USA Statutes : nevada
Title : Title 57 - INSURANCE
Chapter : CHAPTER 689B - GROUP AND BLANKET HEALTH INSURANCE
1. This chapter may be cited as the Group or Blanket Health
Insurance Law.
2. This chapter applies only to group health insurance contracts
and to blanket accident and health insurance contracts as provided in
this chapter.
(Added to NRS by 1971, 1767; A 2001, 2220 )
1. An insurer that issues a policy of group health insurance shall
not charge a provider of health care a fee to include the name of the
provider on a list of providers of health care given by the insurer to
its insureds.
2. An insurer specified in subsection 1 shall not contract with a
provider of health care to provide health care to an insured unless the
insurer uses the form prescribed by the Commissioner pursuant to NRS
629.095 to obtain any information
related to the credentials of the provider of health care.
3. A contract between an insurer 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 insurer
upon giving to the provider 30 days’ written notice of the modification.
If the provider fails to object in writing to the modification within the
30-day period, the modification becomes effective at the end of that
period. If the provider objects in writing to the modification within the
30-day period, the modification must not become effective unless agreed
to by both parties as described in paragraph (a).
4. If an insurer specified in subsection 1 contracts with a
provider of health care to provide health care to an insured, the insurer
shall:
(a) If requested by the provider of health care at the time the
contract is made, submit to the provider of health care the schedule of
payments applicable to the provider of health care; or
(b) If requested by the provider of health care at any other time,
submit to the provider of health care the schedule of payments specified
in paragraph (a) within 7 days after receiving the request.
5. As used in this section, “provider of health care” means a
provider of health care who is licensed pursuant to chapter 630 , 631 , 632 or 633 of NRS.
(Added to NRS by 1999, 1648 ; A 2001, 2730 ; 2003, 3357 )
GROUP POLICIES
1. “Group health insurance” is hereby declared to be that form of
health insurance covering groups of two or more persons, formed for a
purpose other than obtaining insurance.
2. Any group health policy which contains provisions for the
payment by the insurer of benefits for expenses incurred on account of
hospital, nursing, medical, dental or surgical services, home health care
or health supportive services for members of the family or dependents of
a person in the insured group may provide for the continuation of such
benefit provisions, or any part or parts thereof, after the death of the
person in the insured group.
3. The Commissioner may, in his discretion, require the form of
each certificate proposed to be delivered in this state under a group
health policy not made under the laws of this state to be filed with him
by the insurer for informational purposes only.
(Added to NRS by 1971, 1767; A 1971, 1954; 1975, 447)
1. Except as otherwise provided in this section, no policy of
group health insurance may be delivered or issued for delivery in this
state to a group which was formed for the purpose of purchasing one or
more policies of group health insurance.
2. A policy of group health insurance may be delivered to a group
described in subsection 1 if the Commissioner approves the issuance. The
Commissioner shall not grant his approval unless he finds that:
(a) The benefits of the policy are reasonable in relation to the
premiums charged; and
(b) The group to which the policy is issued is organized and
operated in a fiscally sound manner.
3. Upon approval by the Commissioner, an insurer may exclude or
limit the coverage in a policy issued pursuant to this section of any
person as to whom evidence of insurability is not satisfactory to the
insurer.
4. The provisions of this section apply to the offering in this
state of a policy issued in another state.
(Added to NRS by 1985, 1060; A 1995, 1628)
1. The Commissioner shall adopt regulations which require an
insurer to file with the Commissioner, for his approval, a disclosure
summarizing the coverage provided by each policy of group health
insurance offered by the insurer. 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
related definitions of an emergency and medical necessity;
(c) Any provisions concerning the insurer’s right to change premium
rates and the characteristics, other than claim experience, that affect
changes in premium rates;
(d) Any provisions relating to renewability;
(e) Any provisions relating to preexisting conditions; and
(f) Any other information,
Ê that the Commissioner finds necessary to provide for full and fair
disclosure of the provisions of the policy.
2. The disclosure must be written in language which is easily
understood and include a statement that the disclosure is a summary of
the policy only, and that the policy 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 insurer shall make available to an employer or a producer
acting on behalf of an employer upon request a copy of the disclosure
approved by the Commissioner pursuant to this section for each policy of
health insurance coverage for which that employer may be eligible.
(Added to NRS by 1989, 1249; A 1991, 1846; 1997, 2913; 1999, 2806
)
An insurer shall provide to the group policyholder to whom
it offers a policy of group health insurance a copy of the disclosure
approved for that policy pursuant to NRS 689B.027 before the policy is issued. An insurer
shall not offer a policy of health insurance unless the disclosure for
that policy has been approved by the Commissioner.
(Added to NRS by 1989, 1249)
1. An insurer that offers or issues a policy of group health
insurance which provides coverage for prescription drugs shall include
with any summary, certificate or evidence of that coverage provided to an
insured, notice of whether a formulary is used and, if so, of the
opportunity to secure information regarding the formulary from the
insurer pursuant to subsection 2. The notice required by this subsection
must:
(a) Be in a language that is easily understood and in a format that
is easy to understand;
(b) Include an explanation of what a formulary is; and
(c) If a formulary is used, include:
(1) An explanation of:
(I) How often the contents of the formulary are
reviewed; and
(II) The procedure and criteria for determining which
prescription drugs are included in and excluded from the formulary; and
(2) The telephone number of the insurer for making a request
for information regarding the formulary pursuant to subsection 2.
2. If an insurer offers or issues a policy of group health
insurance which provides coverage for prescription drugs and a formulary
is used, the insurer shall:
(a) Provide to any insured or participating provider of health
care, upon request:
(1) Information regarding whether a specific drug is
included in the formulary.
(2) Access to the most current list of prescription drugs in
the formulary, organized by major therapeutic category, with an
indication of whether any listed drugs are preferred over other listed
drugs. If more than one formulary is maintained, the insurer shall notify
the requester that a choice of formulary lists is available.
(b) Notify each person who requests information regarding the
formulary, that the inclusion of a drug in the formulary does not
guarantee that a provider of health care will prescribe that drug for a
particular medical condition.
(Added to NRS by 2001, 857 )
1. Except as otherwise provided in subsection 4, each insurer that
issues a policy of group health insurance in this State shall establish a
system for resolving any complaints of an insured concerning health care
services covered under the policy. The system must be approved by the
Commissioner in consultation with the State Board of Health.
2. A system for resolving complaints established pursuant to
subsection 1 must include an initial investigation, a review of the
complaint by a review board and a procedure for appealing a determination
regarding the complaint. The majority of the members on a review board
must be insureds who receive health care services pursuant to a policy of
group health insurance issued by the insurer.
3. The Commissioner or the State Board of Health may examine the
system for resolving complaints established pursuant to subsection 1 at
such times as either deems necessary or appropriate.
4. Each insurer that issues a policy of group health insurance in
this State that provides, delivers, arranges for, pays for or reimburses
any cost of health care services through managed care shall provide a
system for resolving any complaints of an insured concerning the health
care services that complies with the provisions of NRS 695G.200 to 695G.310 , inclusive.
(Added to NRS by 1997, 309; A 2003, 775 )
1. Each insurer that issues a policy of group health insurance in
this State shall submit to the Commissioner and the State Board of Health
an annual report regarding its system for resolving complaints
established pursuant to subsection 1 of NRS 689B.0285 on a form prescribed by the Commissioner in
consultation with the State Board of Health which includes, without
limitation:
(a) A description of the procedures used for resolving any
complaints of an insured;
(b) The total number of complaints and appeals handled through the
system for resolving complaints since the last report and a compilation
of the causes underlying the complaints filed;
(c) The current status of each complaint and appeal filed; and
(d) The average amount of time that was needed to resolve a
complaint and an appeal, if any.
2. Each insurer shall maintain records of complaints filed with it
which concern something other than health care services and shall submit
to the Commissioner a report summarizing such complaints at such times
and in such format as the Commissioner may require.
(Added to NRS by 1997, 309; A 2003, 775 )
1. Following approval by the Commissioner, each insurer that
issues a policy of group health insurance in this State shall provide
written notice to an insured, in clear and comprehensible language that
is understandable to an ordinary layperson, explaining the right of the
insured to file a written complaint. Such notice must be provided to an
insured:
(a) At the time he receives his certificate of coverage or evidence
of coverage;
(b) Any time that the insurer denies coverage of a health care
service or limits coverage of a health care service to an insured; and
(c) Any other time deemed necessary by the Commissioner.
2. Any time that an insurer denies coverage of a health care
service, including, without limitation, denying a claim relating to a
policy of group health insurance or blanket insurance pursuant to NRS
689B.255 , to an insured it shall
notify the insured in writing within 10 working days after it denies
coverage of the health care service of:
(a) The reason for denying coverage of the service;
(b) The criteria by which the insurer determines whether to
authorize or deny coverage of the health care service; and
(c) His right to file a written complaint and the procedure for
filing such a complaint.
3. A written notice which is approved by the Commissioner shall be
deemed to be in clear and comprehensible language that is understandable
to an ordinary layperson.
(Added to NRS by 1997, 309; A 1999, 3084 )
Each group health insurance
policy must contain in substance the following provisions:
1. A provision that, in the absence of fraud, all statements made
by applicants or the policyholders or by an insured person are
representations and not warranties, and that no statement made for the
purpose of effecting insurance voids the insurance or reduces its
benefits unless the statement is contained in a written instrument signed
by the policyholder or the insured person, a copy of which has been
furnished to him or his beneficiary.
2. A provision that the insurer will furnish to the policyholder
for delivery to each employee or member of the insured group a statement
in summary form of the essential features of the insurance coverage of
that employee or member and to whom benefits thereunder are payable. If
dependents are included in the coverage, only one statement need be
issued for each family.
3. A provision that to the group originally insured may be added
from time to time eligible new employees or members or dependents, as the
case may be, in accordance with the terms of the policy.
4. A provision for benefits for expense arising from care at home
or health supportive services if the care or service was prescribed by a
physician and would have been covered by the policy if performed in a
medical facility or facility for the dependent as defined in chapter 449
of NRS.
5. A provision for benefits payable for expenses incurred for the
treatment of the abuse of alcohol or drugs, as provided in NRS 689B.036
.
6. A provision for benefits for expenses arising from hospice care.
(Added to NRS by 1971, 1767; A 1975, 448, 1850; 1979, 1178; 1983,
1934, 2037; 1985, 1774; 1989, 1032)
1. The provisions of this section apply to a policy of group
health insurance offered or issued by an insurer if an insured covered by
the policy receives health care through a defined set of providers of
health care who are under contract with the insurer.
2. Except as otherwise provided in this section, if an insured who
is covered by a policy described in subsection 1 is receiving medical
treatment for a medical condition from a provider of health care whose
contract with the insurer is terminated during the course of the medical
treatment, the policy must provide that:
(a) The insured may continue to obtain medical treatment for the
medical condition from the provider of health care pursuant to this
section, if:
(1) The insured is actively undergoing a medically necessary
course of treatment; and
(2) The provider of health care and the insured agree that
the continuity of care is desirable.
(b) The provider of health care is entitled to receive
reimbursement from the insurer for the medical treatment he provides to
the insured pursuant to this section, if the provider of health care
agrees:
(1) To provide medical treatment under the terms of the
contract between the provider of health care and the insurer with regard
to the insured, including, without limitation, the rates of payment for
providing medical service, as those terms existed before the termination
of the contract between the provider of health care and the insurer; and
(2) Not to seek payment from the insured for any medical
service provided by the provider of health care that the provider of
health care could not have received from the insured were the provider of
health care still under contract with the insurer.
3. The coverage required by subsection 2 must be provided until
the later of:
(a) The 120th day after the date the contract is terminated; or
(b) If the medical condition is pregnancy, the 45th day after:
(1) The date of delivery; or
(2) If the pregnancy does not end in delivery, the date of
the end of the pregnancy.
4. The requirements of this section do not apply to a provider of
health care if:
(a) The provider of health care was under contract with the insurer
and the insurer terminated that contract because of the medical
incompetence or professional misconduct of the provider of health care;
and
(b) The insurer did not enter into another contract with the
provider of health care after the contract was terminated pursuant to
paragraph (a).
5. A policy subject to the provisions of this chapter that is
delivered, issued for delivery or renewed on or after October 1, 2003,
has the legal effect of including the coverage required by this section,
and any provision of the policy or renewal thereof that is in conflict
with this section is void.
6. The Commissioner shall adopt regulations to carry out the
provisions of this section.
