USA Statutes : nevada
Title : Title 57 - INSURANCE
Chapter : CHAPTER 695B - NONPROFIT CORPORATIONS FOR HOSPITAL, MEDICAL AND DENTAL SERVICE
This chapter may be cited as the
Nonprofit Hospital, Medical and Dental Service Corporation Law.
(Added to NRS by 1971, 1863)
1. This chapter does not:
(a) Apply to or govern any corporation which is organized for
profit, which contemplates any pecuniary gain to its shareholders or
members, or which conducts or is authorized by its articles of
incorporation to conduct any business whatsoever on a profit basis.
(b) Authorize and must not be construed to authorize, directly or
indirectly, any corporation to operate a hospital or a medical or dental
service plan on a profit basis.
2. Except as otherwise provided in subsection 3, a corporation
subject to the provisions of this chapter shall not own or operate any
hospital or engage in any business other than that of establishing,
maintaining and operating a nonprofit hospital, medical or dental service
plan.
3. A corporation subject to the provisions of this chapter may,
with the approval of the Commissioner, engage in any business reasonably
and necessarily incidental to the business of a nonprofit hospital,
medical or dental service plan.
(Added to NRS by 1971, 1863; A 1991, 654)
As used in this chapter:
1. “Dental services” means general and special dental services
ordinarily provided by dentists licensed under the provisions of chapter
631 of NRS to practice in the State of Nevada
in accordance with the generally accepted practices of the community at
the time the service is rendered, and the furnishing of necessary
appliances, drugs, medicines and supplies, prosthetic appliances,
orthodontic appliances, metal, ceramic and other restorations.
2. “Hospital services” means the furnishing or providing of any or
all of the following:
(a) Maintenance and care in the hospital, including but not limited
to, nursing care, drugs, medicines, supplies, physiotherapy,
transportation and use of facilities and appliances.
(b) Reimbursement of the beneficiary or subscriber for, but without
requiring that he first pay, expenses incurred for any of the items
included in paragraph (a).
(c) Reimbursement, at a uniform rate, of the beneficiary or
subscriber for, but without requiring that he first pay, the costs and
expenses incurred for medical supplies.
(d) Reimbursement for expenses incurred outside of the hospital for
continued care and treatment following the subscriber’s discharge from
the hospital, for nursing service, necessary appliances, drugs,
medicines, supplies and any other services which would have been
available in the hospital (excluding physicians’ services), whether or
not provided through a hospital.
(e) Reimbursement for ambulance service expenses.
3. “Medical services” means the furnishing or providing of any or
all of the following:
(a) Medical or surgical services, in or out of a hospital, by a
physician licensed to practice under the laws of Nevada.
(b) Reimbursement for expenses incurred for nursing services,
necessary appliances, drugs, medicines, supplies and any other health
care services.
(Added to NRS by 1971, 1863; A 1977, 966)
1. A corporation subject to the provisions of this chapter 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 corporation
to its insureds.
2. A corporation specified in subsection 1 shall not contract with
a provider of health care to provide health care to an insured unless the
corporation uses the form prescribed by the Commissioner pursuant to NRS
629.095 to obtain any information
related to the credentials of the provider of health care.
3. A contract between a corporation 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
corporation upon giving to the provider 30 days’ written notice of the
modification. If the provider fails to object in writing to the
modification within the 30-day period, the modification becomes effective
at the end of that period. If the provider objects in writing to the
modification within the 30-day period, the modification must not become
effective unless agreed to by both parties as described in paragraph (a).
4. If a corporation specified in subsection 1 contracts with a
provider of health care to provide health care to an insured, the
corporation 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, 1650 ; A 2001, 2732 ; 2003, 3364 )
ORGANIZATION
Any corporation which is organized under the laws of the State of
Nevada, or the laws of any other state, without capital stock, for the
purpose of maintaining and operating a hospital, medical or dental
service plan, and which does not contemplate pecuniary gain or profit to
its members, may undertake and operate a hospital, medical or dental
service plan for rendering hospital, medical or dental service to its
subscribers under and subject to the provisions of this chapter.
(Added to NRS by 1971, 1864; A 1991, 654)
Persons desiring to form a
nonprofit hospital, medical or dental service corporation shall
incorporate pursuant to the provisions of this chapter, and the
provisions of the nonprofit corporation laws of the State of Nevada, so
far as the provisions of such laws are applicable and not inconsistent
with this chapter.
(Added to NRS by 1971, 1864)
1. A majority of the board of directors of a corporation providing
or rendering hospital services shall be persons who are not duly
appointed representatives of hospitals with which the corporation has
contracts for the rendering of hospital services.
2. A majority of the board of directors of a corporation providing
medical services shall be persons who are not physicians or duly
appointed representatives of the physicians who have signed participating
agreements with the corporation for the rendering of medical services.
3. A majority of the board of directors of a corporation providing
dental services shall be persons who are not dentists or duly appointed
representatives of the dentists who have signed participating agreements
with the corporation for the rendering of dental services.
4. This section does not apply to any duly appointed
representative of a hospital, physician or dentist who is a member of the
board of directors of a corporation on July 1, 1977. Such a person may
continue to serve as a member of the board of directors until his term
expires.
(Added to NRS by 1971, 1864; A 1971, 1956; 1977, 624)
Any corporation
operating under this chapter may merge and consolidate with any other
corporation operating or to operate under this chapter as follows:
1. The agreement of merger and consolidation shall be submitted to
and approved by a two-thirds vote of the members of the ceding
corporation present in person or by proxy at a meeting called to consider
that agreement. A written or printed notice of such meeting shall be
mailed or personally delivered to each member at least 30 days before the
day fixed for the meeting.
2. Before the merger and consolidation is effected, the
corporation which proposes to assume the liabilities of the ceding
corporation shall submit to its members the question of merger and
consolidation and a similar notice shall be given and a similar vote
required as in the case of members of the ceding corporation.
3. If the vote in the case of both corporations is in the
affirmative by the required majority, a certified copy of all proceedings
relating to the proposed merger and consolidation shall be filed with the
Commissioner. If the Commissioner finds that the proceedings have been in
accordance with law, he shall approve the agreement.
4. Upon the approval by the Commissioner of such agreement, the
consolidated corporation shall issue certificates of assumption to each
and every subscriber of the ceding corporation. Such certificates shall
be in a form approved by the Commissioner.
5. The approval of the Commissioner of the agreement of merger and
consolidation shall operate to dissolve the ceding corporation, and all
its liability upon its insurance contracts or benefit certificates shall
thereupon cease, but its officers may thereafter perform any act
necessary to close its affairs. The officers of the ceding corporation
shall file a certified copy of the agreement in the office of the
Secretary of State. Such certified copy shall be in lieu of any
certificate of dissolution required by the provisions of the general
corporation law.
