee; and
(b) Is appropriately prescribed and considered safe and effective
for treating the medical condition of the enrollee.
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 organization from charging a deductible, copayment
or coinsurance for the provision of benefits for prescription drugs to
the enrollee 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 evidence of coverage that is medically appropriate for the
enrollee; 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 evidence
of coverage.
3. Any provision of an evidence of coverage 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, 865 ; A 2003, 2301 )
The rates and
charges for a limited health service must be reasonable. The commissioner
may request information from the prepaid limited health service
organization to determine the reasonableness of those rates and charges.
(Added to NRS by 1991, 1117)
1. A prepaid limited health service organization shall file with
the Commissioner a notice of any change in the rates, charges, benefits
or any material change of any matter or document furnished pursuant to
NRS 695F.110 . The organization shall
submit any proof necessary to justify the change. No such change is
effective unless it is approved by the Commissioner. If the Commissioner
does not disapprove of the change within 60 days after the notice is
filed, the change shall be deemed approved.
2. If a prepaid limited health service organization wishes to add
a limited health service, it shall submit:
(a) An application to the Commissioner;
(b) The information required by NRS 695F.110 , if the information is different from the
information filed with the prepaid limited health service organization’s
application; and
(c) Proof of compliance with NRS 695F.200 , 695F.220 and 695F.340 .
Ê A prepaid limited health service organization may not add a limited
health service if the Commissioner determines that adding the service
would qualify the organization as a health maintenance organization
pursuant to chapter 695C of NRS or as an
offeror of a health care plan for which a certificate of authority is
required by any other provisions of this title.
3. If the Commissioner does not deny the application within 60
days after it is filed, the application shall be deemed approved.
4. If the application is denied, the Commissioner shall send a
written notice to the prepaid limited health service organization. The
notice must include the reason for the denial. The prepaid limited health
service organization may request a hearing in the manner set forth in NRS
695F.140 .
(Added to NRS by 1991, 1116; A 1993, 2402)
The money of the prepaid limited health
service organization must be invested in accordance with the guidelines
established by the National Association of Insurance Commissioners for
investments by health maintenance organizations.
(Added to NRS by 1991, 1118)
1. A prepaid limited health service organization shall set aside a
reserve equal to 3 percent of the premiums collected from its enrollees
in an amount not to exceed $500,000. The reserve is in addition to the
bond or deposit filed with the Commissioner.
2. The reserve:
(a) Must be deposited in a trust account in a financial institution
which is located in this state and which is federally insured or insured
by a private insurer approved pursuant to NRS 678.755 . The income earned on money in the account
must be paid to the organization and used for its operations.
(b) Is in addition to the reserve established by the organization
according to good business and accounting practices for incurred but
unreported claims and other similar claims.
(Added to NRS by 1991, 1118; A 1999, 1554 )
Each
prepaid limited health service organization which receives a certificate
of authority shall maintain a:
1. Capital account with a net worth of not less than $200,000
unless a lesser amount is permitted in writing by the Commissioner. The
account must not be obligated for any accrued liabilities and must
consist of cash, securities or a combination thereof which is acceptable
to the Commissioner.
2. Surety bond or deposit of cash or securities for the protection
of enrollees of not less than $250,000.
(Added to NRS by 1991, 1118)
1. A prepaid limited health service organization shall maintain in
force a fidelity bond in its own name on its officers and employees in an
amount not less than $1,000,000 or in any other amount prescribed by the
Commissioner.
2. Except as otherwise provided in subsection 3, the bond must be
issued by an insurer licensed to do business in this State.
3. If the fidelity bond is not available from an insurer licensed
to do business in this State, a prepaid limited health service
organization may procure a fidelity bond from a surplus lines broker
licensed pursuant to chapter 685A of NRS.
4. In lieu of the bond required pursuant to subsection 1, a
prepaid limited health service organization may deposit with the
Commissioner cash, securities or other investments described in NRS
695F.180 . The deposit must be
maintained in joint custody with the Commissioner in the amount and
subject to the same conditions required for a bond pursuant to this
subsection.
(Added to NRS by 1991, 1119)
A prepaid limited health service organization shall
contract with an insurance company licensed in this State or authorized
to do business in this State for the provision of insurance, indemnity or
reimbursement against the cost of health care services provided by the
prepaid limited health service organization.
