USA Statutes : nevada
Title : Title 57 - INSURANCE
Chapter : CHAPTER 695C - HEALTH MAINTENANCE ORGANIZATIONS
This chapter may be cited as the Nevada
Health Maintenance Organization Act.
(Added to NRS by 1973, 1246)
The Legislature hereby
declares that the rising cost of health services in recent years has led
government agencies, private organizations, and legislative bodies to
seek alternatives to the traditional medical delivery system which would
provide improved health care and would provide such health care at a
lower cost. The health maintenance organization is a concept which has
received much attention as one means through which an improvement in
delivery might be achieved. The Legislature therefore enacts this chapter
to carry out this objective.
(Added to NRS by 1973, 1246)
As used in this chapter, unless the
context otherwise requires:
1. “Comprehensive health care services” means medical services,
dentistry, drugs, psychiatric and optometric and all other care necessary
for the delivery of services to the consumer.
2. “Enrollee” means a natural person who has been voluntarily
enrolled in a health care plan.
3. “Evidence of coverage” means any certificate, agreement or
contract issued to an enrollee setting forth the coverage to which he is
entitled.
4. “Health care plan” means any arrangement whereby any person
undertakes to provide, arrange for, pay for or reimburse any part of the
cost of any health care services and at least part of the arrangement
consists of arranging for or the provision of health care services paid
for by or on behalf of the enrollee on a periodic prepaid basis.
5. “Health care services” means any services included in the
furnishing to any natural person of medical or dental care or
hospitalization or incident to the furnishing of such care or
hospitalization, as well as the furnishing to any person of any other
services for the purpose of preventing, alleviating, curing or healing
human illness or injury.
6. “Health maintenance organization” means any person which
provides or arranges for provision of a health care service or services
and is responsible for the availability and accessibility of such service
or services to its enrollees, which services are paid for or on behalf of
the enrollees on a periodic prepaid basis without regard to the dates
health services are rendered and without regard to the extent of services
actually furnished to the enrollees, except that supplementing the fixed
prepayments by nominal additional payments for services in accordance
with regulations adopted by the Commissioner shall not be deemed to
render the arrangement not to be on a prepaid basis. A health maintenance
organization, in addition to offering health care services, may offer
indemnity or service benefits provided through insurers or otherwise.
7. “Provider” means any physician, hospital or other person who is
licensed or otherwise authorized in this state to furnish health care
services.
(Added to NRS by 1973, 1246; A 1985, 538; 1997, 1629)
1. Except as otherwise provided in this chapter or in specific
provisions of this title, the provisions of this title are not applicable
to any health maintenance organization granted a certificate of authority
under this chapter. This provision does not apply to an insurer licensed
and regulated pursuant to this title except with respect to its
activities as a health maintenance organization authorized and regulated
pursuant to this chapter.
2. Solicitation of enrollees by a health maintenance organization
granted a certificate of authority, or its representatives, must not be
construed to violate any provision of law relating to solicitation or
advertising by practitioners of a healing art.
3. Any health maintenance organization authorized under this
chapter shall not be deemed to be practicing medicine and is exempt from
the provisions of chapter 630 of NRS.
4. The provisions of NRS 695C.110 , 695C.125 , 695C.1691 , 695C.1693 , 695C.170 to 695C.200 , inclusive, 695C.250 and 695C.265 do not apply to a health maintenance
organization that provides health care services through managed care to
recipients of Medicaid under the state plan for Medicaid or insurance
pursuant to the Children’s Health Insurance Program pursuant to a
contract with the Division of Health Care Financing and Policy of the
Department of Health and Human Services. This subsection does not exempt
a health maintenance organization from any provision of this chapter for
services provided pursuant to any other contract.
5. The provisions of NRS 695C.1694 , 695C.1695 and 695C.1731 apply to a health maintenance organization
that provides health care services through managed care to recipients of
Medicaid under the state plan for Medicaid.
(Added to NRS by 1973, 1258; A 1983, 2030; 1995, 2720; 1997, 311,
1528; 1999, 418 , 420 , 1945 , 2004 , 2241 ; 2001, 141 , 144 , 864 , 2734 ; 2003, 1335 , 3366 , 3531 )
1. The provisions of NRS 449.465 , 679A.200 ,
679B.700 , subsections 2, 4, 18, 19
and 32 of NRS 680B.010 , NRS 680B.020
to 680B.060 , inclusive, and chapters 686A and 695G of NRS
apply to a health maintenance organization.