6. The consolidated corporation shall be entitled to all the
assets of the ceding corporation and shall assume all its liabilities.
(Added to NRS by 1971, 1865)
In the event of any merger and
consolidation as provided by this chapter, contracts and contribution
certificates issued in compliance with the provisions of this chapter and
outstanding at the time of the date of the merger and consolidation may
be continued in force, reinstated, renewed and repaid without change of
provisions, except as such change may be necessary or advisable at or
following the next renewal or reinstatement.
(Added to NRS by 1971, 1865)
Upon approval by the Commissioner of any such merger and
consolidation, the merged and consolidated corporation may withdraw any
securities therefore deposited pursuant to any requirements of this
chapter.
(Added to NRS by 1971, 1866)
LICENSING; REGULATION
A
corporation shall not establish, maintain or operate a nonprofit service
plan as authorized by the provisions of this chapter unless it has:
1. Procured a certificate of authority from the Commissioner for
the establishment, maintenance and operation of the plan.
2. Paid to the Commissioner the fees required of insurers by NRS
680B.010 for:
(a) The filing of the initial application;
(b) The issuance of the certificate of authority;
(c) Each annual continuation of the certificate of authority; and
(d) The filing of each annual report.
(Added to NRS by 1971, 1866; A 1987, 468)
The
Commissioner shall not issue or renew his certificate of authority to any
corporation proposing to establish, maintain or operate a nonprofit
hospital, medical or dental service plan until such corporation
establishes:
1. If a nonprofit hospital service corporation, that it has
entered into contracts with hospitals in the State of Nevada having an
aggregate bed capacity sufficient to render the services contemplated to
be furnished under the hospital service plan to persons in the State of
Nevada.
2. That the hospital, medical or dental service contract proposed
to be entered into by such corporation with those who may become
subscribers is not such as will work a fraud or injustice upon such
subscribers or any person.
3. That a schedule of the rates, dues, fees or other periodic
charges to be paid by subscribers has been filed with the Commissioner
and the same are not such as will, after providing for such legal
reserves as are required by NRS 695B.140 , result in profit to, or in the accumulation
of excessive reserves or surpluses by, such corporation and are such as
will enable such corporation to furnish or provide the hospital, medical
or dental services which it proposes to make available to its
beneficiaries and subscribers without impairment of its legal reserves
and without a constant depletion of the assets of such corporation. A
reserve or surplus over and above all approved and required reserves in
an amount in excess of the average annual gross income of such
corporation for the immediately preceding 3 calendar years shall be prima
facie an excessive accumulation.
(Added to NRS by 1971, 1866)
1. An application for a certificate of authority must be filed
with the Commissioner in writing by the corporation for medical service
which is applying for the certificate on forms furnished or accepted by
the Commissioner. The application must set forth such information
concerning the applicant and its qualifications and in other respects as
the Commissioner may reasonably require.
2. The application must be accompanied by:
(a) A copy of the applicant’s charter or articles of incorporation,
certified by the public officer with whom the original is required to be
filed in its state of domicile;
(b) A copy of the applicant’s bylaws, certified by the corporate
secretary;
(c) A copy of each contract the applicant has made or proposed to
make with hospitals, or physicians or dentists in this state;
(d) A copy of each service contract proposed to be issued to its
subscribers in this state;
(e) The schedule of the rates, dues, fees or other periodical
charges proposed to be charged for such service contracts; and
(f) The applicable fee for an initial application and the issuance
of a certificate of authority.
3. If upon completion of the application the Commissioner
determines that the applicant is fully qualified and entitled to a
certificate of authority under this chapter, he shall promptly issue a
certificate of authority to the applicant. If the Commissioner refuses to
issue the certificate of authority, he shall give the applicant written
notice of the refusal setting forth the grounds therefor.
(Added to NRS by 1971, 1867; A 1971, 1956; 1987, 468)
1. A certificate of authority issued pursuant to this chapter
expires on March 1 of the year following its date of issuance or renewal.
2. To renew a certificate of authority a corporation for medical
service must:
(a) File a written request for renewal with the Commissioner; and
(b) Pay the applicable fee for renewal for a certificate of
authority.
3. The Commissioner may accept a request for renewal received by
him within 30 days after the expiration of the certificate if the request
is accompanied by a fee for renewal of 150 percent of the fee otherwise
required.
(Added to NRS by 1987, 467)
1. No corporation subject to the provisions of this chapter may
establish, maintain or operate a hospital, medical or dental service plan
unless it has and at all times maintains a reserve fund equal to the
following minimum amounts in relation to the number of natural persons
entitled to hospital, medical or dental services under contracts issued
by the corporation:
Amount of
Number of Natural
Persons
Reserve
Entitled to
Benefits
Fund
1 to 1,000,
inclusive..................................................................
....................... $100,000
1,001 to 10,000,
inclusive..................................................................
................ 500,000
10,000 or
more.......................................................................
............................. 750,000
but such a reserve fund is not required of a corporation acting only as a
fiscal administrator of programs funded by public agencies, authorized
insurers and other authorized health service plans.
2. In computing the amount of a reserve fund, the Commissioner
shall include the amounts agreed to be paid by contracting hospitals to
the corporation or its equivalent value of hospital service to be
rendered without charge by the contracting hospital to the hospital
service corporation.
3. In addition to the reserve fund provided for in this chapter,
the Commissioner shall require every corporation subject to this chapter
to make, and to maintain in force, such contracts with enough hospitals
in the State of Nevada to be adequate, in the opinion of the
Commissioner, to provide care for all natural persons entitled to
hospital benefits in the State of Nevada under contracts issued by such a
corporation.
4. In addition, the Commissioner shall require medical or dental
service corporations to give evidence of the participation of a
sufficient number of physicians or dentists, in his judgment, to render
the medical or dental services specified under the contract.
(Added to NRS by 1971, 1868; A 1971, 1957; 1985, 613)
A
corporation organized under this chapter shall be deemed to be insolvent
if its reserve fund is impaired so as to be less than the amounts set
forth in NRS 695B.140 . For the
purposes of determining such insolvency and the financial condition of
the corporation, for the purposes of preparation of annual statements,
and for all other purposes not otherwise expressly provided for in this
chapter, the corporation is subject to all requirements of the laws of
the State of Nevada as to assets, liabilities and reserves which are
applicable to mutual nonassessable life or health insurers.