(Added to NRS by 1997, 3036)
Each contract
between a prepaid limited health service organization and a provider or
other person subcontracting for the provision of a limited health service
to enrollees on a prepayment basis or any other basis must contain the
following terms and conditions:
1. If the prepaid limited health service organization fails to pay
for a limited health service for any reason, including, but not limited
to, insolvency or breach of this contract, the enrollees are not liable
to the provider for any money owed to the provider pursuant to this
contract.
2. A provider, agent, trustee or assignee thereof may not maintain
an action at law or attempt to collect from an enrollee any money which
the prepaid limited health service organization owes to the provider.
3. These provisions do not prohibit the collection of any
uncovered charges which an enrollee agreed to pay or the collection of
any copayment from an enrollee.
4. These provisions survive the termination of this contract,
regardless of the reason for the termination.
5. The termination of this contract does not release the provider
from its obligation to complete any procedure on an enrollee who is
receiving treatment for a specific condition for a period not to exceed
60 days, at the same schedule of copayment or any other applicable charge
in effect when this contract is terminated.
6. Any amendment to the provisions of this contract must be
submitted to the Commissioner for approval before the amendment is
effective.
(Added to NRS by 1991, 1118)
1. Each prepaid limited health service organization shall
establish a system for the resolution of written complaints submitted by
enrollees and providers.
2. The provisions of subsection 1 do not prohibit an enrollee or
provider from filing a complaint with the Commissioner or limit the
Commissioner’s authority to investigate such a complaint.
3. Each prepaid limited health service organization that issues
any evidence of coverage that provides, delivers, arranges for, pays for
or reimburses any cost of health care services through managed care shall
provide a system for resolving any complaints of an enrollee or
subscriber concerning those health care services that complies with the
provisions of NRS 695G.200 to
695G.310 , inclusive.
(Added to NRS by 1991, 1117; A 2003, 779 )
REGULATION AND ENFORCEMENT
The Commissioner shall
adopt regulations to carry out the provisions of this chapter.
(Added to NRS by 1991, 1121)
1. The Commissioner may examine the affairs of any prepaid limited
health service organization as often as is reasonably necessary to
protect the interests of the residents of this state, but not less
frequently than once every 2 years.
2. A prepaid limited health service organization shall make its
books and records available for examination and cooperate with the
Commissioner to facilitate the examination.
3. In lieu of such an examination, the Commissioner may accept the
report of an examination conducted by the commissioner of insurance of
another state.
4. The reasonable expenses of an examination conducted pursuant to
this section must be charged to the organization being examined and
remitted to the Commissioner.
(Added to NRS by 1991, 1117)
1. Each prepaid limited health service organization shall file
with the Commissioner annually, on or before March 1, a report showing
its financial condition on the last day of the preceding calendar year.
The report must be verified by at least two principal officers of the
organization.
2. The report must be on a form prescribed by the Commissioner and
include:
(a) A financial statement of the organization, including its
balance sheet and receipts and disbursements for the preceding calendar
year;
(b) The number of subscribers at the beginning and the end of the
year and the number of enrollments terminated during the year; and
(c) Such other information as the Commissioner may prescribe.
3. Each prepaid limited health service organization shall file
with the Commissioner annually an audited financial statement prepared by
an independent certified public accountant. The statement must cover the
most recent fiscal year of the organization and must be filed with the
Commissioner within 120 days after the end of that fiscal year.
4. The Commissioner may require more frequent reports containing
such information as is necessary to enable him to carry out his duties
pursuant to this chapter.
5. The Commissioner may:
(a) Assess a fine of not more than $100 per day for each day the
report or financial statement required pursuant to this section is not
filed after the report or financial statement is due, but the fine must
not exceed $3,000; and
(b) Suspend the organization’s certificate of authority until the
organization files the report.
(Added to NRS by 1991, 1119; A 1995, 1634, 2683)
At the time of filing the annual
report pursuant to NRS 695F.320 the
prepaid limited health service organization shall forward to the
Department of Taxation the tax and any penalty for nonpayment or
delinquent payment of the tax in accordance with the provisions of
chapter 680B of NRS.
(Added to NRS by 1991, 1121; A 1993, 1923)
Each prepaid limited health service
organization shall pay to the Commissioner the following fees:
For filing an application for a certificate of
authority.................................... $2,450
For issuance of a certificate of
authority..............................................................
283
For the renewal of a certificate of
authority...................................................... 2,450
For filing a material change or addition of a limited health
service.................. 100
For filing an annual
report.....................................................................