2. For the purposes of subsection 1, unless the context requires
that a provision apply only to insurers, any reference in those sections
to “insurer” must be replaced by “health maintenance organization.”
(Added to NRS by 1987, 469; A 1995, 472, 988; 1997, 299, 311, 2958,
2962; 2001, 2735 ; 2003, 3333 , 3367 )
1. A health maintenance organization is 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 “group health plan” or “carrier” must be replaced by “health
maintenance organization.”
(Added to NRS by 1997, 2957)
1. Any person may apply to the Commissioner for and obtain a
certificate of authority to establish and operate a health maintenance
organization in compliance with this chapter. No person shall operate a
health maintenance organization without obtaining a certificate of
authority under this chapter. A foreign corporation may qualify under
this chapter, subject to its qualification to do business in this state
as a foreign corporation.
2. No person shall be certified to establish or operate a health
maintenance organization in this state, nor sell or offer to sell, or
solicit offers to purchase or receive advance or periodic consideration
in conjunction with health care plans unless such health maintenance
organization provides or arranges for the provision of comprehensive
health care services.
3. Every health maintenance organization or person operating a
health maintenance organization shall submit an application for a
certificate of authority under NRS 695C.070 within 30 days after July 1, 1973. Each such
applicant may continue to operate until the Commissioner acts upon the
application. In the event that an application is denied under NRS
695C.090 and 695C.100 , the applicant shall thereafter be treated
as a health maintenance organization whose certificate of authority has
been revoked. For purposes of this subsection, a health maintenance
organization shall be deemed to be in operation only if health care
services are being provided to the public generally or to some group or
groups thereof.
(Added to NRS by 1973, 1247)
Each
application for a certificate of authority must be verified by an officer
or authorized representative of the applicant, must be in a form
prescribed by the Commissioner, and must set forth or be accompanied by
the following:
1. A copy of the basic organizational document, if any, of the
applicant, and all amendments thereto;
2. A copy of the bylaws, rules or regulations, or a similar
document, if any, regulating the conduct of the internal affairs of the
applicant;
3. A list of the names, addresses and official positions of the
persons who will be responsible for the conduct of the affairs of the
applicant, including all members of the board of directors, board of
trustees, executive committee, or other governing board or committee, the
officers in the case of a corporation, and the partners or members in the
case of a partnership or association;
4. A copy of any contract made or to be made between any providers
or persons listed in subsection 3 and the applicant;
5. A statement generally describing the health maintenance
organization, its health care plan or plans, the location of facilities
at which health care services will be regularly available to enrollees
and the type of health care personnel who will provide the health care
services;
6. A copy of the form of evidence of coverage to be issued to the
enrollees;
7. A copy of the form of the group contract, if any, which is to
be issued to employers, unions, trustees or other organizations;
8. Certified financial statements showing the applicant’s assets,
liabilities and sources of financial support;
9. The proposed method of marketing the plan, a financial plan
which includes a 3-year projection of the initial operating results
anticipated and the sources of working capital and any other sources of
funding;
10. A power of attorney, executed by the applicant, appointing the
Commissioner and his authorized deputies as the true and lawful attorney
of such applicant in and for this State upon whom all lawful process in
any legal action or proceeding against the health maintenance
organization on a cause of action arising in this State may be served;
11. A statement reasonably describing the geographic area to be
served;
12. A description of the procedures for resolving complaints and
procedures for external reviews to be used as required under NRS 695C.260
;
13. A description of the procedures and programs to be implemented
to meet the quality of health care requirements in NRS 695C.080 ;
14. A description of the mechanism by which enrollees will be
afforded an opportunity to participate in matters of program content
under subsection 2 of NRS 695C.110 ;
and
15. Such other information as the Commissioner may require to make
the determinations required in NRS 695C.080 .
(Added to NRS by 1973, 1247, A 2003, 777 )
1. Upon receipt of an application for issuance of a certificate of
authority, the Commissioner shall forthwith transmit copies of such
application and accompanying documents to the State Board of Health.