(Added to NRS by 1971, 1868; A 2005, 2158 )
1. Every corporation subject to the provisions of this chapter
shall annually:
(a) On or before March 1, file in the Office of the Commissioner a
statement verified by at least two of the principal officers of the
corporation, showing its condition and affairs as of December 31 of the
preceding calendar year. The statement must be in the form required by
the Commissioner and must contain statements relative to the matters
required to be established as a condition precedent to maintaining or
operating a nonprofit hospital, medical or dental service plan and to
other matters which the Commissioner may prescribe.
(b) Pay the annual fee for the renewal of a certificate of
authority and the fee for the filing of an annual statement.
2. The Commissioner may examine, as often as he deems it
desirable, the affairs of every corporation subject to the provisions of
this chapter. He shall, if practicable, examine each such corporation at
least once in every 3 years, and in any event, at least once in every 5
years, as to its condition, fulfillment of its contractual obligations
and compliance with applicable laws. For examining the financial
condition of every such corporation the Commissioner shall collect the
actual expenses of the examination. Such expenses must be paid by the
corporation. The Commissioner shall refuse to issue a certificate of
authority or shall revoke his certificate of authority issued to any
corporation which neglects or refuses to pay such expenses.
(Added to NRS by 1971, 1869; A 1987, 468)
All acquisition costs in connection with the
solicitation of subscribers to such hospital, medical or dental service
plan shall at all times be subject to the approval of the Commissioner,
and the administrative expenses for any calendar year, excluding the
first full year of operation, of any such corporation, including
acquisition costs, shall be limited to 25 percent of the aggregate amount
of rates, dues, fees and other periodic charges actually received during
that year. If the Commissioner finds that acquisition costs of any
corporation operating under the provisions of this chapter are excessive,
or that the administrative expenses exceed the amount above stated, such
finding shall be sufficient ground to justify the Commissioner in
revoking his consent to the establishment, maintenance and operation by
such corporation of the hospital, medical or dental service plan.
(Added to NRS by 1971, 1869)
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 contract for hospital or
medical service offered by the insurer. The disclosure must include:
(a) Any significant exception, reduction or limitation that applies
to the contract; and
(b) Any other information,
Ê that the Commissioner finds necessary to provide for full and fair
disclosure of the provisions of the contract.
2. The disclosure must be written in language which is easily
understood and must include a statement that the disclosure is a summary
of the contract only, and that the contract itself should be read to
determine the governing contractual provisions.
3. The Commissioner shall not approve any proposed disclosure
submitted to him pursuant to this section which does not comply with the
requirements of this section and the applicable regulations.
(Added to NRS by 1989, 1251)
An insurer shall provide to the group policyholder to whom
it offers a contract for hospital or medical service a copy of the
disclosure approved for that contract pursuant to NRS 695B.172 before the contract is issued. An insurer
shall not offer a contract for hospital or medical service unless the
disclosure for that contract has been approved by the Commissioner.
(Added to NRS by 1989, 1251)
1. An insurer that offers or issues a contract for hospital or
medical services 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 contract for hospital or
medical services 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, 861 )
CONTRACTS
A contract for hospital,
medical or dental services must not be entered into between a corporation
proposing to furnish or provide any one or more of the services
authorized under this chapter and a subscriber:
1. Unless the entire consideration therefor is expressed in the
contract.
2. Unless the times at which the benefits or services to the
subscriber take effect and terminate are stated in a portion of the
contract above the evidence of its execution.
3. If the contract purports to entitle more than one person to
benefits or services, except for family contracts issued under NRS
695B.190 , group contracts issued
under NRS 695B.200 , and blanket
contracts issued under NRS 695B.220 .
4. Unless every printed portion and any endorsement or attached
papers are plainly printed in type of which the face is not smaller than
10 points.
5. Except for group contracts and blanket contracts issued under
NRS 695B.220 , unless the exceptions
of the contract are printed with greater prominence than the benefits to
which they apply.
6. Except for group contracts and blanket contracts issued under
NRS 695B.230 , unless, if any portion
of the contract purports, by reason of the circumstances under which an
illness, injury or disablement is incurred to reduce any service to less
than that provided for the same illness, injury or disablement incurred
under ordinary circumstances, that portion is printed in boldface type
and with greater prominence than any other text of the contract.
7. If the contract contains any provisions purporting to make any
portion of the charter, constitution or bylaws of a nonprofit corporation
a part of the contract unless that portion is set forth in full in the
contract.
8. Unless the contract, if it is a group contract, contains a
provision for benefits payable for expenses incurred for the treatment of
the abuse of alcohol or drugs, as provided in NRS 695B.194 .
9. Unless the contract provides benefits for expenses incurred for
hospice care.
10. Unless the contract for service in a hospital contains in
blackface type, not less than 10 points, the following provisions:
This contract does not restrict or interfere with the right of any
person entitled to service and care in a hospital to select the
contracting hospital or to make a free choice of his attending physician,
who must be the holder of a valid and unrevoked physician’s license and a
member of, or acceptable to, the attending staff and board of directors
of the hospital in which the services are to be provided.
(Added to NRS by 1971, 1869; A 1975, 1851; 1979, 1180; 1983, 1935,
2039; 1985, 1777; 1989, 515, 1033)
1. Except as otherwise provided in NRS 695B.182 and subject to the approval of the
Commissioner, any contract which is authorized pursuant to this chapter
may include a provision which requires the parties to the contract to
submit for binding arbitration any dispute between the parties concerning
any matter directly or indirectly related to, or associated with, the
contract. If such a provision is included in the contract:
(a) A person who elects to be covered by the contract must be given
the opportunity to decline to participate in binding arbitration at the
time he elects to be covered by the contract.
(b) It must clearly state that the parties to the contract who have
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
person insured under the contract, 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
contract, 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, 2558)
1. Each contract for hospital or medical services 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 a corporation subject to the provisions of this chapter, 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 a contract for hospital or medical services,
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 contract for services 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, 2116)
A group
contract for hospital, medical or dental services 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 copayment
required to be paid by the insured to a preferred provider of health care
and the copayment 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 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 corporation 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, 1782; A 1989, 515; 1991, 1331; 1995, 1631)
Except as otherwise
provided by the provisions of NRS 689B.340 to 689B.590 , inclusive, and chapter 689C of NRS relating to the portability and
availability of health insurance:
1. A group contract for hospital, medical or dental services
issued by a nonprofit hospital, medical or dental service corporation 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 the 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 contract is issued within 60 days after the date on which the
previous policy or coverage was discontinued.
2. If an employer obtains a replacement contract 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 corporation which issues a replacement contract pursuant to
subsection 1 may submit a written request to the insurer which 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 shall give a written statement to the corporation 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 apply to a self-insured employer
who provides health benefits to his employees and replaces those benefits
with a group contract for hospital, medical or dental services issued by
a nonprofit hospital, medical or dental service corporation.