(Added to NRS by 2003, 3356 )
1. A policy of group health insurance must provide coverage for
medical treatment which a person insured under the group policy receives
as part of a clinical trial or study if:
(a) The medical treatment is provided in a Phase I, Phase II, Phase
III or Phase IV study or clinical trial for the treatment of cancer or in
a Phase II, Phase III or Phase IV study or clinical trial for the
treatment of chronic fatigue syndrome;
(b) The clinical trial or study is approved by:
(1) An agency of the National Institutes of Health as set
forth in 42 U.S.C. § 281(b);
(2) A cooperative group;
(3) The Food and Drug Administration as an application for a
new investigational drug;
(4) The United States Department of Veterans Affairs; or
(5) The United States Department of Defense;
(c) In the case of:
(1) A Phase I clinical trial or study for the treatment of
cancer, the medical treatment is provided at a facility authorized to
conduct Phase I clinical trials or studies for the treatment of cancer; or
(2) A Phase II, Phase III or Phase IV study or clinical
trial for the treatment of cancer or chronic fatigue syndrome, the
medical treatment is provided by a provider of health care and the
facility and personnel for the clinical trial or study have the
experience and training to provide the treatment in a capable manner;
(d) There is no medical treatment available which is considered a
more appropriate alternative medical treatment than the medical treatment
provided in the clinical trial or study;
(e) There is a reasonable expectation based on clinical data that
the medical treatment provided in the clinical trial or study will be at
least as effective as any other medical treatment;
(f) The clinical trial or study is conducted in this State; and
(g) The insured has signed, before his participation in the
clinical trial or study, a statement of consent indicating that he has
been informed of, without limitation:
(1) The procedure to be undertaken;
(2) Alternative methods of treatment; and
(3) The risks associated with participation in the clinical
trial or study, including, without limitation, the general nature and
extent of such risks.
2. Except as otherwise provided in subsection 3, the coverage for
medical treatment required by this section is limited to:
(a) Coverage for any drug or device that is approved for sale by
the Food and Drug Administration without regard to whether the approved
drug or device has been approved for use in the medical treatment of the
insured person.
(b) The cost of any reasonably necessary health care services that
are required as a result of the medical treatment provided in a Phase II,
Phase III or Phase IV clinical trial or study or as a result of any
complication arising out of the medical treatment provided in a Phase II,
Phase III or Phase IV clinical trial or study, to the extent that such
health care services would otherwise be covered under the policy of group
health insurance.
(c) The cost of any routine health care services that would
otherwise be covered under the policy of group health insurance for an
insured participating in a Phase I clinical trial or study.
(d) The initial consultation to determine whether the insured is
eligible to participate in the clinical trial or study.
(e) Health care services required for the clinically appropriate
monitoring of the insured during a Phase II, Phase III or Phase IV
clinical trial or study.
(f) Health care services which are required for the clinically
appropriate monitoring of the insured during a Phase I clinical trial or
study and which are not directly related to the clinical trial or study.
Ê Except as otherwise provided in NRS 689B.0303 , the services provided pursuant to
paragraphs (b), (c), (e) and (f) must be covered only if the services are
provided by a provider with whom the insurer has contracted for such
services. If the insurer has not contracted for the provision of such
services, the insurer shall pay the provider the rate of reimbursement
that is paid to other providers with whom the insurer has contracted for
similar services and the provider shall accept that rate of reimbursement
as payment in full.
3. Particular medical treatment described in subsection 2 and
provided to a person insured under the group policy is not required to be
covered pursuant to this section if that particular medical treatment is
provided by the sponsor of the clinical trial or study free of charge to
the person insured under the group policy.
4. The coverage for medical treatment required by this section
does not include:
(a) Any portion of the clinical trial or study that is customarily
paid for by a government or a biotechnical, pharmaceutical or medical
industry.
(b) Coverage for a drug or device described in paragraph (a) of
subsection 2 which is paid for by the manufacturer, distributor or
provider of the drug or device.
(c) Health care services that are specifically excluded from
coverage under the insured’s policy of group health insurance, regardless
of whether such services are provided under the clinical trial or study.
(d) Health care services that are customarily provided by the
sponsors of the clinical trial or study free of charge to the
participants in the trial or study.
(e) Extraneous expenses related to participation in the clinical
trial or study including, without limitation, travel, housing and other
expenses that a participant may incur.
(f) Any expenses incurred by a person who accompanies the insured
during the clinical trial or study.
(g) Any item or service that is provided solely to satisfy a need
or desire for data collection or analysis that is not directly related to
the clinical management of the insured.
(h) Any costs for the management of research relating to the
clinical trial or study.
5. An insurer who delivers or issues for delivery a policy of
group health insurance specified in subsection 1 may require copies of
the approval or certification issued pursuant to paragraph (b) of
subsection 1, the statement of consent signed by the insured, protocols
for the clinical trial or study and any other materials related to the
scope of the clinical trial or study relevant to the coverage of medical
treatment pursuant to this section.
6. An insurer who delivers or issues for delivery a policy of
group health insurance specified in subsection 1 shall:
(a) Include in the disclosure required pursuant to NRS 689B.027
notice to each group policyholder of
the availability of the benefits required by this section.
(b) Provide the coverage required by this section subject to the
same deductible, copayment, coinsurance and other such conditions for
coverage that are required under the policy.
7. A policy of group health insurance subject to the provisions of
this chapter that is delivered, issued for delivery or renewed on or
after January 1, 2006, has the legal effect of including the coverage
required by this section, and any provision of the policy that conflicts
with this section is void.
8. An insurer who delivers or issues for delivery a policy of
group health insurance specified in subsection 1 is immune from liability
for:
(a) Any injury to the insured caused by:
(1) Any medical treatment provided to the insured in
connection with his participation in a clinical trial or study described
in this section; or
(2) An act or omission by a provider of health care who
provides medical treatment or supervises the provision of medical
treatment to the insured in connection with his participation in a
clinical trial or study described in this section.
(b) Any adverse or unanticipated outcome arising out of an
insured’s participation in a clinical trial or study described in this
section.
9. As used in this section:
(a) “Cooperative group” means a network of facilities that
collaborate on research projects and has established a peer review
program approved by the National Institutes of Health. The term includes:
(1) The Clinical Trials Cooperative Group Program; and
(2) The Community Clinical Oncology Program.
(b) “Facility authorized to conduct Phase I clinical trials or
studies for the treatment of cancer” means a facility or an affiliate of
a facility that:
(1) Has in place a Phase I program which permits only
selective participation in the program and which uses clear-cut criteria
to determine eligibility for participation in the program;
(2) Operates a protocol review and monitoring system which
conforms to the standards set forth in the Policies and Guidelines
Relating to the Cancer-Center Support Grant published by the Cancer
Centers Branch of the National Cancer Institute;
(3) Employs at least two researchers and at least one of
those researchers receives funding from a federal grant;
(4) Employs at least three clinical investigators who have
experience working in Phase I clinical trials or studies conducted at a
facility designated as a comprehensive cancer center by the National
Cancer Institute;
(5) Possesses specialized resources for use in Phase I
clinical trials or studies, including, without limitation, equipment that
facilitates research and analysis in proteomics, genomics and
pharmacokinetics;
(6) Is capable of gathering, maintaining and reporting
electronic data; and
(7) Is capable of responding to audits instituted by federal
and state agencies.
(c) “Provider of health care” means:
(1) A hospital; or
(2) A person licensed pursuant to chapter 630 , 631 or 633 of NRS.
(Added to NRS by 2003, 3522 ; A 2005, 2012 )
1. A policy of group health insurance must include a provision
authorizing a woman covered by the policy to obtain covered gynecological
or obstetrical services without first receiving authorization or a
referral from her primary care physician.
2. The provisions of this section do not authorize a woman covered
by a policy of group health insurance to designate an obstetrician or
gynecologist as her primary care physician.
3. A policy subject to the provisions of this chapter that is
delivered, issued for delivery or renewed on or after October 1, 1999,
has the legal effect of including the coverage required by this section,
and any provision of the policy or the renewal which is in conflict with
this section is void.
4. As used in this section, “primary care physician” has the
meaning ascribed to it in NRS 695G.060 .
(Added to NRS by 1999, 1944 )
1. All group health insurance policies providing coverage on an
expense-incurred basis and all employee welfare plans providing medical,
surgical or hospital care or benefits established or maintained for
employees or their families or dependents, or for both, must as to the
family members’ coverage provide that the health benefits applicable for
children are payable with respect to:
(a) A newly born child of the insured from the moment of birth;
(b) An adopted child from the date the adoption becomes effective,
if the child was not placed in the home before adoption; and
(c) A child placed with the insured for the purpose of adoption
from the moment of placement as certified by the public or private agency
making the placement. The coverage of such a child ceases if the adoption
proceedings are terminated as certified by the public or private agency
making the placement.
Ê The policies must provide the coverage specified in subsection 3 and
must not exclude premature births.
2. The policy or contract may require that notification of:
(a) The birth of a newly born child;
(b) The effective date of adoption of a child; or
(c) The date of placement of a child for adoption,
Ê and payments of the required premium or fees, if any, must be furnished
to the insurer or welfare plan within 31 days after the date of birth,
adoption or placement for adoption in order to have the coverage continue
beyond the 31-day period.
3. The coverage for newly born and adopted children and children
placed for adoption consists of coverage of injury or sickness, including
the necessary care and treatment of medically diagnosed congenital
defects and birth abnormalities and, within the limits of the policy,
necessary transportation costs from place of birth to the nearest
specialized treatment center under major medical policies, and with
respect to basic policies to the extent such costs are charged by the
treatment center.
4. An insurer shall not restrict the coverage of a dependent child
adopted or placed for adoption solely because of a preexisting condition
the child has at the time he would otherwise become eligible for coverage
pursuant to the group health policy. Any provision relating to an
exclusion for a preexisting condition must comply with NRS 689B.500
.
(Added to NRS by 1975, 1109; A 1989, 740; 1995, 2430; 1997, 2914)
1. Every policy of group health insurance must contain a provision
which reduces the insurer’s liability because of benefits under other
valid group coverage. To the extent authorized by the Commissioner, such
a provision may include subrogation.
2. A provision for subrogation may include a lien upon any
recovery by an insured from a third person for the cost of medical
benefits paid by the insurer for injuries incurred as a result of the
actions of the third person. The lien may not exceed the amount paid by
the insurer.
3. An insurer may not deny payment for services because of the
inclusion of a provision required by this section.
(Added to NRS by 1985, 1060; A 1995, 1628)
1. As used in this section, “total disability” and “totally
disabled” mean the continuing inability of the employee or member,
because of an injury or illness, to perform substantially the duties
related to his employment for which he is otherwise qualified.
2. No group policy of health insurance may be delivered or issued
for delivery in this state unless it provides continuing coverage for an
employee or member of the insured group, and his dependents who are
otherwise covered by the policy, while the employee or member is on leave
without pay as a result of a total disability. The coverage must be for
any injury or illness suffered by the employee or member which is not
related to the total disability or for any injury or illness suffered by
his dependent. The coverage for such injury or illness must be equal to
or greater than the coverage otherwise provided by the policy.
3. The coverage required pursuant to subsection 2 must continue
until:
(a) The date on which the employment of the employee or member is
terminated;
(b) The date on which the employee or member obtains another policy
of health insurance;
(c) The date on which the group policy of health insurance is
terminated; or
(d) After a period of 12 months in which benefits under such
coverage are provided to the employee or member,
Ê whichever occurs first.
(Added to NRS by 1989, 1249)
1. A group health insurance policy delivered or issued for
delivery after November 1, 1973, which provides for the termination of
coverage on a dependent child of a member of the insured group, when such
child attains a contractually specified limiting age, shall also provide
that such coverage shall not terminate when the dependent child reaches
such age if such child is and continues to be:
(a) Incapable of self-sustaining employment due to a physical
handicap or mental retardation; and
(b) Dependent on the member of the insured group for support and
maintenance.
2. Proof of such child’s incapacity and dependency shall be
furnished to the insurer by the member of the insured group within 31
days after such child attains the specified limiting age and as often as
the insurer may thereafter require, but no more than once a year
beginning 2 years after such child attains the specified limiting age.
(Added to NRS by 1973, 548)
1. A policy of group health insurance must provide coverage for:
(a) Enteral formulas for use at home that are prescribed or ordered
by a physician as medically necessary for the treatment of inherited
metabolic diseases characterized by deficient metabolism, or
malabsorption originating from congenital defects or defects arising
shortly after birth, of amino acid, organic acid, carbohydrate or fat; and
(b) At least $2,500 per year for special food products which are
prescribed or ordered by a physician as medically necessary for the
treatment of a person described in paragraph (a).