2. The State Board of Health shall determine whether the applicant
for a certificate of authority, with respect to health care services to
be furnished:
(a) Has demonstrated the willingness and ability to assure that
such health care services will be provided in a manner to assure both
availability and accessibility of adequate personnel and facilities and
in a manner enhancing availability, accessibility and continuity of
service;
(b) Has organizational arrangements, established in accordance with
regulations promulgated by the State Board of Health; and
(c) Has a procedure established in accordance with regulations of
the State Board of Health to develop, compile, evaluate and report
statistics relating to the cost of its operations, the pattern of
utilization of its services, the availability and accessibility of its
services and such other matters as may be reasonably required by the
State Board of Health.
3. Within 90 days of receipt of the application for issuance of a
certificate of authority, the State Board of Health shall certify to the
Commissioner whether the proposed health maintenance organization meets
the requirements of subsection 2. If the State Board of Health certifies
that the health maintenance organization does not meet such requirements,
it shall specify in what respects it is deficient.
(Added to NRS by 1973, 1249)
The Commissioner
shall issue or deny a certificate of authority to any person filing an
application pursuant to NRS 695C.060
within 90 days of receipt of the certification from the State Board of
Health. Issuance of a certificate of authority must be granted upon
payment of the fees prescribed in NRS 695C.230 if the Commissioner is satisfied that the
following conditions are met:
1. The persons responsible for the conduct of the affairs of the
applicant are competent, trustworthy and possess good reputations.
2. The State Board of Health certifies, in accordance with NRS
695C.080 , that the health maintenance
organization’s proposed plan of operation meets the requirements of
subsection 2 of NRS 695C.080 .
3. The health care plan furnishes comprehensive health care
services.
4. The health maintenance organization is financially responsible
and may reasonably be expected to meet its obligations to enrollees and
prospective enrollees. In making this determination, the Commissioner may
consider:
(a) The financial soundness of the health care plan’s arrangements
for health care services and the schedule of charges used in connection
therewith;
(b) The adequacy of working capital;
(c) Any agreement with an insurer, a government, or any other
organization for insuring the payment of the cost of health care services;
(d) Any agreement with providers for the provision of health care
services; and
(e) Any surety bond or deposit of cash or securities submitted in
accordance with NRS 695C.270 as a
guarantee that the obligations will be duly performed.
5. The enrollees will be afforded an opportunity to participate in
matters of program content pursuant to NRS 695C.110 .
6. Nothing in the proposed method of operation, as shown by the
information submitted pursuant to NRS 695C.060 , 695C.070 and 695C.140 , or by independent investigation is contrary
to the public interest.
(Added to NRS by 1973, 1249; A 1987, 469; 1993, 2400)
A certificate of
authority shall be denied only after compliance with the requirements of
NRS 695C.340 .
(Added to NRS by 1973, 1250)
1. The governing body of any health maintenance organization may
include providers, other individuals or both.
2. Such governing body shall establish a mechanism to afford the
enrollees an opportunity to participate in matters of program content
through the establishment of advisory panels, by the use of advisory
referenda on major policy decisions or through the use of other
mechanisms. In addition there shall be a provider advisory board to
advise the health plan in the matter of quality of care. There shall be a
joint board of consumers and providers to advise on consumer satisfaction.
(Added to NRS by 1973, 1250)
The powers of a health
maintenance organization include, but are not limited to, the following:
1. The purchase, lease, construction, renovation, operation or
maintenance of hospitals, medical facilities, or both, and their
ancillary equipment, and such property as may reasonably be required for
its principal office or for such other purposes as may be necessary in
the transaction of the business of the organization;
2. The making of loans to a medical group under contract with it
in furtherance of its program or the making of loans to a corporation
under its control for the purpose of acquiring or constructing medical
facilities and hospitals or in furtherance of a program providing health
care services to enrollees;
3. The furnishing of health care service through providers which
are under contract with or employed by the health maintenance
organization;
4. The contracting with any person for the performance on its
behalf of certain functions such as marketing, enrollment and
administration; and
5. The contracting with an insurance company licensed in this
state or authorized to do business in this state for the provision of
such insurance, indemnity, or reimbursement against the cost of health
care services provided by the health maintenance organization.