(Added to NRS by 1987, 849; A 1997, 2954)
A group contract issued by a corporation under the
provisions of this chapter must contain a provision which permits the
continuation of coverage pursuant to the provisions of NRS 689B.245
to 689B.249 , inclusive, and 689B.340 to 689B.590 , inclusive, and chapter 689C of NRS relating to the portability and
availability of health insurance.
(Added to NRS by 1987, 2235; A 1997, 2955)
Family hospital or family medical
or dental service contracts may be issued to a family consisting of an
individual and one or more persons dependent upon him, or of one or more
persons dependent upon an individual, and may include his spouse, whether
or not dependent upon him. Such contracts shall contain a provision to
the effect that to the family originally covered may be added from time
to time all new members of the family group eligible for coverage and
that the head of the family shall give the corporation notice of the
addition to the family of any person eligible for coverage under the
contracts.
(Added to NRS by 1971, 1870)
1. The provisions of this section apply to a policy of health
insurance offered or issued by a hospital or medical service corporation
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
hospital or medical service corporation.
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 hospital or medical service corporation 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 hospital or medical service corporation 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 hospital or medical
service corporation 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 hospital or medical service corporation; 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 hospital or medical service
corporation.
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
hospital or medical service corporation and the hospital or medical
service corporation terminated that contract because of the medical
incompetence or professional misconduct of the provider of health care;
and
(b) The hospital or medical service corporation 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, 3363 )
1. A policy of health insurance issued by a medical services
corporation must provide coverage for medical treatment which a person
insured under the 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
health insurance.
(c) The cost of any routine health care services that would
otherwise be covered under the policy of 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 695B.1901 , 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 medical services corporation has
contracted for such services. If the medical services corporation has not
contracted for the provision of such services, the medical services
corporation shall pay the provider the rate of reimbursement that is paid
to other providers with whom the medical services corporation 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 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 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 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 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. A medical services corporation that delivers or issues for
delivery a policy of health insurance specified in subsection 1 may
require copies of the approval or certification issued pursuant to
paragraph (b) of subsection 1, the statement of consent signed by the
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. A medical services corporation that delivers or issues for
delivery a policy of health insurance specified in subsection 1 shall:
(a) Include in the disclosure required pursuant to NRS 695B.172
notice to each person insured under
the policy of the availability of the benefits required by this section.
(b) Provide the coverage required by this section subject to the
same deductible, copayment, coinsurance and other such conditions for
coverage that are required under the policy.
7. A policy of health insurance subject to the provisions of this
chapter that is delivered, issued for delivery or renewed on or after
January 1, 2006, has the legal effect of including the coverage required
by this section, and any provision of the policy that conflicts with this
section is void.
8. A medical services corporation that delivers or issues for
delivery a policy of 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, 3525 ; A 2005, 2015 )
1. Except as otherwise provided in this section, a contract for
hospital or medical services 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 contract 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 contract.
3. Any provision of a contract for hospital or medical services
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, 862 ; A 2003, 2300 )
1. A policy of health insurance issued by a hospital or medical
service corporation that provides coverage for the treatment of
colorectal cancer must provide coverage for colorectal cancer screening
in accordance with:
(a) The guidelines concerning colorectal cancer screening which are
published by the American Cancer Society; or
(b) Other guidelines or reports concerning colorectal cancer
screening which are published by nationally recognized professional
organizations and which include current or prevailing supporting
scientific data.
2. A policy of health insurance subject to the provisions of this
chapter that is delivered, issued for delivery or renewed on or after
October 1, 2003, has the legal effect of including the coverage required
by this section, and any provision of the policy that conflicts with the
provisions of this section is void.
(Added to NRS by 2003, 1335 )
Except as otherwise provided in NRS
695B.1903 :
1. No contract for hospital or medical services 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 contract
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 a person covered under the contract.
(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 contract for hospital or medical services 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 contract
that conflicts with the provisions of this section is void.
(Added to NRS by 1999, 760 ; A 2003, 3528 )
1. A policy of health insurance, issued by a medical service
corporation, 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, 1890; 2001, 2249 )
1. A policy of health insurance issued by a hospital or medical
service corporation must provide coverage for benefits payable for
expenses incurred for:
(a) An annual cytologic screening test for women 18 years of age or
older;
(b) A baseline mammogram for women between the ages of 35 and 40;
and
(c) An annual mammogram for women 40 years of age or older.
2. A policy of health insurance issued by a hospital or medical
service corporation 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, 1890; A 1997, 1730)
1. A contract for hospital or medical service must include a
provision authorizing a woman covered by the contract 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 contract for hospital or medical service to designate an
obstetrician or gynecologist as her primary care physician.
3. A contract 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 contract 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. Except as otherwise provided in subsection 5, an insurer that
offers or issues a contract for hospital or medical service which
provides coverage for prescription drugs or devices shall include in the
contract 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 contract for hospital or
medical service 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
contract;
(b) Refuse to issue a contract for hospital or medical service or
cancel a contract for hospital or medical service solely because the
person applying for or covered by the contract 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 contract
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
contract 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 contract.
5. An insurer which offers or issues a contract for hospital or
medical service 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 contract for hospital or medical service
and before the renewal of such a contract, 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, 1999 )
1. Except as otherwise provided in subsection 5, an insurer that
offers or issues a contract for hospital or medical service which
provides coverage for outpatient care shall include in the contract
coverage for any health care service related to contraceptives or hormone
replacement therapy.
2. An insurer that offers or issues a contract for hospital or
medical service 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 contract;
(b) Refuse to issue a contract for hospital or medical service or
cancel a contract for hospital or medical service solely because the
person applying for or covered by the contract 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 contract
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
contract 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 contract.
5. An insurer which offers or issues a contract for hospital or
medical service 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
contract for hospital or medical service and before the renewal of such a
contract, 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, 2000 )
1. No hospital, medical or dental service contract issued by a
corporation pursuant to the provisions of this chapter may contain any
exclusion, reduction or other limitation of coverage relating to
complications of pregnancy, unless the provision applies generally to all
benefits payable under the contract and complies with the provisions of
NRS 689B.340 to 689B.590 , inclusive, and chapter 689C of NRS relating to the portability and
availability of health insurance.
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 contract subject to the provisions of this chapter which is
issued or delivered on or after July 1, 1977, has the legal effect of
including the coverage required by this section, and any provision of the
contract which is in conflict with this section is void.
(Added to NRS by 1977, 416; A 1997, 2955)
1. A contract for hospital or medical service 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 contract was purchased.