................... 25
For filing periodic reports required by the
Commissioner................................... 25
(Added to NRS by 1991, 1121; A 1993, 2403)
1. The Commissioner may suspend or revoke the certificate of
authority of a prepaid limited health service organization issued
pursuant to this chapter if he determines that:
(a) The prepaid limited health service organization is operating
substantially in violation of its basic organizational document or in a
manner contrary to the manner described in and reasonably inferred from
any other information submitted pursuant to NRS 695F.110 unless any amendment to its basic
organization document or other information has been filed with and
approved by the Commissioner;
(b) The prepaid limited health service organization issued an
evidence of coverage or used rates or charges which do not comply with
the requirements of NRS 695F.150 and
695F.160 ;
(c) The prepaid limited health service organization is not able to
carry out its obligations to provide its limited health service;
(d) The prepaid limited health service organization is not
financially responsible and may reasonably be expected to be unable to
carry out its obligations to enrollees or prospective enrollees;
(e) The capital of the prepaid limited health service organization
is less than the amount required by NRS 695F.200 or the organization has failed to correct
any deficiency concerning its capital as required by the Commissioner;
(f) The prepaid limited health service organization has failed to
establish and maintain in a reasonable manner the complaint system
required by NRS 695F.230 ;
(g) The continued operation of the prepaid limited health service
organization would be hazardous to its enrollees; or
(h) The prepaid limited health service organization has failed to
comply with any other provision of this chapter.
2. If the Commissioner has cause to believe that grounds for the
suspension or revocation of a certificate of authority of a prepaid
limited health service organization exist, he shall send written notice
to the organization. The notice must include the reason for the
suspension or revocation and a time not more than 30 days thereafter for
a hearing on the matter. The hearing must be held in the manner set forth
in NRS 695F.140 .
3. If the certificate of authority of a prepaid limited health
service organization is revoked, the organization shall proceed,
immediately following the effective date of the order of revocation, to
wind up its affairs. The organization shall not:
(a) Conduct any further business unless it is essential for the
orderly conclusion of its affairs; and
(b) Engage in any further advertising or solicitation.
4. The Commissioner may, by written order, permit such further
operation of the organization as he considers necessary to enable the
enrollees to obtain limited health services from another organization or
provider.
(Added to NRS by 1991, 1119)
If the Commissioner, after a hearing held pursuant to NRS 695F.140
, finds that a prepaid limited health
service organization or other person subject to this chapter has violated
a provision of this chapter, he may:
1. Issue and cause to be served upon the organization or any other
person charged with a violation of this chapter, a copy of his findings
and an order directing the organization or person to cease and desist
from engaging in the act or practice which constitutes the violation; and
2. Impose a fine of not more than $1,000 for each violation, not
to exceed a total amount of $10,000.
(Added to NRS by 1991, 1120)
MISCELLANEOUS PROVISIONS
A person shall
not apply, procure, negotiate or place for another person any policy or
contract of a prepaid limited health service organization unless he holds
a license issued pursuant to chapter 683A
of NRS.
(Added to NRS by 1991, 1118)
1. Any information relating to the diagnosis, treatment or health
of any enrollee obtained from the enrollee or from any provider by a
prepaid limited health service organization and any contract with a
provider submitted pursuant to the requirements of this chapter must not
be disclosed to any person except:
(a) To the extent that it is necessary to carry out the provisions
of this chapter;
(b) Upon the written consent of the enrollee or applicant, provider
or prepaid limited health service organization, as appropriate;
(c) Pursuant to a specific statute or court order for the
production of evidence or the discovery thereof; or
(d) For a claim or legal action if that data or information is
relevant.
2. A prepaid limited health service organization may claim any
privilege against disclosure which the provider who furnished the
information relating to the diagnosis, treatment or health of an enrollee
or applicant to the organization is entitled to claim.
(Added to NRS by 1991, 1121)
Notwithstanding any other
provision of this title, any person who is licensed as an insurer
pursuant to chapter 680A of NRS or issued a
certificate of authority pursuant to chapter 695A , 695B or 695C of NRS may exclude, in any contract or policy
issued to a group, any coverage which would duplicate the coverage of a
limited health service, whether for services, supplies or reimbursement,
to the extent that the coverage or service is provided in accordance with
this chapter pursuant to a contract or policy issued to the same group or
to a part of that group by a prepaid limited health service organization
or a person who is licensed as an insurer pursuant to chapter 680A of NRS or issued a certificate of authority
pursuant to chapter 695A , 695B or 695C of NRS.
(Added to NRS by 1991, 1117)
1. The provision of limited health services by a prepaid limited
health service organization or any other person pursuant to this chapter
shall not be deemed to be the practice of medicine or any other healing
arts.