(Added to NRS by 1973, 1250; A 1995, 2166; 1999, 1834 )
1. Except as otherwise provided in NRS 422.273 , a health maintenance organization that
furnishes health care services through providers which are under contract
with the organization shall use its best efforts to contract with at
least one health center in each geographic area served by the
organization to provide such services to enrollees if the health center:
(a) Meets all conditions imposed by the organization on similarly
situated providers of health care that are under contract with the
organization, including, without limitation:
(1) Certification for participation in the Medicaid or
Medicare program; and
(2) Requirements relating to the appropriate credentials for
providers of health care; and
(b) Agrees to reasonable reimbursement rates that are generally
consistent with those offered by the organization to similarly situated
providers of health care that are under contract with the organization.
2. As used in this section, “health center” has the meaning
ascribed to it in 42 U.S.C. § 254b.
(Added to NRS by 2001, 1924 )
1. A health maintenance organization shall not contract with a
provider of health care to provide health care to an insured unless the
health maintenance organization 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.
2. A contract between a health maintenance organization 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 health
maintenance organization 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).
3. If a health maintenance organization contracts with a provider
of health care to provide health care to an enrollee, the health
maintenance organization 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.
4. 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, 1651 ; A 2001, 2735 ; 2003, 3367 )
Any contract or other
agreement entered into or renewed by a health maintenance organization on
or after October 1, 2001:
1. To provide health care services through managed care to
recipients of Medicaid under the state plan for Medicaid; or
2. With the Division of Health Care Financing and Policy of the
Department of Health and Human Services to provide insurance pursuant to
the Children’s Health Insurance Program,
Ê must require the health maintenance organization to pay interest to a
provider of health care services on a claim that is not paid within the
time provided in the contract or agreement 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.
(Added to NRS by 2001, 2734 )
1. A health maintenance organization shall file notice, with
adequate supporting information, with the Commissioner prior to the
exercise of any power granted in subsections 1 and 2 of NRS 695C.120
. The Commissioner shall disapprove
such exercise of power if in his opinion it would substantially and
adversely affect the financial soundness of the health maintenance
organization and endanger its ability to meet its obligations. If the
Commissioner does not disapprove within 60 days of the filing, it is
deemed approved.
2. The Commissioner may promulgate rules or regulations.
(Added to NRS by 1973, 1250)
1. A health maintenance organization shall, unless otherwise
provided for in this chapter, file notice with the Commissioner and the
State Board of Health before any material modification of the operations
described in the information required by NRS 695C.070 . If the Commissioner does not disapprove
within 90 days after filing of the notice, the modification is deemed
approved.
2. The Commissioner may adopt regulations to carry out the
provisions of this section.
(Added to NRS by 1973, 1248; A 1995, 1632)
1. A health maintenance organization shall use accounting
principles that are recognized by the laws of this state or approved by
the Commissioner for:
(a) All financial reports;
(b) The accounting of investments and deposits; and
(c) Transactions between affiliates and holding companies.
2. A health maintenance organization is subject to the
requirements for insurers for:
(a) Administrators, agents, brokers and solicitors, pursuant to
chapter 683A of NRS;
(b) Borrowing, pursuant to NRS 693A.180 ;
(c) Impairment of capital, surplus or assets, pursuant to NRS
693A.260 , 693A.270 and 693A.280 ;
(d) Management and agency contracts executed on or after January 1,
1992; and
(e) Officers, pursuant to NRS 693A.120 and 693A.130 .
3. A domestic health maintenance organization is subject to the
requirements for insurers for corporations pursuant to NRS 693A.040
to 693A.070 , inclusive.
(Added to NRS by 1991, 2036)
Any director, officer,
partner, member or employee of a health maintenance organization who
receives, collects, disburses or invests funds in connection with the
activities of such organization shall be responsible for such funds in a
fiduciary relationship to the enrollees.
(Added to NRS by 1973, 1250)
With the exception of investments made
in accordance with subsections 1 and 2 of NRS 695C.120 and NRS 695C.130 , the investable funds of a health
maintenance organization shall be invested only in securities or other
investments permitted by the laws of this state for the investment of
assets constituting the legal reserves of life insurance companies or
such other securities or investments as the Commissioner may permit.
(Added to NRS by 1973, 1253)
As used in
NRS 695C.161 to 695C.169 , inclusive, unless the context otherwise
requires:
1. “Medicaid” means a program established in any state pursuant to
Title XIX of the Social Security Act (42 U.S.C. §§ 1396 et seq.) to
provide assistance for part or all of the cost of medical care rendered
on behalf of indigent persons.