3. A contract 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 contract 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, 1527)
1. No contract for hospital or medical service that provides
coverage for hospital, medical or surgical expenses may be delivered or
issued for delivery in this state unless the contract 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 contract
specified in subsection 1:
(a) Shall include in the disclosure required pursuant to NRS
695B.172 notice to each policyholder
or subscriber covered under the contract 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 contract.
3. A contract for hospital or medical service 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 contract
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 a person covered
under the contract 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 person covered under the contract 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, 744)
1. All individual and group service or indemnity-type contracts
issued by a nonprofit corporation which provide coverage for a family
member of the subscriber must as to such coverage provide that the health
benefits applicable for children are payable with respect to:
(a) A newly born child of the subscriber 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 subscriber 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 contracts must provide the coverage specified in subsection 3, and
must not exclude premature births.
2. The 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 fees, if any, must be furnished to the
nonprofit service corporation 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. A corporation 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 that contract. Any provision relating to an
exclusion for a preexisting condition must comply with NRS 689C.190
.
5. For covered services provided to the child, the corporation
shall reimburse noncontracted providers of health care to an amount equal
to the average amount of payment for which the organization has
agreements, contracts or arrangements for those covered services.
(Added to NRS by 1975, 1110; A 1989, 741; 1995, 2434; 1997, 2956)
1. Except as otherwise provided in this section, no contract for
hospital or medical service 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 contract
or by a claims settlement practice. A contract for hospital or medical
service 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. Pursuant to a contract for hospital or medical service, a
corporation 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 a subscriber, but in no case more
than 50 percent of the maximum benefits provided by the contract for such
treatment; and
(b) Treatment which is medically necessary.
3. Any provision of a contract 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)
1. Notwithstanding any provisions of this title to the contrary, a
contract for hospital or medical service 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 contract year and 40 visits for treatment as an outpatient
per contract 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 contract required to provide
coverage for more than 40 days of hospitalization as an inpatient per
contract 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 contract for hospital or medical
services.
4. The provisions of this section do not apply to a contract for
hospital or medical service:
(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 contract year, the premiums charged for
that contract, or a standard grouping of contracts, 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 contract year the amount of premiums
charged during the period immediately preceding the contract 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 contract for hospital or medical service 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 contract
or the renewal which is in conflict with this section is void, unless the
contract 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, 3103 )
1. The annual benefits provided by a policy for group health
insurance issued by a medical service corporation, as required by
subsection 8 of NRS 695B.180 , 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, 1179; A 1983, 2040; 1985, 1570, 1778; 1989,
516; 1993, 1922; 1997, 1302; 1999, 1889 ; 2001, 439 )
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 subscriber contract for hospital, medical or dental
service may be delivered or issued for delivery in this state unless it
provides continuing coverage for an employee or member 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 subscriber contract 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, 1251)
If any contract for
hospital or medical services 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)
If any contract for hospital or medical service provides coverage for
treatment of an illness which is within the authorized scope of the
practice of a qualified psychologist, the insured is entitled to
reimbursement for treatments by a psychologist who is licensed pursuant
to chapter 641 of NRS.
(Added to NRS by 1981, 576; A 1989, 1553)
If any contract for hospital or medical service
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 contract for hospital or medical service 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 contract for hospital or medical service 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, 328)
1. If any contract for medical service 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 contract 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 contract
for medical service 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 subscriber or the provider may submit the claim for
reimbursement. The provider shall not demand payment from the subscriber
until after that reimbursement has been granted or denied.
3. Subsection 1 does not apply to any agreement between a
corporation for medical service and a provider of medical transportation
for the direct payment by the corporation for the provider’s services.
(Added to NRS by 1989, 1274)
Group hospital or group medical or
dental service contracts written under a master hospital or medical or
dental service contract may be issued to cover groups of two or more
persons, formed for a purpose other than of obtaining insurance.
(Added to NRS by 1971, 1871)
Every group master hospital or group medical or dental service contract
issued shall contain the following provisions:
1. A provision that the contract, the application of the employer,
or executive officer or trustee of any association or trustees, and the
individual applications, if any, of the employees or members covered
shall constitute the entire contract between the parties, and that all
statements made by the employer, or the executive officer, or trustee or
trustees, or by the individual employee or member shall, in the absence
of fraud, be deemed representations and not warranties, and that no such
statement shall be used in defense to a claim under the contract, unless
it is contained in a written application.
2. A provision that the corporation will issue to the employer or
to the executive officer or trustee of the association or to the
trustees, for delivery to each of the employees or members who are
covered under such contract, an individual certificate setting forth a
statement as to the hospital or medical or dental service to which he is
entitled.
3. A provision that to the group or class thereof originally
covered shall be added from time to time all new employees of the
employer or members of the association eligible to and applying for
coverage in such group or class.
4. A statement that such contract is not in lieu of workmen’s
compensation insurance.
5. Such provisions as may be promulgated by the Commissioner from
time to time.
(Added to NRS by 1971, 1871)
Blanket hospital or blanket medical or dental service contracts may be
issued to a college or school or to the head or principal thereof or to
the governing board of any school district providing for services to
pupils of such schools when such services are required as the result of
accident to such pupils while they are required to be in or on buildings
or other premises of the school or district during the time they are
required to be therein or thereon by reason of their attendance upon a
college or regular day school or any regular day school of a school
district or while being transported to and from school or other place of
instruction. No pupil shall be compelled to accept such service without
the consent of his parent or guardian.
(Added to NRS by 1971, 1871)
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 shall 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 nor 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 1989, 514)
If more than one class of risk is included:
1. A hospital or medical or dental service contract or evidence of
coverage under a group or nongroup contract must not be issued or
delivered in this state until a copy of the form of the contract is filed
with the Commissioner and either:
(a) Thirty days expires without notice from the Commissioner after
the copy is filed; or
(b) The Commissioner gives his written approval before that time.
2. A schedule of premium rates to be paid by subscribers under
either a group or nongroup contract must not be issued, delivered or used
by any nonprofit hospital, medical or dental service corporation until
that corporation files with the Commissioner a copy of the schedule
together with any supplementary information required by the Commissioner
and either:
(a) Thirty days expires without notice from the Commissioner after
the copy is filed; or
(b) The Commissioner gives his written approval before that time.
(Added to NRS by 1971, 1872; A 1989, 517)
1. A corporation subject to the provisions of this chapter is
permitted to provide group hospital or group medical or dental service
coverage prior to the approval of the form of the contract or certificate
if all the conditions of subsection 2 of this section are met prior
thereto and if thereafter it acts as required by subsection 3.
2. The conditions referred to in subsection 1 are that:
(a) The group is one eligible for coverage pursuant to the
provisions of this chapter.