2. The solicitation by a prepaid limited health service
organization to arrange for or provide a limited health service in
accordance with this chapter does not violate any statutory provision
relating to solicitation or advertising by a practitioner of a healing
art.
(Added to NRS by 1991, 1117)
ELIGIBILITY FOR COVERAGE
1. An organization shall not, when considering eligibility for
coverage or making payments under any evidence of coverage, consider the
availability of, or eligibility of a person for, medical assistance under
Medicaid.
2. To the extent that payment has been made by Medicaid for health
care a prepaid limited health service organization:
(a) Shall treat Medicaid as having a valid and enforceable
assignment of benefits due a subscriber or claimant under him regardless
of any exclusion of Medicaid or the absence of a written assignment; and
(b) May, as otherwise allowed by its evidence of coverage or
contract and applicable law or regulation concerning subrogation, seek to
enforce any rights of a recipient of Medicaid against any other liable
party if:
(1) It is so authorized pursuant to a contract with Medicaid
for managed care; or
(2) It has reimbursed Medicaid in full for the health care
provided by Medicaid to its subscriber.
3. If a state agency is assigned any rights of a person who is:
(a) Eligible for medical assistance under Medicaid; and
(b) Covered by any evidence of coverage,
Ê the prepaid limited health service organization that issued the
evidence of coverage shall not impose any requirements upon the state
agency except requirements it imposes upon the agents or assignees of
other persons covered by any evidence of coverage.
(Added to NRS by 1995, 2437)
A prepaid limited health service organization shall not deny
the enrollment of a child pursuant to an order for medical coverage under
any evidence of coverage pursuant to which a parent of the child is
insured on the ground that the child:
1. Was born out of wedlock;
2. Has not been claimed as a dependent on the parent’s federal
income tax return; or
3. Does not reside with the parent or within the organization’s
geographic area of service.
(Added to NRS by 1995, 2438)
If a child
has coverage under any evidence of coverage pursuant to which a
noncustodial parent of the child is insured, the prepaid limited health
service organization issuing that evidence of coverage shall:
1. Provide to the custodial parent such information as necessary
for the child to obtain any benefits under that coverage.
2. Allow the custodial parent or, with the approval of the
custodial parent, a provider to submit claims for covered services
without the approval of the noncustodial parent.
3. Make payments on claims submitted pursuant to subsection 2
directly to the custodial parent, the provider or an agency of this or
another state responsible for the administration of Medicaid.
(Added to NRS by 1995, 2438)
If a parent is required
by an order for medical coverage to provide coverage for a child and the
parent is eligible for coverage of members of his family under any
evidence of coverage, the prepaid limited health service organization
that issued the evidence of coverage:
1. Shall, if the child is otherwise eligible for that coverage,
allow the parent to enroll the child in that coverage without regard to
any restrictions upon periods for enrollment.
2. Shall, if:
(a) The child is otherwise eligible for that coverage; and
(b) The parent is enrolled in that coverage but fails to apply for
enrollment of the child,
Ê enroll the child in that coverage upon application by the other parent
of the child, or by an agency of this or another state responsible for
the administration of Medicaid or a state program for the enforcement of
child support established pursuant to 42 U.S.C. §§ 651 et seq., without
regard to any restrictions upon periods for enrollment.
3. Shall not terminate the enrollment of the child in that
coverage or otherwise eliminate that coverage of the child unless the
prepaid limited health service organization has written proof that:
(a) The order for medical coverage is no longer in effect; or
(b) The child is or will be enrolled in comparable coverage through
another insurer on or before the effective date of the termination of
enrollment or elimination of coverage.
(Added to NRS by 1995, 2438)
1. If a person:
(a) Adopts a dependent child; or
(b) Assumes and retains a legal obligation for the total or partial
support of a dependent child in anticipation of adopting the child,
Ê while the person is eligible for group coverage under any evidence of
coverage, the prepaid limited health service organization issuing that
evidence of coverage shall not restrict the coverage of the child based
solely on a preexisting condition the child has at the time he would
otherwise become eligible for coverage pursuant to that evidence of
coverage. Any provision relating to an exclusion for a preexisting
condition must comply with NRS 689B.500 or 689C.190 , as appropriate.
2. For the purposes of this section, “child” means a person who is
under 18 years of age at the time of his adoption or the assumption of a
legal obligation for his support in anticipation of his adoption.
(Added to NRS by 1995, 2439; A 1997, 2960)
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