2. “Order for medical coverage” means an order of a court or
administrative tribunal to provide coverage under a health care plan to a
child pursuant to the provisions of 42 U.S.C. § 1396g-1.
(Added to NRS by 1995, 2435)
1. A health maintenance organization shall not, when considering
eligibility for coverage or making payments under a health care plan,
consider the availability of, or eligibility of a person for, medical
assistance under Medicaid.
2. To the extent that payment has been made by Medicaid for health
care, a health maintenance organization:
(a) Shall treat Medicaid as having a valid and enforceable
assignment of benefits due an enrollee or claimant under him regardless
of any exclusion of Medicaid or the absence of a written assignment; and
(b) May, as otherwise allowed by its plan, evidence of coverage or
contract and applicable law or regulation concerning subrogation, seek to
enforce any rights of a recipient of Medicaid to reimbursement against
any other liable party if:
(1) It is so authorized pursuant to a contract with Medicaid
for managed care; or
(2) It has reimbursed Medicaid in full for the health care
provided by Medicaid to its enrollee.
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 health care plan,
Ê the organization responsible for the health care plan 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 plan.
(Added to NRS by 1995, 2435)
An organization shall
not deny the enrollment of a child pursuant to an order for medical
coverage under a health care plan in which a parent of the child is
enrolled, on the ground that the child:
1. Was born out of wedlock;
2. Has not been claimed as a dependent on the parent’s federal
income tax return; or
3. Does not reside with the parent or within the organization’s
geographic area of service.
(Added to NRS by 1995, 2436)
If a child has coverage under a health care plan in which a
noncustodial parent of the child is enrolled, the organization
responsible for that plan shall:
1. Provide to the custodial parent such information as necessary
for the child to obtain any benefits under that coverage.
2. Allow the custodial parent or, with the approval of the
custodial parent, a provider to submit claims for covered services
without the approval of the noncustodial parent.
3. Make payments on claims submitted pursuant to subsection 2
directly to the custodial parent, the provider or an agency of this or
another state responsible for the administration of Medicaid.
(Added to NRS by 1995, 2436)
If a parent is required by an order for medical coverage to provide
coverage for a child and the parent is eligible for coverage of members
of his family under a health care plan, the organization responsible for
that plan:
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
organization has written proof that:
(a) The order for medical coverage is no longer in effect; or
(b) The child is or will be enrolled in comparable coverage through
another insurer on or before the effective date of the termination of
enrollment or elimination of coverage.
(Added to NRS by 1995, 2436)
1. The provisions of this section apply to a health care plan
offered or issued by a health maintenance organization if an insured
covered by the health care plan receives health care through a defined
set of providers of health care who are under contract with the health
maintenance organization.
2. Except as otherwise provided in this section, if an insured who
is covered by a health care plan described in subsection 1 is receiving
medical treatment for a medical condition from a provider of health care
whose contract with the health maintenance organization is terminated
during the course of the medical treatment, the health care plan 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 health maintenance organization 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 health maintenance
organization 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 health maintenance organization; 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 health maintenance organization.
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 health
maintenance organization and the health maintenance organization
terminated that contract because of the medical incompetence or
professional misconduct of the provider of health care; and
(b) The health maintenance organization did not enter into another
contract with the provider of health care after the contract was
terminated pursuant to paragraph (a).
5. An evidence of coverage for a health care plan 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 evidence
of coverage 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, 3365 )
1. Except as otherwise provided in NRS 695C.050 , a health care plan issued by a health
maintenance organization must provide coverage for medical treatment
which an enrollee 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 enrollee 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
enrollee.
(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 health care
plan.
(c) The cost of any routine health care services that would
otherwise be covered under the health care plan for an enrollee in a
Phase I clinical trial or study.
(d) The initial consultation to determine whether the enrollee is
eligible to participate in the clinical trial or study.
(e) Health care services required for the clinically appropriate
monitoring of the enrollee 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 enrollee 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 695C.1691 , 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 health maintenance organization has
contracted for such services. If the health maintenance organization has
not contracted for the provision of such services, the health maintenance
organization shall pay the provider the rate of reimbursement that is
paid to other providers with whom the health maintenance organization 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 an enrollee 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 enrollee.