(b) An executed memorandum has been or is concurrently delivered to
the subscriber containing a provision that unless a group hospital or
group medical or dental service certificate, the form of which has been
approved by the Commissioner, which is issued under a group hospital or
group medical or dental service contract the form of which has been
approved by the Commissioner, and which embodies the coverage, has been
issued and delivered to the subscriber within 90 days after the date on
which the coverage is provided or agreed to be provided, the coverage
provided pursuant to such memorandum terminates 120 days after such date.
The memorandum shall contain a specification in either complete or
summary form of:
(1) The class or classes of employees eligible for coverage.
(2) The benefits to be provided.
(3) The exceptions and reductions to such benefits, if any.
3. A corporation subject to the provisions of this chapter
providing coverage pursuant to this section shall:
(a) Within 60 days after the date on which the coverage is provided
or agreed to be provided, submit to the Commissioner for approval a form
of a group hospital or group medical or dental service contract, and a
form of a certificate of individual coverage, drafted to provide the
coverage provided by such memorandum and to meet all requirements of law.
(b) Make such revisions in the contract and certificate submitted
as the Commissioner may lawfully require.
(c) Terminate such coverage in accordance with the provisions of
paragraph (b) of subsection 2 of this section if approval of such
contract and certificate is not secured within the time specified therein.
(Added to NRS by 1971, 1872)
1. Upon written request from the corporation subject to the
provisions of this chapter filed within 50 days after the date on which
the coverage is provided or agreed to be provided and upon proof
satisfactory to him that the corporation is acting with due diligence and
that hardship will result unless an extension is granted, the
Commissioner may extend the time set forth in paragraph (a) of subsection
3 of NRS 695B.240 for a period of not
to exceed 30 days. Upon such extension, the corporation with the consent
of the subscriber may amend the memorandum referred to in paragraph (b)
of subsection 2 of NRS 695B.240 to
extend the time within which the certificate must be issued and delivered
to the subscriber to 30 days after the date to which the Commissioner has
extended the time within which a form of contract and certificate must be
submitted to him for approval and to extend the date for termination of
coverage to 30 days thereafter.
2. A contract and certificate submitted to the Commissioner with a
letter from the corporation stating that coverage has been provided in
accordance with this section shall be automatically approved unless the
Commissioner disapproves the same within 30 days of the date of its
submission to him.
(Added to NRS by 1971, 1873)
1. Except as otherwise provided in subsection 2, a corporation
subject to the provisions of this chapter shall approve or deny a claim
relating to a contract for dental, hospital or medical services within 30
days after the corporation receives the claim. If the claim is approved,
the corporation 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 corporation 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 corporation 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 corporation shall notify the provider of dental, hospital
or medical services of all the specific reasons for the delay in
approving or denying the claim. The corporation shall approve or deny the
claim within 30 days after receiving the additional information. If the
claim is approved, the corporation shall pay the claim within 30 days
after it receives the additional information. If the approved claim is
not paid within that period, the corporation shall pay interest on the
claim in the manner prescribed in subsection 1.
3. A corporation shall not request a claimant to resubmit
information that the claimant has already provided to the corporation,
unless the corporation provides a legitimate reason for the request and
the purpose of the request is not to delay the payment of the claim,
harass the claimant or discourage the filing of claims.
4. A corporation 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 corporation.
7. The Commissioner may require a corporation to provide evidence
which demonstrates that the corporation has substantially complied with
the requirements set forth in this section, including, without
limitation, payment within 30 days of at least 95 percent of approved
claims or at least 90 percent of the total dollar amount for approved
claims.
8. If the Commissioner determines that a corporation is not in
substantial compliance with the requirements set forth in this section,
the Commissioner may require the corporation to pay an administrative
fine in an amount to be determined by the Commissioner. Upon a second or
subsequent determination that a corporation 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
corporation.
(Added to NRS by 1991, 1330; A 1999, 1650 ; 2001, 2733 ; 2003, 3364 )
CONVERSION OF GROUP CONTRACTS TO INDIVIDUAL CONTRACTS
1. Except as otherwise provided in the provisions of this section,
NRS 689B.340 to 689B.590 , inclusive, and chapter 689C of NRS relating to the portability and
availability of health insurance, all group subscriber contracts
delivered or issued for delivery in this state providing for hospital,
surgical or major medical coverage, or any combination of these
coverages, on a service basis or an expense-incurred basis, or both, must
contain a provision that the employee or member is entitled to have
issued to him a subscriber contract of health coverage when the employee
or member is no longer covered by the group subscriber contract.
2. The requirement in subsection 1 does not apply to contracts
providing benefits only for specific diseases or accidental injuries.
3. If an employee or member was a recipient of benefits under the
coverage provided pursuant to NRS 695B.1944 , he is not entitled to have issued to him
by a replacement insurer a subscriber contract of health coverage 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 695B.1944 .
(Added to NRS by 1979, 1087; A 1989, 1252; 1997, 2956)
Subject to the conditions set forth in NRS
695B.251 to 695B.259 , 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 contract is terminated by reason of such death, or if there is
no surviving spouse, to each surviving child whose coverage under the
group contract terminates by reason of such death, or, if the group
contract 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 covered under
the group contract, if the spouse ceases to be a dependent as defined by
the group contract, and to any child whose coverage under the group
contract 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 dependent as defined by the group
contract, if a conversion privilege is not otherwise provided with
respect to the termination.
(Added to NRS by 1979, 1089)
1. The medical service corporation is not required to issue a
converted contract 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
or 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 contract,
would result in overinsurance according to the medical service
corporation’s standards.
2. Before denying a converted contract to an applicant because he
has coverage as described in paragraph (a) of subsection 1, the medical
service corporation shall notify him that the converted contract will be
issued only if the other coverage is cancelled.
(Added to NRS by 1979, 1087)
1. A person who is entitled to a converted contract must be given
his choice of at least three types of contracts offering benefits on a
service basis or an expense-incurred basis, or both.
2. The converted contract may include major medical or
catastrophic benefits if they were provided under the group contract.
3. For those subscribers eligible for Medicare, the medical
service corporation may provide for a supplement to Medicare as part of
the conversion privilege.
(Added to NRS by 1979, 1088)
A medical service
corporation is not required to issue a converted contract which provides
benefits in excess of those provided under the group contract from which
conversion is made, and a converted contract may contain any exclusion or
benefit limitation contained in the group contract.
(Added to NRS by 1979, 1088)
A converted contract
must not exclude a preexisting condition not excluded by the group
contract, but a converted contract 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 contract after his
termination. A converted contract may provide that during the first
contract year the benefits payable under it, together with the benefits
payable under the group contract, must not exceed those that would have
been payable if the subscriber’s coverage under the group contract had
remained in effect.