2. The coverage required by subsection 1 must be provided whether
or not the condition existed when the policy was purchased.
3. A policy subject to the provisions of this chapter that is
delivered, issued for delivery or renewed on or after January 1, 1998,
has the legal effect of including the coverage required by this section,
and any provision of the policy or the renewal which is in conflict with
this section is void.
4. As used in this section:
(a) “Inherited metabolic disease” means a disease caused by an
inherited abnormality of the body chemistry of a person.
(b) “Special food product” means a food product that is specially
formulated to have less than one gram of protein per serving and is
intended to be consumed under the direction of a physician for the
dietary treatment of an inherited metabolic disease. The term does not
include a food that is naturally low in protein.
(Added to NRS by 1997, 1526)
1. No group policy of health insurance that provides coverage for
hospital, medical or surgical expenses may be delivered or issued for
delivery in this state unless the policy includes coverage for the
management and treatment of diabetes, including, without limitation,
coverage for the self-management of diabetes.
2. An insurer who delivers or issues for delivery a policy
specified in subsection 1:
(a) Shall include in the disclosure required pursuant to NRS
689B.027 notice to each policyholder
and subscriber under the policy of the availability of the benefits
required by this section.
(b) Shall provide the coverage required by this section subject to
the same deductible, copayment, coinsurance and other such conditions for
coverage that are required under the policy.
3. A policy subject to the provisions of this chapter that is
delivered, issued for delivery or renewed on or after January 1, 1998,
has the legal effect of including the coverage required by this section,
and any provision of the policy that conflicts with this section is void.
4. As used in this section:
(a) “Coverage for the management and treatment of diabetes”
includes coverage for medication, equipment, supplies and appliances that
are medically necessary for the treatment of diabetes.
(b) “Coverage for the self-management of diabetes” includes:
(1) The training and education provided to the employee or
member of the insured group after he is initially diagnosed with diabetes
which is medically necessary for the care and management of diabetes,
including, without limitation, counseling in nutrition and the proper use
of equipment and supplies for the treatment of diabetes;
(2) Training and education which is medically necessary as a
result of a subsequent diagnosis that indicates a significant change in
the symptoms or condition of the employee or member of the insured group
and which requires modification of his program of self-management of
diabetes; and
(3) Training and education which is medically necessary
because of the development of new techniques and treatment for diabetes.
(c) “Diabetes” includes type I, type II and gestational diabetes.
(Added to NRS by 1997, 743)
1. Notwithstanding any provisions of this title to the contrary, a
policy of group health insurance delivered or issued for delivery in this
state pursuant to this chapter must provide coverage for the treatment of
conditions relating to severe mental illness.
2. The coverage required by this section:
(a) Must provide:
(1) Benefits for at least 40 days of hospitalization as an
inpatient per policy year and 40 visits for treatment as an outpatient
per policy year, excluding visits for the management of medication; and
(2) That two visits for partial or respite care, or a
combination thereof, may be substituted for each 1 day of hospitalization
not used by the insured. In no event is the policy required to provide
coverage for more than 40 days of hospitalization as an inpatient per
policy year.
(b) Is not required to provide benefits for psychosocial
rehabilitation or care received as a custodial inpatient.
3. Any deductibles and copayments required to be paid for the
coverage required by this section must not be greater than 150 percent of
the out-of-pocket expenses required to be paid for medical and surgical
benefits provided pursuant to the policy of group health insurance.
4. The provisions of this section do not apply to a policy of
group health insurance:
(a) Delivered or issued for delivery to an employer to provide
coverage for his employees if the employer has no more than 25 employees.
(b) If, at the end of the policy year, the premiums charged for
that policy, or a standard grouping of policies, increase by more than 2
percent as a result of providing the coverage required by this section
and the insurer obtains an exemption from the Commissioner pursuant to
subsection 5.
5. To obtain the exemption required by paragraph (b) of subsection
4, an insurer must submit to the Commissioner a written request therefor
that is signed by an actuary and sets forth the reasons and actuarial
assumptions upon which the request is based. To determine whether an
exemption may be granted, the Commissioner shall subtract from the amount
of premiums charged during the policy year the amount of premiums charged
during the period immediately preceding the policy year and the amount of
any increase in the premiums charged that is attributable to factors that
are unrelated to providing the coverage required by this section. The
Commissioner shall verify the information within 30 days after receiving
the request. The request shall be deemed approved if the Commissioner
does not deny the request within that time.
6. The provisions of this section do not:
(a) Limit the provision of specialized services covered by Medicaid
for persons with conditions relating to mental health or substance abuse.
(b) Supersede any provision of federal law, any federal or state
policy relating to Medicaid, or the terms and conditions imposed on any
Medicaid waiver granted to this state with respect to the provisions of
services to persons with conditions relating to mental health or
substance abuse.
7. A policy of group health insurance subject to the provisions of
this chapter which is delivered, issued for delivery or renewed on or
after January 1, 2000, has the legal effect of including the coverage
required by this section, and any provision of the policy or the renewal
which is in conflict with this section is void, unless the policy is
otherwise exempt from the provisions of this section pursuant to
subsection 4.
8. As used in this section, “severe mental illness” means any of
the following mental illnesses that are biologically based and for which
diagnostic criteria are prescribed in the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, published by the American
Psychiatric Association:
(a) Schizophrenia.
(b) Schizoaffective disorder.
(c) Bipolar disorder.
(d) Major depressive disorders.
(e) Panic disorder.
(f ) Obsessive-compulsive disorder.
(Added to NRS by 1999, 3101 )
1. The benefits provided by a group policy for health insurance,
as required in subsection 5 of NRS 689B.030 , for treatment of the abuse of alcohol or
drugs must consist of:
(a) Treatment for withdrawal from the physiological effects of
alcohol or drugs, with a minimum benefit of $1,500 per calendar year.
(b) Treatment for a patient admitted to a facility, with a minimum
benefit of $9,000 per calendar year.
(c) Counseling for a person, group or family who is not admitted to
a facility, with a minimum benefit of $2,500 per calendar year.
2. These benefits must be paid in the same manner as benefits for
any other illness covered by a similar policy are paid.
3. The insured person is entitled to these benefits if treatment
is received in any:
(a) Facility for the treatment of abuse of alcohol or drugs which
is certified by the Health Division of the Department of Health and Human
Services.
(b) Hospital or other medical facility or facility for the
dependent which is licensed by the Health Division of the Department of
Health and Human Services, accredited by the Joint Commission on
Accreditation of Healthcare Organizations and provides a program for the
treatment of abuse of alcohol or drugs as part of its accredited
activities.
(Added to NRS by 1979, 1178; A 1983, 2038; 1985, 1570, 1775; 1993,
1918; 1997, 1301; 1999, 1889 ; 2001, 439 )
Except as otherwise provided in
NRS 689B.0306 :
1. No group policy of health insurance that provides coverage for
a drug approved by the Food and Drug Administration for use in the
treatment of an illness, disease or other medical condition may be
delivered or issued for delivery in this state unless the policy includes
coverage for any other use of the drug for the treatment of cancer, if
that use is:
(a) Specified in the most recent edition of or supplement to:
(1) The United States Pharmacopoeia Drug Information; or
(2) The American Hospital Formulary Service Drug
Information; or
(b) Supported by at least two articles reporting the results of
scientific studies that are published in scientific or medical journals,
as defined in 21 C.F.R. § 99.3.
2. The coverage required pursuant to this section:
(a) Includes coverage for any medical services necessary to
administer the drug to the employee or member of the insured group.
(b) Does not include coverage for any:
(1) Experimental drug used for the treatment of cancer if
that drug has not been approved by the Food and Drug Administration; or
(2) Use of a drug that is contraindicated by the Food and
Drug Administration.
3. A policy subject to the provisions of this chapter that is
delivered, issued for delivery or renewed on or after October 1, 1999,
has the legal effect of including the coverage required by this section,
and any provision of the policy that conflicts with the provisions of
this section is void.
(Added to NRS by 1999, 760 ; A 2003, 3525 )
1. A policy of group health insurance that provides coverage for
the treatment of colorectal cancer must provide coverage for colorectal
cancer screening in accordance with:
(a) The guidelines concerning colorectal cancer screening which are
published by the American Cancer Society; or
(b) Other guidelines or reports concerning colorectal cancer
screening which are published by nationally recognized professional
organizations and which include current or prevailing supporting
scientific data.
2. A policy of group health insurance subject to the provisions of
this chapter that is delivered, issued for delivery or renewed on or
after October 1, 2003, has the legal effect of including the coverage
required by this section, and any provision of the policy that conflicts
with the provisions of this section is void.
(Added to NRS by 2003, 1335 )
1. Except as otherwise provided in this section, a policy of group
health insurance which provides coverage for prescription drugs must not
limit or exclude coverage for a drug if the drug:
(a) Had previously been approved for coverage by the insurer for a
medical condition of an insured and the insured’s provider of health care
determines, after conducting a reasonable investigation, that none of the
drugs which are otherwise currently approved for coverage are medically
appropriate for the insured; and
(b) Is appropriately prescribed and considered safe and effective
for treating the medical condition of the insured.
2. The provisions of subsection 1 do not:
(a) Apply to coverage for any drug that is prescribed for a use
that is different from the use for which that drug has been approved for
marketing by the Food and Drug Administration;
(b) Prohibit:
(1) The insurer from charging a deductible, copayment or
coinsurance for the provision of benefits for prescription drugs to the
insured or from establishing, by contract, limitations on the maximum
coverage for prescription drugs;
(2) A provider of health care from prescribing another drug
covered by the policy that is medically appropriate for the insured; or
(3) The substitution of another drug pursuant to NRS
639.23286 or 639.2583 to 639.2597 , inclusive; or
(c) Require any coverage for a drug after the term of the policy.
3. Any provision of a policy subject to the provisions of this
chapter that is delivered, issued for delivery or renewed on or after
October 1, 2001, which is in conflict with this section is void.
(Added to NRS by 2001, 858 ; A 2003, 2298 )
1. A policy of group health insurance must provide coverage for
benefits payable for expenses incurred for:
(a) An annual cytologic screening test for women 18 years of age or
older;
(b) A baseline mammogram for women between the ages of 35 and 40;
and
(c) An annual mammogram for women 40 years of age or older.
2. A policy of group health insurance must not require an insured
to obtain prior authorization for any service provided pursuant to
subsection 1.
3. A policy subject to the provisions of this chapter which is
delivered, issued for delivery or renewed on or after October 1, 1989,
has the legal effect of including the coverage required by subsection 1,
and any provision of the policy or the renewal which is in conflict with
subsection 1 is void.
(Added to NRS by 1989, 1889; A 1997, 1730)
1. A policy of group health insurance which provides coverage for
the surgical procedure known as a mastectomy must also provide
commensurate coverage for:
(a) Reconstruction of the breast on which the mastectomy has been
performed;
(b) Surgery and reconstruction of the other breast to produce a
symmetrical structure; and
(c) Prostheses and physical complications for all stages of
mastectomy, including lymphedemas.
2. The provision of services must be determined by the attending
physician and the patient.
3. The plan or issuer may require deductibles and coinsurance
payments if they are consistent with those established for other benefits.
4. Written notice of the availability of the coverage must be
given upon enrollment and annually thereafter. The notice must be sent to
all participants:
(a) In the next mailing made by the plan or issuer to the
participant or beneficiary; or
(b) As part of any annual information packet sent to the
participant or beneficiary,
Ê whichever is earlier.
5. A plan or issuer may not:
(a) Deny eligibility, or continued eligibility, to enroll or renew
coverage, in order to avoid the requirements of subsections 1 to 4,
inclusive; or
(b) Penalize, or limit reimbursement to, a provider of care, or
provide incentives to a provider of care, in order to induce the provider
not to provide the care listed in subsections 1 to 4, inclusive.
6. A plan or issuer may negotiate rates of reimbursement with
providers of care.
7. If reconstructive surgery is begun within 3 years after a
mastectomy, the amount of the benefits for that surgery must equal those
amounts provided for in the policy at the time of the mastectomy. If the
surgery is begun more than 3 years after the mastectomy, the benefits
provided are subject to all of the terms, conditions and exclusions
contained in the policy at the time of the reconstructive surgery.