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 enrollee’s health care plan, 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 enrollee
during the clinical trial or study.
(g) Any item or service that is provided solely to satisfy a need
or desire for data collection or analysis that is not directly related to
the clinical management of the enrollee.
(h) Any costs for the management of research relating to the
clinical trial or study.
5. A health maintenance organization that delivers or issues for
delivery a health care plan 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 enrollee, 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 health maintenance organization that delivers or issues for
delivery a health care plan specified in subsection 1 shall:
(a) Include in the disclosure required pursuant to NRS 695C.193
notice to each enrollee 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 plan.
7. A health care plan 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 plan that conflicts with this section
is void.
8. A health maintenance organization that delivers or issues for
delivery a health care plan specified in subsection 1 is immune from
liability for:
(a) Any injury to an enrollee caused by:
(1) Any medical treatment provided to the enrollee 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 enrollee 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
enrollee’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, 3528 ; A 2005, 2018 )
1. Except as otherwise provided in subsection 5, a health
maintenance organization which offers or issues a health care plan that
provides coverage for prescription drugs or devices shall include in the
plan 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. A health maintenance organization that offers or issues a
health care plan that provides coverage for prescription drugs shall not:
(a) Require an enrollee 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 plan;
(b) Refuse to issue a health care plan or cancel a health care plan
solely because the person applying for or covered by the plan 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 enrollee to discourage the enrollee 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 enrollee, 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
enrollee.
3. Except as otherwise provided in subsection 5, evidence of
coverage 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 evidence of coverage or the renewal which is in conflict
with this section is void.
4. The provisions of this section do not:
(a) Require a health maintenance organization to provide coverage
for fertility drugs.
(b) Prohibit a health maintenance organization from requiring an
enrollee 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 enrollee is required to pay for other prescription drugs covered by
the plan.
5. A health maintenance organization which offers or issues a
health care plan and which is affiliated with a religious organization is
not required to provide the coverage required by paragraph (a) of
subsection 1 if the health maintenance organization objects on religious
grounds. The health maintenance organization shall, before the issuance
of a health care plan and before renewal of enrollment in such a plan,
provide to the group policyholder or prospective enrollee, as applicable,
written notice of the coverage that the health maintenance organization
refuses to provide pursuant to this subsection. The health maintenance
organization shall provide notice to each enrollee, at the time the
enrollee receives his evidence of coverage, that the health maintenance
organization refused to provide coverage pursuant to this subsection.
6. If a health maintenance organization 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, 2001 )
1. Except as otherwise provided in subsection 5, a health
maintenance organization that offers or issues a health care plan which
provides coverage for outpatient care shall include in the plan coverage
for any health care service related to contraceptives or hormone
replacement therapy.
2. A health maintenance organization that offers or issues a
health care plan that provides coverage for outpatient care shall not:
(a) Require an enrollee 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 plan;
(b) Refuse to issue a health care plan or cancel a health care plan
solely because the person applying for or covered by the plan 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 enrollee to discourage the enrollee 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 enrollee, 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
enrollee.
3. Except as otherwise provided in subsection 5, evidence of
coverage 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 evidence of coverage or the renewal which is in conflict
with this section is void.
4. The provisions of this section do not prohibit a health
maintenance organization from requiring an enrollee to pay a deductible,
copayment or coinsurance for the coverage required by subsection 1 that
is the same as the enrollee is required to pay for other outpatient care
covered by the plan.
5. A health maintenance organization which offers or issues a
health care plan 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 health maintenance
organization objects on religious grounds. The health maintenance
organization shall, before the issuance of a health care plan and before
renewal of enrollment in such a plan, provide to the group policyholder
or prospective enrollee, as applicable, written notice of the coverage
that the health maintenance organization refuses to provide pursuant to
this subsection. The health maintenance organization shall provide notice
to each enrollee, at the time the enrollee receives his evidence of
coverage, that the health maintenance organization refused to provide
coverage pursuant to this subsection.
6. If a health maintenance organization 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, 2002 )
1. Every enrollee residing in this state is entitled to evidence
of coverage under a health care plan. If the enrollee obtains coverage
under a health care plan through an insurance policy, whether by option
or otherwise, the insurer shall issue the evidence of coverage.