(Added to NRS by 1979, 1088)
The medical service corporation shall:
1. Issue the converted contract without evidence of insurability;
2. Base the premium on the converted policies for the first 12
months, and subsequent renewals, upon the medical service corporation’s
table of premium rates applicable to the age and class of risk of each
person to be covered under the contract and to the type and amount of
coverage provided. The frequency of premium payments must be the same as
is customarily required by the medical service corporation for the
contract form and plan selected except that premium payments must not be
required more often than quarterly;
3. Provide that the effective date of the converted contract is
12:01 a.m. on the day after the termination of coverage under the group
contract; and
4. Provide that the converted contract covers the employee or
member and his dependents who were covered by the group contract on the
date of his termination. At the option of the insurer, a separate
converted contract may be issued to cover any dependent.
(Added to NRS by 1979, 1087)
1. A converted contract issued under NRS 695B.251 may include a provision permitting the
medical service corporation to request from the applicant, in advance of
any premium due date, information as to whether he is covered for similar
benefits under any of the sources listed in NRS 695B.253 .
2. The medical service corporation may not refuse to renew the
contract or the coverage of any person unless:
(a) Benefits provided under the sources listed in subsection 1 of
NRS 695B.253 , together with the
benefits provided by the converted contract would result in overinsurance
according to the medical service corporation’s standards;
(b) The holder of the converted contract has refused to provide
requested information as to such sources; or
(c) Fraud was committed in applying for any benefits under the
converted contract.
3. Before refusing to renew a converted contract because of
overinsurance, the medical service corporation shall notify the
subscriber that the converted contract will be renewed only if the other
coverage is cancelled.
(Added to NRS by 1979, 1088)
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 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 contract. 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 contract. 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, 1089)
A converted contract which is to be delivered outside this state must be
in such form as would be deliverable in the other jurisdiction as a
converted contract if the group contract had been issued in that
jurisdiction.
(Added to NRS by 1979, 1089)
The medical service corporation may elect to extend coverage of a
subscriber under the existing group contract for a period not to exceed 6
months following the day of the person’s eligibility for a converted
contract if the conversion privilege is offered upon termination of the
extended coverage under the group contract.
(Added to NRS by 1979, 1089)
The medical service corporation may elect to
provide group coverage in lieu of the issuance of a converted individual
contract.
(Added to NRS by 1979, 1089)
The medical service corporation
may continue coverage identical to that provided under the group contract
instead of issuing a converted contract. Coverage may be offered by
amending the group certificate or by issuing an individual contract and,
except as otherwise provided in NRS 689B.245 to 689B.249 , inclusive, must otherwise comply with every
requirement of NRS 695B.251 to
695B.259 , inclusive.
(Added to NRS by 1979, 1089; A 1987, 2235)
MISCELLANEOUS PROVISIONS
The Commissioner may suspend or
revoke the permission granted by NRS 695B.240 if, after notice and hearing, he finds that
the corporation has:
1. Misrepresented the conditional nature of the coverage.
2. Neglected or refused either to cancel or otherwise terminate
such coverage within the time required by such section.
3. Delivered any such memorandum which did not comply with such
section.
4. Shown a lack of diligence in making revisions in the contract
or certificate necessary to obtain its approval by the Commissioner.
5. Failed so often in so many important respects in drafting any
such contract or certificate to conform to the applicable requirements of
the insurance laws that a conclusion of lack of good faith or competency
in drafting is reasonably justified.
6. Circulated announcements of coverage to individual subscribers
which failed to advise them of the conditional nature of the coverage.
7. In any other manner so negligently or carelessly handled the
effecting of group hospital or group medical or dental service coverage
under NRS 695B.240 or the
administration thereof that the subscriber or the persons covered by the
contract or certificate have been misled or exposed to the danger of loss.
(Added to NRS by 1971, 1873)
If the
Commissioner notifies the corporation, in writing, that the filed form
does not comply with the requirements of law, specifying the reasons for
his opinion, it is unlawful for the corporation thereafter to issue any
contract in such form.
(Added to NRS by 1971, 1874)
The Commissioner may adopt
such reasonable regulations, not inconsistent with the provisions of this
chapter, relating to the substance, form and issuance of any contract
covering the furnishing of hospital or medical or dental services and
required to be approved by him as are necessary or desirable. The
regulations may not prohibit the use in any such contract or agreement of:
1. The word “subscriber” as a designation of the obligee.
2. The phrase “a family member” as a designation for the members
of the family of the obligee.
3. The word “contract” or “agreement” as a designation for the
undertakings of the hospital or medical or dental service corporation.
4. The phrases “furnishing of service” or “payment of benefits” as
a designation for the commitments of the hospital or medical or dental
service corporation.
5. The phrase “the service” as a designation for the corporate
obligor in any such contract or agreement.
(Added to NRS by 1971, 1874; A 1981, 107)
Every nonprofit hospital or medical or dental service corporation may
utilize the Uniform Billing and Claims Forms established by the American
Hospital Association.
(Added to NRS by 1975, 897)
Any agent of a nonprofit
hospital or medical or dental service corporation who acts as such in the
solicitation, negotiation, procurement or making of a hospital service or
medical or dental care contract shall be qualified, examined and licensed
in the same manner and pay the same fees as provided for health insurance
agents in NRS 680B.010 (fee schedule)
and chapter 683A of NRS.
(Added to NRS by 1971, 1874)
Any
nonprofit hospital or medical or dental service corporation organized and
created under the provisions of this chapter and engaged in the operation
of a hospital or medical or dental service plan may contract, without
regard to the limitations in respect to contracts imposed by this
chapter, with any agency, instrumentality or political subdivision of the
United States of America or of the State of Nevada for the furnishing of
hospital or medical or dental service and care and, in aid or furtherance
of such contract, may accept, receive and administer, in trust, funds
directly or indirectly made available by such agency, instrumentality or
political subdivision. Any such nonprofit hospital or medical or dental
service corporation may subcontract with any organization which has
contracted with any agency, instrumentality or political subdivision of
the United States of America or of the State of Nevada for the furnishing
of medical, dental and hospital services, by which subcontract such
hospital or medical or dental service corporation undertakes to furnish
the hospital or medical or dental services required by the basic contract.
(Added to NRS by 1971, 1874)
Any nonprofit hospital or
medical or dental service corporation subject to the provisions of this
chapter shall be subject to the same taxes, licenses, fees and, to the
extent not regulated by the provisions of this chapter, the same
supervision as a mutual insurer organized under the laws of the State of
Nevada.
(Added to NRS by 1971, 1875)
1. If a policyholder requests information for the renewal of his
policy, an insurer shall provide to the policyholder information
regarding claims paid on behalf of the policyholder. The information must
be provided within 30 working days after the insurer receives a written
request from the policyholder. The insurer may charge the policyholder a
reasonable fee for the information.