8. A policy subject to the provisions of this chapter which is
delivered, issued for delivery or renewed on or after October 1, 2001,
has the legal effect of including the coverage required by this section,
and any provision of the policy or the renewal which is in conflict with
this section is void.
9. For the purposes of this section, “reconstructive surgery”
means a surgical procedure performed following a mastectomy on one breast
or both breasts to reestablish symmetry between the two breasts. The term
includes augmentation mammoplasty, reduction mammoplasty and mastopexy.
(Added to NRS by 1983, 615; A 1989, 1889; 2001, 2220 )
1. Except as otherwise provided in subsection 5, an insurer that
offers or issues a policy of group health insurance which provides
coverage for prescription drugs or devices shall include in the policy
coverage for:
(a) Any type of drug or device for contraception; and
(b) Any type of hormone replacement therapy,
Ê which is lawfully prescribed or ordered and which has been approved by
the Food and Drug Administration.
2. An insurer that offers or issues a policy of group health
insurance that provides coverage for prescription drugs shall not:
(a) Require an insured to pay a higher deductible, copayment or
coinsurance or require a longer waiting period or other condition for
coverage for a prescription for a contraceptive or hormone replacement
therapy than is required for other prescription drugs covered by the
policy;
(b) Refuse to issue a policy of group health insurance or cancel a
policy of group health insurance solely because the person applying for
or covered by the policy uses or may use in the future any of the
services listed in subsection 1;
(c) Offer or pay any type of material inducement or financial
incentive to an insured to discourage the insured from accessing any of
the services listed in subsection 1;
(d) Penalize a provider of health care who provides any of the
services listed in subsection 1 to an insured, including, without
limitation, reducing the reimbursement of the provider of health care; or
(e) Offer or pay any type of material inducement, bonus or other
financial incentive to a provider of health care to deny, reduce,
withhold, limit or delay any of the services listed in subsection 1 to an
insured.
3. Except as otherwise provided in subsection 5, a policy subject
to the provisions of this chapter that is delivered, issued for delivery
or renewed on or after October 1, 1999, has the legal effect of including
the coverage required by subsection 1, and any provision of the policy or
the renewal which is in conflict with this section is void.
4. The provisions of this section do not:
(a) Require an insurer to provide coverage for fertility drugs.
(b) Prohibit an insurer from requiring an insured to pay a
deductible, copayment or coinsurance for the coverage required by
paragraphs (a) and (b) of subsection 1 that is the same as the insured is
required to pay for other prescription drugs covered by the policy.
5. An insurer which offers or issues a policy of group health
insurance and which is affiliated with a religious organization is not
required to provide the coverage required by paragraph (a) of subsection
1 if the insurer objects on religious grounds. Such an insurer shall,
before the issuance of a policy of group health insurance and before the
renewal of such a policy, provide to the group policyholder or
prospective insured, as applicable, written notice of the coverage that
the insurer refuses to provide pursuant to this subsection. The insurer
shall provide notice to each insured, at the time the insured receives
his certificate of coverage or evidence of coverage, that the insurer
refused to provide coverage pursuant to this subsection.
6. If an insurer refuses, pursuant to subsection 5, to provide the
coverage required by paragraph (a) of subsection 1, an employer may
otherwise provide for the coverage for his employees.
7. As used in this section, “provider of health care” has the
meaning ascribed to it in NRS 629.031 .
(Added to NRS by 1999, 1997 )
1. Except as otherwise provided in subsection 5, an insurer that
offers or issues a policy of group health insurance which provides
coverage for outpatient care shall include in the policy coverage for any
health care service related to contraceptives or hormone replacement
therapy.
2. An insurer that offers or issues a policy of group health
insurance that provides coverage for outpatient care shall not:
(a) Require an insured to pay a higher deductible, copayment or
coinsurance or require a longer waiting period or other condition for
coverage for outpatient care related to contraceptives or hormone
replacement therapy than is required for other outpatient care covered by
the policy;
(b) Refuse to issue a policy of group health insurance or cancel a
policy of group health insurance solely because the person applying for
or covered by the policy uses or may use in the future any of the
services listed in subsection 1;
(c) Offer or pay any type of material inducement or financial
incentive to an insured to discourage the insured from accessing any of
the services listed in subsection 1;
(d) Penalize a provider of health care who provides any of the
services listed in subsection 1 to an insured, including, without
limitation, reducing the reimbursement of the provider of health care; or
(e) Offer or pay any type of material inducement, bonus or other
financial incentive to a provider of health care to deny, reduce,
withhold, limit or delay any of the services listed in subsection 1 to an
insured.
3. Except as otherwise provided in subsection 5, a policy subject
to the provisions of this chapter that is delivered, issued for delivery
or renewed on or after October 1, 1999, has the legal effect of including
the coverage required by subsection 1, and any provision of the policy or
the renewal which is in conflict with this section is void.
4. The provisions of this section do not prohibit an insurer from
requiring an insured to pay a deductible, copayment or coinsurance for
the coverage required by subsection 1 that is the same as the insured is
required to pay for other outpatient care covered by the policy.
5. An insurer which offers or issues a policy of group health
insurance and which is affiliated with a religious organization is not
required to provide the coverage for health care service related to
contraceptives required by this section if the insurer objects on
religious grounds. Such an insurer shall, before the issuance of a policy
of group health insurance and before the renewal of such a policy,
provide to the group policyholder or prospective insured, as applicable,
written notice of the coverage that the insurer refuses to provide
pursuant to this subsection. The insurer shall provide notice to each
insured, at the time the insured receives his certificate of coverage or
evidence of coverage, that the insurer refused to provide coverage
pursuant to this subsection.
6. If an insurer refuses, pursuant to subsection 5, to provide the
coverage required by paragraph (a) of subsection 1, an employer may
otherwise provide for the coverage for his employees.
7. As used in this section, “provider of health care” has the
meaning ascribed to it in NRS 629.031 .
(Added to NRS by 1999, 1998 )
1. Except as otherwise provided in this section, no policy of
group health insurance may be delivered or issued for delivery in this
state if it contains an exclusion of coverage of the treatment of the
temporomandibular joint whether by specific language in the policy or by
a claims settlement practice. A policy may exclude coverage of those
methods of treatment which are recognized as dental procedures,
including, but not limited to, the extraction of teeth and the
application of orthodontic devices and splints.
2. The insurer may limit its liability on the treatment of the
temporomandibular joint to:
(a) No more than 50 percent of the usual and customary charges for
such treatment actually received by an insured, but in no case more than
50 percent of the maximum benefits provided by the policy for such
treatment; and
(b) Treatment which is medically necessary.
3. Any provision of a policy subject to the provisions of this
chapter and issued or delivered on or after January 1, 1990, which is in
conflict with this section is void.
(Added to NRS by 1989, 2138)
If any policy of group health insurance provides coverage
for treatment of an illness which is within the authorized scope of the
practice of a qualified psychologist, the insured is entitled to
reimbursement for treatment by a psychologist who is licensed pursuant to
chapter 641 of NRS.
(Added to NRS by 1981, 575; A 1989, 1553)
If any policy of group health insurance provides
coverage for treatment of an illness which is within the authorized scope
of the practice of a licensed marriage and family therapist, the insured
is entitled to reimbursement for treatment by a marriage and family
therapist who is licensed pursuant to chapter 641A of NRS.
(Added to NRS by 1987, 2133)
If any policy of group health insurance provides coverage
for treatment of an illness which is within the authorized scope of the
practice of a licensed associate in social work, social worker,
independent social worker or clinical social worker, the insured is
entitled to reimbursement for treatment by an associate in social work,
social worker, independent social worker or clinical social worker who is
licensed pursuant to chapter 641B of NRS.
(Added to NRS by 1987, 1123)
1. If any group policy of health insurance provides coverage for
treatment of an illness which is within the authorized scope of practice
of a qualified chiropractor, the insured is entitled to reimbursement for
treatments by a chiropractor who is licensed pursuant to chapter 634
of NRS.
2. The terms of the policy must not limit:
(a) Coverage for treatments by a chiropractor to a number less than
for treatments by other physicians.
(b) Reimbursement for treatments by a chiropractor to an amount
less than that charged for similar treatments by other physicians.
(Added to NRS by 1981, 930; A 1983, 327)
1. Any group health policy may provide that all or any portion of
any indemnities provided by any such policy on account of hospital,
nursing, medical or surgical services, home health care or supportive
services:
(a) May, at the insurer’s option; or
(b) Must, upon the written request of the insured,
Ê be paid directly to the hospital or person rendering the services.
Payments made in this manner discharge the insurer’s obligation.
2. If the insured assigns his benefits pursuant to this section
but the insurer after receiving a copy of the assignment pays the
benefits to the insured, the insurer shall also pay the benefits to the
assignee as soon as the insurer receives the notice of the incorrect
payment.
(Added to NRS by 1971, 1767; A 1975, 448; 1983, 880)
1. If any group policy of health insurance provides coverage for
services which are within the authorized scope of practice of a
registered nurse who is authorized pursuant to chapter 632 of NRS to perform additional acts in an emergency or
under other special conditions as prescribed by the State Board of
Nursing, and which are reimbursed when provided by another provider of
health care, the insured is entitled to reimbursement for services
provided by such a registered nurse.
2. The terms of the policy must not limit:
(a) Coverage for services provided by such a registered nurse to a
number of occasions less than for services provided by another provider
of health care.
(b) Reimbursement for services provided by such a registered nurse
to an amount less than that reimbursed for similar services provided by
another provider of health care.
3. An insurer is not required to pay for services provided by such
a registered nurse which duplicate services provided by another provider
of health care.
(Added to NRS by 1985, 1447)
1. Except as otherwise provided in subsection 3, every policy of
group health insurance amended, delivered or issued for delivery in this
State after October 1, 1989, that provides coverage for medical
transportation, must contain a provision for the direct reimbursement of
a provider of medical transportation for covered services if that
provider does not receive reimbursement from any other source.
2. The insured or the provider may submit the claim for
reimbursement. The provider shall not demand payment from the insured
until after that reimbursement has been granted or denied.
3. Subsection 1 does not apply to any agreement between an insurer
and a provider of medical transportation for the direct payment by the
insurer for the provider’s services.
(Added to NRS by 1989, 1273)
If any policy of
group health insurance provides coverage for acupuncture performed by a
physician, the insured is entitled to reimbursement for acupuncture
performed by a person who is licensed pursuant to chapter 634A of NRS.
(Added to NRS by 1991, 1134)
Any group health policy
may provide for payment not exceeding three times the amount of the
monthly benefit under the policy as an extended disability benefit upon
the insured’s death from any cause. The extended disability benefit must
not be construed as life insurance.
(Added to NRS by 1971, 1768; A 1993, 1982)
1. Any contract of group health insurance may provide for the
readjustment of the rate of premium based upon the experience thereunder.
If a policy dividend is declared after January 1, 1972, or a reduction in
rate is made after January 1, 1972, or continued for the first or any
subsequent year of insurance under any policy of group health insurance
issued before, on or after January 1, 1972, to any policyholder, the
excess, if any, of the aggregate dividends or rate reductions under such
a policy and all other group insurance policies of the policyholder over
the aggregate expenditure for insurance under such policies made from
money contributed by the policyholder, or by an employer of insured
persons, or by a union or association to which the insured persons
belong, including expenditures made in connection with administration of
such policies, must be applied by the policyholder for the sole benefit
of insured employees or members.
2. This section does not apply as to debtor groups.
(Added to NRS by 1971, 1768; A 1997, 1627)
A policy
of group health insurance 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 require an insured, another insurer who issues policies
of group health insurance, a nonprofit medical service corporation or a
health maintenance organization to pay any amount in excess of the
deductible or coinsurance due from the insured based on the rates agreed
upon with a provider.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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 1987, 1781; A 1991, 1329; 1995, 1629)
1. When a policy of group insurance is primary, its benefits are
determined before those of another policy and the benefits of another
policy are not considered. When a policy of group insurance is secondary,
its benefits are determined after those of another policy. Secondary
benefits may not be reduced because of benefits under the primary policy.
When there are more than two policies, a policy may be primary as to one
and may be secondary as to another.
2. The benefits payable under a policy of group health insurance
may not be reduced because of any benefits payable under an individual
health insurance policy, health insurance on a franchise plan or
first-party coverage under an automobile insurance policy.
3. As used in this section, “a policy of group insurance” includes
Medicare.