Otherwise, the health maintenance organization shall issue the evidence
of coverage.
2. Evidence of coverage or amendment thereto must not be issued or
delivered to any person in this state until a copy of the form of the
evidence of coverage or amendment thereto has been filed with and
approved by the Commissioner.
3. An evidence of coverage:
(a) Must not contain any provisions or statements which are unjust,
unfair, inequitable, misleading, deceptive, which encourage
misrepresentation or which are untrue, misleading or deceptive as defined
in subsection 1 of NRS 695C.300 ; and
(b) Must contain a clear and complete statement, if a contract, or
a reasonably complete summary if a certificate, of:
(1) The health care services and the insurance or other
benefits, if any, to which the enrollee is entitled under the health care
plan;
(2) Any limitations on the services, kind of services,
benefits, or kind of benefits, to be provided, including any deductible
or copayment feature;
(3) Where and in what manner the services may be obtained;
(4) The total amount of payment for health care services and
the indemnity or service benefits, if any, which the enrollee is
obligated to pay; and
(5) A provision for benefits payable for expenses incurred
for the treatment of the abuse of alcohol or drugs, as provided in NRS
695C.174 .
Ê Any subsequent change may be evidenced in a separate document issued to
the enrollee.
4. A copy of the form of the evidence of coverage to be used in
this state and any amendment thereto is subject to the requirements for
filing and approval of subsection 2 unless it is subject to the
jurisdiction of the Commissioner under the laws governing health
insurance, in which event the provisions for filing and approval of those
laws apply. To the extent that such provisions do not apply to the
requirements in subsection 3, such provisions are amended to incorporate
the requirements of subsection 3 in approving or disapproving an evidence
of coverage required by subsection 2.
(Added to NRS by 1973, 1251; A 1975, 1852; 1979, 1182; 1983, 2041)
1. A health maintenance organization or insurer that offers or
issues evidence of coverage which provides coverage for prescription
drugs shall include with any evidence of that coverage provided to an
enrollee, notice of whether a formulary is used and, if so, of the
opportunity to secure information regarding the formulary from the
organization or 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 organization or insurer for
making a request for information regarding the formulary pursuant to
subsection 2.
2. If a health maintenance organization or insurer offers or
issues evidence of coverage which provides coverage for prescription
drugs and a formulary is used, the organization or insurer shall:
(a) Provide to any enrollee or participating provider of health
care upon request:
(1) Information regarding whether a specific drug is
included in the formulary.
(2) Access to the most current list of prescription drugs in
the formulary, organized by major therapeutic category, with an
indication of whether any listed drugs are preferred over other listed
drugs. If more than one formulary is maintained, the organization or
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, 863 )
Except as otherwise provided in the provisions of NRS 689B.340 to 689B.590 , inclusive, and chapter 689C of NRS relating to the portability and
accountability of health insurance:
1. A group health care plan issued by a health maintenance
organization to replace any discontinued policy or coverage for group
health insurance must:
(a) Provide coverage for all persons who were covered under the
previous policy or coverage on the date it was discontinued; and
(b) Except as otherwise provided in subsection 2, provide benefits
which are at least as extensive as the benefits provided by the previous
policy or coverage, except that benefits may be reduced or excluded to
the extent that such a reduction or exclusion was permissible under the
terms of the previous policy or coverage,
Ê if that plan is issued within 60 days after the date on which the
previous policy or coverage was discontinued.
2. If an employer obtains a replacement plan 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 health maintenance organization which issues a replacement
plan 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 organization indicating what benefits were provided and what
exclusions or reductions were in effect under the previous policy or
coverage.
4. If an employee or enrollee was a recipient of benefits under
the coverage provided pursuant to NRS 695C.1709 , he is not entitled to have issued to him
by a health maintenance organization a replacement plan 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 695C.1709 .
5. 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 health care plan issued by a health maintenance organization.
(Added to NRS by 1987, 850; A 1989, 1253; 1997, 2958)
Any policy of group insurance to which an enrollee is entitled under a
health care plan provided by a health maintenance organization must
contain a provision which permits the continuation of coverage pursuant
to the provisions of NRS 689B.245 to
689B.249 , inclusive, 689B.340 to 689B.590 , inclusive, and chapter 689C of NRS relating to the portability and
accountability of health insurance.