2. The Commissioner may adopt regulations to carry out the
provisions of subsection 1.
(Added to NRS by 1993, 2400)
A corporation shall not
deny a claim, refuse to issue a contract for hospital, medical or dental
services or cancel a contract for hospital, medical or dental services
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 contract was the victim
of such an act of domestic violence, regardless of whether the insured or
applicant contributed to any loss or injury.
(Added to NRS by 1997, 1096)
[Effective July 1, 2006.]
1. Except as otherwise provided in subsection 2, a medical
services corporation that issues contracts for hospital, medical or
dental services shall not:
(a) Deny a claim under such a contract 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 such a contract 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 such a contract to an eligible applicant solely
because the applicant has made a claim involving an injury sustained by
the applicant as a consequence of being intoxicated or under the
influence of a controlled substance.
2. The provisions of this section do not prohibit a medical
services corporation from enforcing a provision included in a contract
for hospital, medical or dental services 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 such a contract solely because of such a claim; or
(c) Refuse to issue such a contract to an eligible applicant solely
because of such a claim.
(Added to NRS by 2005, 2345 , effective July 1, 2006)
1. Except as otherwise provided in subsection 2, a corporation
that provides health insurance shall not:
(a) Require an insured person or any member of his family to take a
genetic test;
(b) Require an insured person to disclose whether he or any member
of his family has taken a genetic test or any genetic information of the
insured person or a member of his family; or
(c) Determine the rates or any other aspect of the coverage or
benefits for health care provided to an insured person based on:
(1) Whether the insured person or any member of his family
has taken a genetic test; or
(2) Any genetic information of the insured person or any
member of his family.
2. The provisions of this section do not apply to a corporation
that issues a policy of health insurance that provides coverage for
long-term care or disability income.
3. As used in this section:
(a) “Genetic information” means any information that is obtained
from a genetic test.
(b) “Genetic test” means a test, including a laboratory test that
uses deoxyribonucleic acid extracted from the cells of a person or a
diagnostic test, to determine the presence of abnormalities or
deficiencies, including carrier status, that:
(1) Are linked to physical or mental disorders or
impairments; or
(2) Indicate a susceptibility to illness, disease,
impairment or any other disorder, whether physical or mental.
(Added to NRS by 1997, 1461)
1. Nonprofit hospital, medical or dental service corporations are
subject to the provisions of NRS 689B.340 to 689B.590 , inclusive, and chapter 689C of NRS relating to the portability and
availability of health insurance offered by such organizations. If there
is a conflict between the provisions of this chapter and the provisions
of NRS 689B.340 to 689B.590 , inclusive, and chapter 689C of NRS, the provisions of NRS 689B.340 to 689B.590 , inclusive, and chapter 689C of NRS control.
2. For the purposes of subsection 1, unless the context requires
that a provision apply only to a group health plan or a carrier that
provides coverage under a group health plan, any reference in those
sections to:
(a) “Carrier” must be replaced by “corporation.”
(b) “Group health plan” must be replaced by “group contract for
hospital, medical or dental services.”
(Added to NRS by 1997, 2954; A 2001, 1924 )
A corporation 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, 2158 )
Nonprofit
hospital and medical or dental service corporations are subject to the
provisions of this chapter, and to the provisions of chapters 679A and 679B of NRS, NRS
686A.010 to 686A.315 , inclusive, 687B.010 to 687B.040 , inclusive, 687B.070 to 687B.140 , inclusive, 687B.150 , 687B.160 , 687B.180 , 687B.200 to 687B.255 , inclusive, 687B.270 , 687B.310 to 687B.380 , inclusive, 687B.410 , 687B.420 , 687B.430 , and chapters 692C and 696B of NRS, to
the extent applicable and not in conflict with the express provisions of
this chapter.
(Added to NRS by 1971, 1875; A 1995, 988, 1631, 1636; 1997, 2957,
3036; 1999, 631 )
ELIGIBILITY FOR COVERAGE
As used in NRS 695B.330 to 695B.370 , inclusive, unless the context otherwise
requires:
1. “Contract” means a contract for hospital, medical or dental
services issued pursuant to this chapter.
2. “Corporation” means a corporation organized pursuant to this
chapter.
3. “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.
4. “Order for medical coverage” means an order of a court or
administrative tribunal to provide coverage under a contract to a child
pursuant to the provisions of 42 U.S.C. § 1396g-1.
(Added to NRS by 1995, 2433)
1. A corporation shall not, when considering eligibility for
coverage or making payments under a contract, consider the availability
of, or any eligibility of a person for, medical assistance under Medicaid.
2. To the extent that payment has been made by Medicaid for health
care, a corporation:
(a) Shall treat Medicaid as having a valid and enforceable
assignment of benefits of a subscriber or policyholder or claimant under
him 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 against any other liable
party if:
(1) It is so authorized pursuant to a contract with Medicaid
for managed care; or
(2) It has reimbursed Medicaid in full for the health care
provided by Medicaid to its subscriber or policyholder.
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 contract,
Ê the corporation that issued the contract shall not impose any
requirements upon the state agency except requirements it imposes upon
the agents or assignees of other persons covered by the same contract.
(Added to NRS by 1995, 2433)
A corporation
shall not deny the enrollment of a child pursuant to an order for medical
coverage under a contract 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 corporation’s
geographic area of service.
(Added to NRS by 1995, 2433)
If a child has coverage
under a contract pursuant to which a noncustodial parent of the child is
insured, the corporation issuing that contract 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, 2433)
If a parent is required
by an order for medical coverage to provide coverage for a child and the
parent is eligible for family coverage under a contract, the corporation
that issued the contract:
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
corporation 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, 2434)
SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS
1. Except as otherwise provided in subsection 4, each insurer that
issues a contract for hospital or medical services 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 contract
for hospital or medical services 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 contract specified in subsection 1
shall, if the contract provides, delivers, arranges for, pays for or
reimburses any cost of health care services through managed care, provide
a system for resolving any complaints of an insured concerning those
health care services that complies with the provisions of NRS 695G.200
to 695G.310 , inclusive.
(Added to NRS by 1997, 310; A 2003, 776 )
1. Each insurer that issues a contract for hospital or medical
services 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 695B.380 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, 310; A 2003, 776 )
1. Following approval by the Commissioner, each insurer that
issues a contract for hospital or medical services 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 to a beneficiary or subscriber, including, without limitation,
denying a claim relating to a contract for dental, hospital or medical
services pursuant to NRS 695B.2505 ,
it shall notify the beneficiary or subscriber 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, 310; A 1999, 3093 )