(Added to NRS by 1987, 848; A 1989, 1250; 1995, 1629)
A
policy of group insurance determines its order of benefits using the
first of the following which applies:
1. A policy that does not coordinate with other policies is always
the primary policy.
2. The benefits of the policy which covers a person as an
employee, member or subscriber, other than a dependent, is the primary
policy. The policy which covers the person as a dependent is the
secondary policy.
3. When more than one policy covers the same child as a dependent
of different parents who are not divorced or separated, the primary
policy is the policy of the parent whose birthday falls earlier in the
year. The secondary policy is the policy of the parent whose birthday
falls later in the year. If both parents have the same birthday, the
benefits of the policy which covered the parent the longer is the primary
policy. The policy which covered the parent the shorter time is the
secondary policy.
4. If more than one policy covers a person as a dependent child of
divorced or separated parents, benefits for the child are determined in
the following order:
(a) First, the policy of the parent with custody of the child;
(b) Second, the policy of the spouse of the parent with custody; and
(c) Third, the policy of the parent without custody of the child,
Ê unless the specific terms of a court decree state that one parent is
responsible for the health care expenses of the child, in which case, the
policy of that parent is the primary policy. A parent responsible for the
health care pursuant to a court decree must notify the insurer of the
terms of the decree.
5. The primary policy is the policy which covers a person as an
employee who is neither laid off or retired, or that employee’s
dependent. The secondary policy is the policy which covers that person as
a laid off or retired employee, or that employee’s dependent.
6. If none of the rules in subsections 1 to 5, inclusive,
determines the order of benefits, the primary policy is the policy which
covered an employee, member or subscriber longer. The secondary policy is
the policy which covered that person the shorter time.
Ê When a policy is determined to be a secondary policy it acts to provide
benefits in excess of those provided by the primary policy. The secondary
policy may not reduce benefits based upon payments by the primary policy,
except that this provision does not require duplication of benefits.
(Added to NRS by 1987, 848)
1. A policy of group health insurance issued to replace any
discontinued policy or coverage for group health insurance must:
(a) Provide coverage for all persons who were covered under the
previous policy or coverage on the date it was discontinued; and
(b) Except as otherwise provided in subsection 2, provide benefits
which are at least as extensive as the benefits provided by the previous
policy or coverage, except that benefits may be reduced or excluded to
the extent that such a reduction or exclusion was permissible under the
terms of the previous policy or coverage,
Ê if that replacement policy is issued within 60 days after the date on
which the previous policy or coverage was discontinued.
2. If an employer obtains a replacement policy pursuant to
subsection 1 to cover his employees, any benefits provided by the
previous policy or coverage may be reduced if notice of the reduction is
given to his employees pursuant to NRS 608.1577 .
3. Any insurer which issues a replacement policy pursuant to
subsection 1 may submit a written request to the insurer who provided the
previous policy or coverage for a statement of benefits which were
provided under that policy or coverage. Upon receiving such a request,
the insurer who provided the previous policy or coverage shall give a
written statement to the insurer providing the replacement policy which
indicates what benefits were provided and what exclusions or reductions
were in effect under the previous policy or coverage.
4. The provisions of this section:
(a) Apply to a self-insured employer who provides health benefits
to his employees and replaces those benefits with a policy of group
health insurance.
(b) Do not apply to the Public Employees’ Benefits Program
established pursuant to NRS 287.0402
to 287.049 , inclusive.
(Added to NRS by 1987, 849; A 1991, 251; 1999, 3042 )
1. Except as otherwise provided in NRS 689B.270 and subject to the approval of the
Commissioner, a policy of group health insurance may include a provision
which requires a member or a dependent of a member of the insured group
and the insurer to submit for binding arbitration any dispute between the
member or dependent and the insurer concerning any matter directly or
indirectly related to, or associated with, the policy. If such a
provision is included in the policy:
(a) A member and any dependent of the member must be given the
opportunity to decline to participate in binding arbitration at the time
they elect to be covered by the policy.
(b) It must clearly state that the insurer and a member or
dependent of a member of the insured group who has not declined to
participate in binding arbitration agree to forego their right to resolve
any such dispute in a court of law or equity.
2. Except as otherwise provided in subsection 3, the arbitration
must be conducted pursuant to the rules for commercial arbitration
established by the American Arbitration Association. The insurer is
responsible for any administrative fees and expenses relating to the
arbitration, except that the insurer is not responsible for attorney’s
fees and fees for expert witnesses unless those fees are awarded by the
arbitrator.
3. If a dispute required to be submitted to binding arbitration
requires an immediate resolution to protect the physical health of a
member or a dependent of a member, any party to the dispute may waive
arbitration and seek declaratory relief in a court of competent
jurisdiction.
4. If a provision described in subsection 1 is included in a
policy of group health insurance, the provision shall not be deemed
unenforceable as an unreasonable contract of adhesion if the provision is
included in compliance with the provisions of subsection 1.
(Added to NRS by 1995, 2557)
An insurer shall not
deny a claim, refuse to issue a policy of group health insurance or
cancel a policy of group health insurance solely because the claim
involves an act that constitutes domestic violence pursuant to NRS 33.018
, or because the person applying for or
covered by the policy of group health insurance 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)
1. Except as otherwise provided in subsection 2, an insurer who
provides group health insurance shall not:
(a) Require an insured person or any member of his family to take a
genetic test;
(b) Require an insured person to disclose whether he or any member
of his family has taken a genetic test or any genetic information of the
insured person or a member of his family; or
(c) Determine the rates or any other aspect of the coverage or
benefits for health care provided to an insured person based on:
(1) Whether the insured person or any member of his family
has taken a genetic test; or
(2) Any genetic information of the insured person or any
member of his family.
2. The provisions of this section do not apply to an insurer who
issues a policy of group 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)
BLANKET POLICIES
“Blanket accident and health insurance” is that form of accident
insurance, health insurance, or both, covering groups of persons as
enumerated in one of the following subsections under a policy or contract
issued to:
1. Any common carrier or to any operator, owner or lessee of a
means of transportation, who or which shall be deemed the policyholder,
covering a group of persons who may become passengers defined by
reference to their travel status on the common carrier or means of
transportation.
2. An employer, who shall be deemed the policyholder, covering any
group of employees, dependents or guests, defined by reference to
specified hazards incident to an activity or activities or operations of
the policyholder.
3. A college, school or other institution of learning, a school
district or districts, or school jurisdictional unit, or to the head,
principal or governing board of any such educational unit, who or which
shall be deemed the policyholder, covering students, teachers or
employees.
4. A religious, charitable, recreational, educational or civic
organization, or branch thereof, which shall be deemed the policyholder,
covering any group of members or participants defined by reference to
specified hazards incident to an activity or activities or operations
sponsored or supervised by the policyholder.
5. A sports team, camp or sponsor thereof, which shall be deemed
the policyholder, covering members, campers, employees, officials or
supervisors.
6. A volunteer fire department, organization providing first aid,
organization for emergency management or other such volunteer
organization, which shall be deemed the policyholder, covering any group
of members or participants defined by reference to specified hazards
incident to an activity or activities or operations sponsored or
supervised by the policyholder.
7. A newspaper or other publisher, which shall be deemed the
policyholder, covering its carriers.
8. An association, including a labor union, which has a
constitution and bylaws and which has been organized and is maintained in
good faith for purposes other than that of obtaining insurance, which
shall be deemed the policyholder, covering any group of members or
participants defined by reference to specified hazards incident to an
activity or activities or operations sponsored or supervised by the
policyholder.
9. Cover any other risk or class of risks which, in the discretion
of the Commissioner, may be properly eligible for blanket accident and
health insurance. The discretion of the Commissioner may be exercised on
the basis of an individual risk or class of risks, or both.
(Added to NRS by 1971, 1768; A 1983, 177; 2001, 2221 )
Any insurer
authorized to write health insurance in this state, including a nonprofit
corporation for hospital, medical or dental services that has a
certificate of authority issued pursuant to chapter 695B of NRS, may issue blanket accident and health
insurance. No blanket policy, except as provided in subsection 4 of NRS
687B.120 , may be issued or delivered
in this state unless a copy of the form thereof has been filed in
accordance with NRS 687B.120 . Every
blanket policy must contain provisions which in the opinion of the
Commissioner are not less favorable to the policyholder and the
individual insured than the following:
1. A provision that the policy, including endorsements and a copy
of the application, if any, of the policyholder and the persons insured
constitutes the entire contract between the parties, and that any
statement made by the policyholder or by a person insured is in the
absence of fraud a representation and not a warranty, and that no such
statements may be used in defense to a claim under the policy, unless
contained in a written application. The insured, his beneficiary or
assignee has the right to make a written request to the insurer for a
copy of an application, and the insurer shall, within 15 days after the
receipt of a request at its home office or any branch office of the
insurer, deliver or mail to the person making the request a copy of the
application. If a copy is not so delivered or mailed, the insurer is
precluded from introducing the application as evidence in any action
based upon or involving any statements contained therein.
2. A provision that written notice of sickness or of injury must
be given to the insurer within 20 days after the date when the sickness
or injury occurred. Failure to give notice within that time does not
invalidate or reduce any claim if it is shown that it was not reasonably
possible to give notice and that notice was given as soon as was
reasonably possible.
3. A provision that the insurer will furnish to the claimant or to
the policyholder for delivery to the claimant such forms as are usually
furnished by it for filing proof of loss. If the forms are not furnished
before the expiration of 15 days after giving written notice of sickness
or injury, the claimant shall be deemed to have complied with the
requirements of the policy as to proof of loss upon submitting, within
the time fixed in the policy for filing proof of loss, written proof
covering the occurrence, the character and the extent of the loss for
which claim is made.
4. A provision that in the case of a claim for loss of time for
disability, written proof of the loss must be furnished to the insurer
within 90 days after the commencement of the period for which the insurer
is liable, and that subsequent written proofs of the continuance of the
disability must be furnished to the insurer at such intervals as the
insurer may reasonably require, and that in the case of a claim for any
other loss, written proof of the loss must be furnished to the insurer
within 90 days after the date of the loss. Failure to furnish such proof
within that time does not invalidate or reduce any claim if it is shown
that it was not reasonably possible to furnish proof and that the proof
was furnished as soon as was reasonably possible.
5. A provision that all benefits payable under the policy other
than benefits for loss of time will be payable immediately upon receipt
of written proof of loss, and that, subject to proof of loss, all accrued
benefits payable under the policy for loss of time will be paid not less
frequently than monthly during the continuance of the period for which
the insurer is liable, and that any balance remaining unpaid at the
termination of that period will be paid immediately upon receipt of proof.
6. A provision that the insurer at its own expense has the right
and opportunity to examine the person of the insured when and so often as
it may reasonably require during the pendency of claim under the policy
and also the right and opportunity to make an autopsy where it is not
prohibited by law.
7. A provision, if applicable, setting forth the provisions of NRS
689B.035 .
8. A provision for benefits for expense arising from care at home
or health supportive services if that care or service was prescribed by a
physician and would have been covered by the policy if performed in a
medical facility or facility for the dependent as defined in chapter 449
of NRS.
9. A provision that no action at law or in equity may be brought
to recover under the policy before the expiration of 60 days after
written proof of loss has been furnished in accordance with the
requirements of the policy and that no such action may be brought after
the expiration of 3 years after the time written proof of loss is
required to be furnished.
(Added to NRS by 1971, 1769; A 1973, 548; 1975, 448; 1985, 1775;
1993, 500; 2001, 2221 )
1. An individual application need not be required from a person
covered under a blanket health policy or contract, nor shall it be
necessary for the insurer to furnish each person a certificate, if such
person does not pay all or part of the premium for such insurance.
2. The Commissioner may, by rule or regulation, require the
delivery of an individual certificate or a statement of the coverage to
individuals insured under such a blanket policy or contract who are
either required to make an individual written application or pay part or
all of the premium therefor, and applying to such classes of cases and
circumstances, specified in such rule or regulation, as the Commissioner
may find such delivery to be reasonably necessary and practicable.
(Added to NRS by 1971, 1770)
1. Except as provided in subsection 2, all benefits under any
blanket health policy or contract must be payable to the person insured,
or to his designated beneficiary or beneficiaries, or to his estate,
except that if the person insured is a minor or otherwise not competent
to give a valid release, these benefits may be made payable to his
parent, guardian or other person actually supporting him.
2. The policy may provide that all or a portion of any indemnities
provided by any such policy on account of hospital, nursing, medical or
surgical services, home health care or supportive services:
(a) May, at the option of the insurer and unless the insured
requests otherwise in writing not later than the time of filing proofs of
such loss; or
(b) Must, upon the written request of the insured,
Ê be paid directly to the hospital or person rendering those services.
The policy may not require that the service be rendered by a particular
hospital or person. Payment so made discharges the obligation of the
insurer with respect to the amount of insurance so paid.
3. If the insured assigns his benefits pursuant to this section
but the insurer after receiving a copy of the assignment pays the
benefits to the insured, the insurer shall also pay the benefits to the
assignee as soon as the insurer receives the notice of the incorrect
payment.
(Added to NRS by 1971, 1771; A 1975, 450; 1983, 880)
Nothing contained in NRS 689B.070
to 689B.100 , inclusive, shall be deemed to affect the
legal liability of policyholders for death of or injury to any member
insured under a blanket insurance policy.
(Added to NRS by 1971, 1771)
An insurer providing blanket
health insurance shall make all information concerning rates available to
the Commissioner upon request. The information is proprietary,
constitutes a trade secret, and may not be disclosed by the Commissioner
to any person outside the Division except as agreed by the insurer or
ordered by a court of competent jurisdiction.
(Added to NRS by 2001, 2219 )
CONVERSION OF GROUP POLICIES TO INDIVIDUAL POLICIES
1. Except as otherwise provided in subsection 3, all policies of
group health insurance delivered or issued for delivery in this state
providing for hospital, surgical or major medical expense insurance, or
any combination of these coverages, on an expense-incurred basis must
contain a provision that the employee or member is entitled to have
issued to him by the insurer a policy of health insurance when the
employee or member is no longer covered by the group policy.
2. The requirement in subsection 1 does not apply to policies
providing benefits only for specific diseases or accidental injuries, and
it applies to other policies only if:
(a) The termination of coverage under the group policy is not due
to termination of the group policy itself unless the termination of the
group policy has resulted from failure of the policyholder to remit the
required premiums;
(b) The termination is not due to failure of the employee or member
to remit any required contributions;
(c) The employee or member has been continuously insured under any
group policy of the employer for at least 3 consecutive months
immediately before the termination; and
(d) The employee or member applies in writing for the converted
policy and pays his first premium to the insurer no later than 31 days
after the termination.
3. If an employee or member was a recipient of benefits under the
coverage provided pursuant to NRS 689B.0345 , he is not entitled to have issued to him
by a replacement insurer a policy of health insurance unless he has
reported for his normal employment for a period of 90 consecutive days
after last being eligible to receive any benefits under the coverage
provided pursuant to NRS 689B.0345 .
(Added to NRS by 1979, 1084; A 1985, 1060; 1989, 1250)
Subject to the conditions set forth in NRS
689B.120 to 689B.210 , inclusive, the conversion privilege must
also be made available:
1. To the surviving spouse, if any, upon the death of the employee
or member, with respect to the spouse and any child whose coverage under
the group policy is terminated by reason of the death, or if there is no
surviving spouse, to each surviving child whose coverage under the group
policy terminates by reason of the death, or, if the group policy
provides for continuation of dependents’ coverage following the
employee’s or member’s death, at the end of the continued coverage;
2. To the spouse of the employee or member upon termination of
coverage of the spouse while the employee or member remains insured under
the group policy, if the spouse ceases to be a qualified family member
under the group policy, and to any child whose coverage under the group
policy terminates at the same time; or
3. To a child solely with respect to himself upon termination of
his coverage because he ceases to be a qualified family member under the
group policy, if a conversion privilege is not otherwise provided with
respect to the termination.
(Added to NRS by 1979, 1086; A 2001, 2223 )
1. The insurer is not required to issue a converted policy to any
person who:
(a) Is covered for similar benefits by another hospital, surgical,
medical or major medical expense insurance policy, a hospital or medical
service subscriber contract, a medical practice or other prepayment plan,
or by any other kind of plan or program;
(b) Is eligible to be covered for similar benefits under any
arrangement of coverage for individuals in a group, whether on an insured
on uninsured basis; or
(c) Has similar benefits provided for or available under the
requirements of any state or federal law,
Ê if any benefits provided under the sources listed in this subsection,
together with the benefits to be provided by the converted policy, would
result in overinsurance according to the insurer’s standards.
2. Before denying a converted policy to an applicant because he
has coverage as described in paragraph (a) of subsection 1, the insurer
shall notify him that the converted policy will be issued only if the
other coverage is cancelled.
(Added to NRS by 1979, 1085)
A person who
is entitled to a converted policy must be given his choice of a basic or
standard health benefit plan in the manner provided in NRS 689B.590
.
(Added to NRS by 1979, 1085; A 1981, 907; 2001, 2223 )
1. A converted policy must not exclude a preexisting condition not
excluded by the group policy, but a converted policy may provide that any
hospital, surgical or medical benefits payable under it may be reduced by
the amount of any benefits payable under the group policy after its
termination. A converted policy may provide that during the first policy
year the benefits payable under it, together with the benefits payable
under the group policy, must not exceed those that would have been
payable if the policyholder’s insurance under the group policy had
remained in effect.
2. Any exclusion for a preexisting condition provided by a
converted policy must comply with NRS 689B.500 .
(Added to NRS by 1979, 1085; A 1997, 2915)
The insurer shall:
1. Issue the converted policy, as described in NRS 689B.590 , without evidence of insurability;
2. Establish the premium on the converted policies in the manner
provided in subsections 3, 4 and 5, or pursuant to subsection 6, of NRS
689B.590 , and may not require that
premiums be paid annually, semi-annually or quarterly unless so requested
by the employee, a member or a dependent;
3. Provide that the effective date of the converted policy is
12:01 a.m. on the day after the termination of insurance under the group
policy; and
4. Provide that the converted policy covers the employee or member
and his dependents who were covered by the group policy on the date of
its termination. A separate converted policy may be issued to cover any
dependent.
(Added to NRS by 1979, 1084; A 2001, 2223 )
Repealed. (See chapter 456,
Statutes of Nevada 2005, at page 2160 .)
A notification of
the conversion privilege must be included in each certificate of
coverage. A written notice of the existence of the conversion privilege
must also be given by the policyholder to the employee or member at least
15 days before the expiration of the 31 days permitted a person to make a
written application for the converted policy. The insurer shall prepare
the notice in a form approved by the Commissioner and give the notice to
the policyholder for distribution to the employees or members. If written
notice of the right to convert is not given as required under this
section, an additional period must be allowed the person to apply for the
converted policy. The additional period expires 15 days after written
notice of the conversion privilege has been given, or 60 days after the
expiration of the 31-day period, whichever is earlier.
(Added to NRS by 1979, 1086; A 1985, 1061)
A
converted policy which is to be delivered outside this state must be in
such form as would be deliverable in the other jurisdiction as a
converted policy if the group policy had been issued in that jurisdiction.
(Added to NRS by 1979, 1086)
CONTINUATION OF COVERAGE UNDER CERTAIN GROUP POLICIES
1. If an employer who employs less than 20 employees maintains a
policy of group health insurance which covers those employees, the policy
must contain a provision which permits:
(a) An employee to elect to continue identical coverage under the
policy, 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 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 an employee’s spouse or dependent child.
3. An employee who voluntarily leaves his employment, or the
spouse or dependent child of that employee, is not eligible to continue
coverage pursuant to this section.
4. An employee, spouse or dependent child who has not been covered
under any group policy 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 1987, 2233; A 1997, 2915)
1. An employee, spouse or dependent child shall notify the
employer that he is eligible to continue his coverage pursuant to NRS
689B.245 not later than 60 days after
he becomes eligible to do so.
2. The employer shall, within 14 days after receipt of the
notification given 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 689B.247 within 60 days after receipt of the
information provided pursuant to subsection 2.
(Added to NRS by 1987, 2234)
1. Any person who elects to continue coverage pursuant to NRS
689B.245 shall pay the premium for
that coverage in an amount not to exceed 125 percent of the premium
charged to the employer by the insurer 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 1987, 2234)
If an
employer changes his insurer during a period of a person’s continued
coverage, the new insurer shall provide continued coverage for that
person for the remainder of the continuation period.
(Added to NRS by 1987, 2234)
Continued coverage pursuant to NRS 689B.245 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
the new spouse’s policy of group health insurance.
(Added to NRS by 1987, 2234)
MISCELLANEOUS PROVISIONS
Every insurer under a group health insurance contract or a blanket
accident and health insurance contract and every state agency, for its
records shall accept from:
1. A hospital the Uniform Billing and Claims Forms established by
the American Hospital Association in lieu of its individual billing and
claims forms.
2. An individual who is licensed to practice one of the health
professions regulated by title 54 of NRS such uniform health insurance
claims forms as the Commissioner shall prescribe, except in those cases
where the Commissioner has excused uniform reporting.
(Added to NRS by 1975, 897; A 2001, 2224 )
1. Except as otherwise provided in subsection 2, an insurer shall
approve or deny a claim relating to a policy of group health insurance or
blanket insurance within 30 days after the insurer receives the claim. If
the claim is approved, the insurer shall pay the claim within 30 days
after it is approved. Except as otherwise provided in this section, if
the approved claim is not paid within that period, the insurer shall pay
interest on the claim at a rate of interest equal to the prime rate at
the largest bank in Nevada, as ascertained by the Commissioner of
Financial Institutions, on January 1 or July 1, as the case may be,
immediately preceding the date on which the payment was due, plus 6
percent. The interest must be calculated from 30 days after the date on
which the claim is approved until the date on which the claim is paid.
2. If the insurer requires additional information to determine
whether to approve or deny the claim, it shall notify the claimant of its
request for the additional information within 20 days after it receives
the claim. The insurer shall notify the provider of health care of all
the specific reasons for the delay in approving or denying the claim. The
insurer shall approve or deny the claim within 30 days after receiving
the additional information. If the claim is approved, the insurer shall
pay the claim within 30 days after it receives the additional
information. If the approved claim is not paid within that period, the
insurer shall pay interest on the claim in the manner prescribed in
subsection 1.
3. An insurer shall not request a claimant to resubmit information
that the claimant has already provided to the insurer, unless the insurer
provides a legitimate reason for the request and the purpose of the
request is not to delay the payment of the claim, harass the claimant or
discourage the filing of claims.
4. An insurer shall not pay only part of a claim that has been
approved and is fully payable.
5. A court shall award costs and reasonable attorney’s fees to the
prevailing party in an action brought pursuant to this section.
6. The payment of interest provided for in this section for the
late payment of an approved claim may be waived only if the payment was
delayed because of an act of God or another cause beyond the control of
the insurer.
7. The Commissioner may require an insurer to provide evidence
which demonstrates that the insurer has substantially complied with the
requirements set forth in this section, including, without limitation,
payment within 30 days of at least 95 percent of approved claims or at
least 90 percent of the total dollar amount for approved claims.
8. If the Commissioner determines that an insurer is not in
substantial compliance with the requirements set forth in this section,
the Commissioner may require the insurer to pay an administrative fine in
an amount to be determined by the Commissioner. Upon a second or
subsequent determination that an insurer is not in substantial compliance
with the requirements set forth in this section, the Commissioner may
suspend or revoke the certificate of authority of the insurer.
(Added to NRS by 1991, 1328; A 1999, 1648 ; 2001, 2730 ; 2003, 3358 )
1. No group health or blanket health policy may be delivered or
issued for delivery in this state if it contains any exclusion, reduction
or other limitation of coverage relating to complications of pregnancy,
unless the provision applies generally to all benefits payable under the
policy.
2. As used in this section, the term “complications of pregnancy”
includes any condition which requires hospital confinement for medical
treatment and:
(a) If the pregnancy is not terminated, is caused by an injury or
sickness not directly related to the pregnancy or by acute nephritis,
nephrosis, cardiac decompensation, missed abortion or similar medically
diagnosed conditions; or
(b) If the pregnancy is terminated, results in nonelective cesarean
section, ectopic pregnancy or spontaneous termination.
3. A policy subject to the provisions of this chapter which is
delivered or issued for delivery on or after July 1, 1977, has the legal
effect of including the coverage required by this section, and any
provision of the policy which is in conflict with this section is void.
(Added to NRS by 1977, 415)—(Substituted in revision for NRS
689B.032)
1. Each policy of group or blanket health insurance must include a
procedure for binding arbitration to resolve disputes concerning
independent medical evaluations pursuant to the rules of the American
Arbitration Association.
2. If an insurer, for any final determination of benefits or care,
requires an independent evaluation of the medical or chiropractic care of
any person for whom such care is covered under the terms of a policy of
group or blanket health insurance, only a physician or chiropractor who
is certified to practice in the same field of practice as the primary
treating physician or chiropractor or who is formally educated in that
field may conduct the independent evaluation.
3. The independent evaluation must include a physical examination
of the patient, unless he is deceased, and a personal review of all X
rays and reports prepared by the primary treating physician or
chiropractor. A certified copy of all reports of findings must be sent to
the primary treating physician or chiropractor and the insured person
within 10 working days after the evaluation. If the insured person
disagrees with the finding of the evaluation, he must submit an appeal to
the insurer pursuant to the procedure for binding arbitration set forth
in the policy of insurance within 30 days after he receives the finding
of the evaluation. Upon its receipt of an appeal, the insurer shall so
notify in writing the primary treating physician or chiropractor.
4. The insurer shall not limit or deny coverage for care related
to a disputed claim while the dispute is in arbitration, except that, if
the insurer prevails in the arbitration, the primary treating physician
or chiropractor may not recover any payment from either the insurer,
insured person or the patient for services that he provided to the
patient after receiving written notice from the insurer pursuant to
subsection 3 concerning the appeal of the insured person.
(Added to NRS by 1989, 2114)
1. An insurer shall provide to each policyholder, or producer of
insurance acting on behalf of a policyholder, on a form approved by the
Commissioner, a summary of the coverage provided by each policy of group
or blanket health insurance offered by the insurer. The summary must
disclose any:
(a) Significant exception, reduction or limitation that applies to
the policy;
(b) Restriction on payment for care in an emergency, including
related definitions of emergency and medical necessity;
(c) Right of the insurer to change the rate of premium and the
factors, other than claims experienced, which affect changes in rate;
(d) Provisions relating to renewability;
(e) Provisions relating to preexisting conditions; and
(f) Other information that the Commissioner finds necessary for
full and fair disclosure of the provisions of the policy.
2. The language of the disclosure must be easily understood. The
disclosure must state that it is only a summary of the policy and that
the policy should be read to ascertain the governing contractual
provisions.
3. The Commissioner shall not approve a proposed disclosure that
does not satisfy the requirements of this section and of applicable
regulations.
4. In addition to the disclosure, the insurer shall provide
information about guaranteed availability of basic and standard plans for
benefits to an eligible person.
5. The insurer shall provide the summary before the policy is
issued.
(Added to NRS by 2001, 2219 )
1. Except as otherwise provided in subsection 2, an insurer or any
agent or employee of an insurer who delivers or issues for delivery a
policy of group health or blanket health insurance in this state shall
not disclose to the policyholder or any agent or employee of the
policyholder:
(a) The fact that an insured is taking a prescribed drug or
medicine; or
(b) The identity of that drug or medicine.
2. The provisions of subsection 1 do not prohibit disclosure to an
administrator who acts as an intermediary for claims for insurance
coverage.
(Added to NRS by 1989, 1978)
Coverage provided under a conversion health benefit plan
must be renewed by the carrier that issued the plan, at the option of the
person covered under the health benefit plan, unless:
1. The person failed to pay premiums or contributions in
accordance with the terms of the health benefit plan or the individual
carrier has not received timely premium payments;
2. The person committed an act or practice that constitutes fraud
or has made an intentional misrepresentation of material fact under the
terms of the coverage; or
3. The carrier who is obligated to offer a conversion health
benefit plan pursuant to NRS 689B.590
or a health maintenance organization organized pursuant to chapter 695C
of NRS decides to discontinue offering and
renewing all health benefit plans delivered or issued for delivery in
this State. If the carrier or health maintenance organization decides to
discontinue offering and renewing those plans, the carrier or health
maintenance organization shall:
(a) Provide notice of its intention to the Commissioner and the
chief regulatory officer for insurance in each state in which the carrier
or health maintenance organization is licensed to transact insurance at
least 60 days before the date on which notice of cancellation or
nonrenewal is delivered or mailed to the persons covered by the insurance
to be discontinued;
(b) Provide notice of its intention at least 180 days before the
renewal of any conversion health benefit plan to all persons covered
under its conversion health benefit plans and to the Commissioner and the
chief regulatory officer for insurance in each state in which the carrier
or health maintenance organization is licensed to transact insurance; and
(c) Discontinue all group health insurance delivered or issued for
delivery to persons in this State and not renew coverage under any policy
of group health insurance issued to those persons.
(Added to NRS by 2005, 2136 )
An insurer may, subject to
regulation by the Commissioner, offer a policy of health insurance that
has a high deductible and is in compliance with 26 U.S.C. § 223 for the
purposes of establishing a health savings account.
(Added to NRS by 2005, 2137 )
[Effective July 1, 2006.]
1. Except as otherwise provided in subsection 2, an insurer shall
not:
(a) Deny a claim under a policy of health insurance solely because
the claim involves an injury sustained by an insured as a consequence of
being intoxicated or under the influence of a controlled substance.
(b) Cancel a policy of health insurance solely because an insured
has made a claim involving an injury sustained by the insured as a
consequence of being intoxicated or under the influence of a controlled
substance.
(c) Refuse to issue a policy of health insurance to an eligible
applicant solely because the applicant has made a claim involving an
injury sustained by the applicant as a consequence of being intoxicated
or under the influence of a controlled substance.
2. The provisions of this section do not prohibit an insurer from
enforcing a provision included in a policy of group health insurance to:
(a) Deny a claim which involves an injury to which a contributing
cause was the insured’s commission of or attempt to commit a felony;
(b) Cancel a policy of group health insurance solely because of
such a claim; or
(c) Refuse to issue a policy of group health insurance to an
eligible applicant solely because of such a claim.
(Added to NRS by 2005, 2344 , effective July 1, 2006)
ELIGIBILITY FOR COVERAGE UNDER GROUP POLICY
As used in NRS 689B.290 to 689B.330 , inclusive, unless the context otherwise
requires:
1. “Medicaid” means a program established in any state pursuant to
Title XIX of the Social Security Act (42 U.S.C. §§ 1396 et seq.) to
provide assistance for part or all of the cost of medical care rendered
on behalf of indigent persons.
2. “Order for medical coverage” means an order of a court or
administrative tribunal to provide coverage under a group health policy
to a child pursuant to the provisions of 42 U.S.C. § 1396g-1.
(Added to NRS by 1995, 2428)
1. An insurer shall not, when considering eligibility for coverage
or making payments under a group health policy, consider the availability
of, or eligibility of a person for, medical assistance under Medicaid.
2. To the extent that payment has been made by Medicaid for health
care, an insurer, group health plan as defined in section 607(1) of the
Employee Retirement Income Security Act of 1974 (29 U.S.C.A. § 1167(1)),
health maintenance organization or other organization that has issued a
group health policy:
(a) Shall treat Medicaid as having a valid and enforceable
assignment of an insured’s benefits regardless of any exclusion of
Medicaid or the absence of a written assignment; and
(b) May, as otherwise allowed by the policy, evidence of coverage
or contract and applicable law or regulation concerning subrogation, seek
to enforce any rights of a recipient of Medicaid to reimbursement against
any other liable party if:
(1) It is so authorized pursuant to a contract with Medicaid
for managed care; or
(2) It has reimbursed Medicaid in full for the health care
provided by Medicaid to its insured.
3. If a state agency is assigned any rights of a person who is:
(a) Eligible for medical assistance under Medicaid; and
(b) Covered by a group health policy,
Ê the insurer that issued the policy shall not impose any requirements
upon the state agency except requirements it imposes upon the agents or
assignees of other persons covered by the policy.
(Added to NRS by 1995, 2429)
An insurer shall
not deny the enrollment of a child pursuant to an order for medical
coverage under a group health policy pursuant to which a parent of the
child is insured, on the ground that the child:
1. Was born out of wedlock;
2. Has not been claimed as a dependent on the parent’s federal
income tax return; or
3. Does not reside with the parent or within the insurer’s
geographic area of service.
(Added to NRS by 1995, 2429)
If a child has coverage
under a group health policy pursuant to which a noncustodial parent of
the child is insured, the health insurer issuing that policy shall:
1. Provide to the custodial parent such information as necessary
for the child to obtain any benefits under that coverage.
2. Allow the custodial parent or, with the approval of the
custodial parent, a provider of health care to submit claims for covered
services without the approval of the noncustodial parent.
3. Make payments on claims submitted pursuant to subsection 2
directly to the custodial parent, the provider of health care or an
agency of this or another state responsible for the administration of
Medicaid.
(Added to NRS by 1995, 2429)
If a
parent is required by an order for medical coverage to provide coverage
under a group health policy for a child and the parent is eligible for
coverage of members of his family under a group health policy, the
insurer that issued the policy:
1. Shall, if the child is otherwise eligible for that coverage,
allow the parent to enroll the child in that coverage without regard to
any restrictions upon periods for enrollment.
2. Shall, if:
(a) The child is otherwise eligible for that coverage; and
(b) The parent is enrolled in that coverage but fails to apply for
enrollment of the child,
Ê enroll the child in that coverage upon application by the other parent
of the child, or by an agency of this or another state responsible for
the administration of Medicaid or a state program for the enforcement of
child support established pursuant to 42 U.S.C. §§ 651 et seq., without
regard to any restrictions upon periods for enrollment.
3. Shall not terminate the enrollment of the child in that
coverage or otherwise eliminate that coverage of the child unless the
insurer has written proof that:
(a) The order for medical coverage is no longer in effect; or
(b) The child is or will be enrolled in comparable coverage through
another insurer on or before the effective date of the termination of
enrollment or elimination of coverage.
(Added to NRS by 1995, 2429)
PORTABILITY AND ACCOUNTABILITY
As used in NRS 689B.340 to 689B.590 , inclusive, unless the context otherwise
requires, the words and terms defined in NRS 689B.350 to 689B.460 , inclusive, have the meanings ascribed to
them in those sections.
(Added to NRS by 1997, 2900; A 2001, 1923 , 2224 )
“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, an 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, 2900)
“Blanket accident and health insurance” has the meaning ascribed to it
in NRS 689B.070 .
(Added to NRS by 2001, 2219 )
“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 1997, 2900)
“Contribution” means the
minimum employer contribution toward the premium for enrollment of
participants and beneficiaries in a health benefit plan.
(Added to NRS by 1997, 2900)
“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 45 C.F.R. § 146.113,
authorized by the Public Health Service Act, 42 U.S.C. § 300gg(c)(1)(I);
10. A health benefit plan under section 5(e) of the Peace Corps
Act, 22 U.S.C. § 2504(e);
11. The Children’s Health Insurance Program established pursuant
to 42 U.S.C. §§ 1397aa to 1397jj, inclusive;
12. A short-term health insurance policy; or
13. A blanket accident and health insurance policy.
(Added to NRS by 1997, 2900; A 1999, 2240 , 2806 ; 2001, 2224 )
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 any 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, 2900)
“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, 2901)
1. “Health benefit plan” means a policy, contract, certificate or
agreement offered by a carrier to provide for, arrange for the payment
of, pay for or reimburse any of the costs of health care services. Except
as otherwise provided in this section, the term includes catastrophic
health insurance policies, and a policy that pays on a cost-incurred
basis.
2. The term does not include:
(a) Coverage that is only for accident or disability income
insurance, or any combination thereof;
(b) Coverage issued as a supplement to liability insurance;
(c) Liability insurance, including general liability insurance and
automobile liability insurance;
(d) Workers’ compensation or similar insurance;
(e) Coverage for medical payments under a policy of automobile
insurance;
(f) Credit insurance;
(g) Coverage for on-site medical clinics;
(h) Other similar insurance coverage specified in federal
regulations issued pursuant to 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;
(i) Coverage under a short-term health insurance policy; and
(j) Coverage under a blanket student accident and health insurance
policy.
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. For the purposes of NRS 689B.340 to 689B.590 , inclusive, 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. For the purposes of NRS 689B.340 to 689B.590 , inclusive, 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 1997, 2901; A 1999, 2807 , 3085 , 3107 ; 2001, 204 )
“Health
status-related factor” means, with regard to an insured or a person 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, 2902)
“Open enrollment” means
the period designated for enrollment in a health benefit plan.
(Added to NRS by 1997, 2903)
“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, 2903)
“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, 2903)
“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, 2903; A 1999, 2808 )
For the purposes of NRS 689B.340 to 689B.590 , inclusive:
1. Any plan, fund or program which would not be, but for section
2721(e) of the Public Health Service Act, as amended by Public Law
104-191, as that section existed on July 16, 1997, an employee welfare
benefit plan and which is established or maintained by a partnership to
the extent that the plan, fund or program provides medical care,
including items and services paid for as medical care, to current or
former partners in the partnership, or to their dependents, as defined
under the terms of the plan, fund or program, directly or through
insurance, reimbursement, or otherwise, must be treated, subject to 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, 2903)
1. In determining the applicable creditable coverage of a person
for the purposes of NRS 689B.340 to
689B.590 , inclusive, 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, a person must present any
certificates of coverage provided to him in accordance with NRS 689B.490
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 689B.500 , 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
in the regulations of the United States Department of Health and Human
Services, 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 person at the time of enrollment in the health
benefit plan.
(Added to NRS by 1997, 2903)
1. For the purpose of determining the period of creditable
coverage of a person accumulated under a health benefit plan, blanket
accident and health insurance or group health insurance, the insurer
shall provide written certification on a form prescribed by the
Commissioner of coverage 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, 2904; A 2001, 2225 )
1. Except as otherwise provided in this section, a carrier that
issues a group health plan or coverage under blanket accident and health
insurance or group health insurance shall not deny, exclude or limit a
benefit for a preexisting condition for:
(a) More than 12 months after the effective date of coverage if the
employee or other insured enrolls through open enrollment or after the
first day of the waiting period for that enrollment, whichever is
earlier; or
(b) More than 18 months after the effective date of coverage for a
late enrollee.
Ê A carrier may not define a preexisting condition more restrictively
than that term is defined in NRS 689B.450 .
2. The period of any exclusion for a preexisting condition imposed
by a group health plan or coverage under blanket accident and health
insurance or group health insurance 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 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 group health 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 or
other persons insured 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 or other insured.
4. An insurer 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 benefit under the plan, if the
creditable coverage was continuous to a date not more than 63 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 group health
plan following the initial period of enrollment, if that 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 contributions by his employer, termination of employment or
eligibility, reduction in the number of hours of employment, involuntary
termination of creditable coverage, or 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 employee enrolls during the open enrollment period, as
provided in the contract or as otherwise specifically provided by
specific statute.
(c) The employer of the employee offers several health benefit
plans and the employee 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 employee 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, Public Law
99-272, and that coverage has been exhausted.
(Added to NRS by 1997, 2904; A 1999, 2808 ; 2001, 2225 )
A carrier may modify the health
insurance coverage for a product offered pursuant to a group health plan
by the carrier at the time of renewal of such coverage if the
modification is consistent with the provisions of this chapter.
(Added to NRS by 1997, 2906)
1. Except as otherwise provided in this subsection, a group health
plan or coverage offered under group health insurance 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 or coverage 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 group health plan or health insurance
coverage 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 group health plan or health insurance coverage 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 group health plan or coverage under group health insurance
that offers coverage for maternity care and pediatric care of newborn
infants may not:
(a) Deny a mother or her newborn infant coverage or continued
coverage under the terms of the plan or coverage if the sole purpose of
the denial of coverage or continued coverage is to avoid the requirements
of this section;
(b) Provide monetary payments or rebates to a mother to encourage
her to accept less than the minimum protection available pursuant to this
section;
(c) Penalize, or otherwise reduce or limit, the reimbursement of an
attending provider of health care because he provided care to a mother or
newborn infant in accordance with the provisions of this section;
(d) Provide incentives of any kind to an attending physician to
induce him to provide care to a mother or newborn infant in a manner that
is inconsistent with the provisions of this section; or
(e) Except as otherwise provided in subsection 4, restrict benefits
for any portion of a hospital stay required pursuant to the provisions of
this section in a manner that is less favorable than the benefits
provided for any preceding portion of that stay.
4. Nothing in this section:
(a) Prohibits a group health 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 group health
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 group health 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, 2906)
A carrier offering group health insurance shall permit an employee or a
dependent of an employee covered by the group health insurance who is
eligible, but not enrolled, for coverage in connection with the group
health insurance to enroll for coverage under the terms of the group
health insurance if:
1. The employee or dependent was covered under a different group
health insurance 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, 2907)
1. A carrier that offers group health insurance which makes
coverage available to the dependent of an employee covered by the group
health plan 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 group health 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 group health 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 group health 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 group health plan.
(Added to NRS by 1997, 2908)
1. A carrier shall not place any restriction on a person or his
dependent as a condition of being a participant in or a beneficiary of a
policy of blanket accident and health insurance or group health insurance
that is inconsistent with the provisions of this chapter.
2. A carrier that offers coverage under a policy of blanket
accident and health insurance or group health insurance pursuant to this
chapter shall not establish rules of eligibility, including rules which
define applicable waiting periods, for the initial or continued
enrollment under a group health plan offered by the carrier that are
based on the following factors relating to the 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 689B.500 , 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 blanket
health and accident insurance or group health insurance 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
policy of blanket accident and health insurance or group health
insurance, a carrier shall not require an employee 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 employee or his
dependent.
5. This section does not:
(a) Restrict the amount that an employer or employee may be charged
for coverage by a carrier;
(b) Prevent 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) Preclude a carrier from establishing rules relating to employer
contribution or group participation when offering health insurance
coverage to small employers in this state.
(Added to NRS by 1997, 2908; A 2001, 2227 )
1. Except as otherwise provided in this section, coverage under a
policy of group health insurance must be renewed by the carrier at the
option of the plan sponsor, unless:
(a) The plan sponsor has failed to pay premiums or contributions in
accordance with the terms of the group health insurance or the carrier
has not received timely premium payments;
(b) The plan sponsor has performed an act or a practice that
constitutes fraud or has made an intentional misrepresentation of
material fact under the terms of the coverage;
(c) The plan sponsor has failed to comply with any material
provision of the group health insurance relating to employer
contributions and group participation; or
(d) The carrier decides to discontinue offering coverage under
group health insurance. If the carrier decides to discontinue offering
and renewing such insurance, the carrier shall:
(1) Provide notice of its intention to 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 the
date on which notice of cancellation or nonrenewal is delivered or mailed
to the persons covered by the discontinued insurance pursuant to
subparagraph (2).
(2) Provide notice of its intention to all persons covered
by the discontinued insurance and to the Commissioner and the chief
regulatory officer for insurance in each state in which such a person is
known to reside. The notice must be made at least 180 days before the
discontinuance of any group health plan by the carrier.
(3) Discontinue all health insurance issued or delivered for
issuance for persons in this state and not renew coverage under any group
health insurance issued to such persons.
2. A carrier may discontinue the issuance and renewal of a form of
a product of group health insurance 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 may be
discontinued by the carrier pursuant to this subsection only if:
(a) The carrier notifies the Commissioner and the chief regulatory
officer in each state in which it is licensed of its decision pursuant to
this subsection to discontinue the issuance and renewal of the form of
the product at least 60 days before the individual carrier notifies the
persons covered by the discontinued insurance pursuant to paragraph (b).
(b) The carrier notifies each person covered by the discontinued
insurance and the Commissioner and the chief regulatory officer in each
state in which such a person is known to reside 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 person covered by the discontinued
insurance the option to purchase any other health benefit plan currently
offered by the carrier to large groups in this state.
(d) In exercising the option to discontinue the form of the product
and in offering the option to purchase other coverage pursuant to
paragraph (c), the carrier acts uniformly without regard to the claim
experience of the persons covered by the discontinued insurance or any
health status-related factor relating to those persons or beneficiaries
covered by the discontinued form of the product or any person or
beneficiary who may become eligible for such coverage.
3. A carrier may discontinue the issuance and renewal of any type
of group health insurance offered by the carrier in this state that is
made available pursuant to this chapter only to a member of a bona fide
association if:
(a) The membership of the person in the bona fide association was
the basis for the provision of coverage under the group health insurance;
(b) The membership of the person in the bona fide association
ceases; and
(c) Coverage is terminated pursuant to this subsection for all such
former members uniformly without regard to any health status-related
factor relating to the former member.
4. A carrier that elects not to renew group health insurance
pursuant to paragraph (d) of subsection 1 shall not write new business
pursuant to this chapter for 5 years after the date on which notice is
provided to the Commissioner pursuant to subparagraph (2) of paragraph
(d) of subsection 1.
5. If the 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.
6. As used in this section, “bona fide association” has the
meaning ascribed to it in NRS 689A.485 .
(Added to NRS by 1997, 2909)
1. A carrier that offers coverage through a network plan is not
required to offer coverage to or accept an application from an employer
that does not employ or no longer employs any enrollees who reside or
work in the established geographic service area of the carrier or the
geographic area for which the carrier is authorized to transact
insurance, provided that such coverage is refused or terminated uniformly
without regard to any health status-related factor for any employee of
the employer.
2. As used in this section, “network plan” means a health benefit
plan offered by a health carrier under which the financing and delivery
of medical care, 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, 2911)
1. A carrier that offers coverage through a network plan shall use
its best efforts to contract with at least one health center in each
established geographic service area of the carrier or geographic area for
which the carrier is authorized to transact insurance to provide medical
care for enrollees if the health center:
(a) Meets all conditions imposed by the carrier on similarly
situated providers of health care with which the carrier contracts,
including, without limitation:
(1) Certification for participation in the Medicaid or
Medicare program; and
(2) Requirements relating to the appropriate credentials for
providers of health care; and
(b) Agrees to reasonable reimbursement rates that are generally
consistent with those offered by the carrier to similarly situated
providers of health care with which the carrier contracts.
2. As used in this section:
(a) “Health center” has the meaning ascribed to it in 42 U.S.C. §
254b.
(b) “Network plan” has the meaning ascribed to it in NRS 689B.570
.
(Added to NRS by 2001, 1923 )
1. A plan sponsor of a governmental plan that is a group health
plan to which the provisions of NRS 689B.340 to 689B.590 , inclusive, otherwise apply may elect to
exclude the governmental plan from compliance with those sections. Such
an election:
(a) Must be made in such a form and in such a manner as the
Commissioner prescribes by regulation.
(b) Is effective for a single specified year of the plan or, if the
plan is provided pursuant to a collective bargaining agreement, for the
term of that agreement.
(c) May be extended by subsequent elections.
(d) Excludes the governmental plan from those provisions in this
chapter that apply only to group health plans.
2. If a plan sponsor of a governmental plan makes an election
pursuant to this section, the plan sponsor shall:
(a) Annually and at the time of enrollment, notify the enrollees in
the plan of the election and the consequences of the election; and
(b) Provide certification and disclosure of creditable coverage
under the plan with respect to those enrollees pursuant to NRS 689B.490
.
3. As used in this section, “governmental plan” has the meaning
ascribed to in section 3(32) of the Employee Retirement Income Security
Act of 1974, as that section existed on July 16, 1997.
(Added to NRS by 1997, 2911)
1. Not later than 180 days after the date on which the basic and
standard health benefit plans are approved pursuant to NRS 689C.770
as part of the plan of operation of
the Program of Reinsurance, each carrier required to offer to a person a
converted policy pursuant to NRS 689B.120 shall only offer as a converted policy a
choice of the basic and standard health benefit plans.
2. A person with a converted policy issued before the effective
date of the requirement set forth in subsection 1 may, at each annual
renewal of the converted policy elect a basic or standard health benefit
plan as a substitute converted policy, except that the carrier may, if
the person has not made an election within 3 years after first becoming
eligible to do so, require the person to make such an election. Once a
person has elected the basic or standard health benefit plan as a
substitute converted policy, he may not elect another converted policy.
3. The premium for a converted policy may not exceed the small
group index rate, as defined in paragraph (b) of subsection 3 of NRS
689C.230 , applicable to the carrier
by more than 75 percent. The small group index rate used by a carrier
that does not write insurance to small employers in this state must be
the average small group index rate, as determined by the Commissioner, of
the five largest carriers that provide coverage to small employers
pursuant to this chapter for their basic and standard health benefit
plans. The Commissioner shall annually determine the average small group
index rate, as measured by the premium volume of the plans, of those five
largest carriers.
4. The rates for new and renewal converted policies for persons
with the same converted policies whose case characteristics are similar
must be the same.
5. Any losses suffered by a carrier on its converted policies
issued pursuant to this section must be spread across the entire book of
the health benefit coverage of the carrier issued or delivered for
issuance to small employers and large group employers in this state.
6. The Commissioner shall adopt such regulations as are necessary
to carry out the provisions of this section.
(Added to NRS by 1997, 2911; A 1999, 2810 )