(Added to NRS by 1987, 2235; A 1997, 2959)
1. As used in this section, “total disability” and “totally
disabled” mean the continuing inability of the enrollee, because of an
injury or illness, to perform substantially the duties related to his
employment for which he is otherwise qualified.
2. No policy of group insurance to which an enrollee is entitled
under a health care plan provided by a health maintenance organization
may be delivered or issued for delivery in this state unless it provides
continuing coverage for an enrollee and his dependents who are otherwise
covered by the policy while the enrollee is on leave without pay as a
result of a total disability. The coverage must be for any injury or
illness suffered by the enrollee which is not related to the total
disability or for any injury or illness suffered by his dependent. The
coverage 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 enrollee is terminated;
(b) The date on which the enrollee obtains another policy of health
insurance;
(c) The date on which the policy of group insurance is terminated;
or
(d) After a period of 12 months in which benefits under such
coverage are provided to the enrollee,
Ê whichever occurs first.
(Added to NRS by 1989, 1253)
1. A health maintenance plan 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, but is not limited to, augmentation mammoplasty, reduction
mammoplasty and mastopexy.
(Added to NRS by 1983, 615; A 1989, 1891; 2001, 2250 )
1. A health care plan must include a provision authorizing a woman
covered by the plan 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 health care plan to designate an obstetrician or gynecologist as her
primary care physician.
3. An evidence of coverage 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 evidence of coverage 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. No health maintenance organization may issue evidence of
coverage under a health care plan to any enrollee in this state if it
contains any exclusion, reduction or other limitation of coverage
relating to complications of pregnancy unless the provision applies
generally to all benefits payable under the policy and complies with the
provisions of NRS 689B.340 to
689B.590 , inclusive, and chapter 689C
of NRS relating to the portability and
accountability 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. Evidence of coverage under a health care plan subject to the
provisions of this chapter which is issued on or after July 1, 1977, has
the legal effect of including the coverage required by this section, and
any provision which is in conflict with this section is void.
(Added to NRS by 1977, 416; A 1997, 2959)
1. A health maintenance plan 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 health maintenance plan was
purchased.
3. Any evidence of coverage 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 evidence of coverage 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 evidence of coverage that provides coverage for hospital,
medical or surgical expenses may be delivered or issued for delivery in
this state unless the evidence of coverage 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 an evidence of
coverage specified in subsection 1:
(a) Shall include in the disclosure required pursuant to NRS
695C.193 notice to each enrollee
under the evidence of coverage 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
the evidence of coverage that are required under the evidence of coverage.
3. Evidence of coverage 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 evidence of coverage that conflicts
with this section is void.
4. As used in this section:
(a) “Coverage for the management and treatment of diabetes”
includes coverage for medication, equipment, supplies and appliances that
are medically necessary for the treatment of diabetes.
(b) “Coverage for the self-management of diabetes” includes:
(1) The training and education provided to the enrollee
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 enrollee 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, 745)
1. All individual and group health care plans which provide
coverage for a family member of the enrollee must as to such coverage
provide that the health care services applicable for children are payable
with respect to:
(a) A newly born child of the enrollee 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 enrollee 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 plans must provide the coverage specified in subsection 3, and must
not exclude premature births.
2. The evidence of coverage 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 charge, if any, must be furnished to the
health maintenance organization 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 preventive health care services as well
as 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 health maintenance organization 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 plan. Any
provision relating to an exclusion for a preexisting condition must
comply with NRS 689B.500 or 689C.190
, as appropriate.
5. For covered services provided to the child, the health
maintenance organization 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, 2436; 1997, 2959)
1. A health care plan issued by a health maintenance organization
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. An evidence of coverage for a health care plan 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 evidence
of coverage that conflicts with the provisions of this section is void.
(Added to NRS by 2003, 1335 )
Except as otherwise provided in NRS
695C.1693 :
1. No evidence of coverage 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 evidence of coverage includes
coverage for any other use of the drug for the treatment of cancer, if
that use is:
(a) Specified in the most recent edition of or supplement to:
(1) The United States Pharmacopoeia Drug Information; or
(2) The American Hospital Formulary Service Drug
Information; or
(b) Supported by at least two articles reporting the results of
scientific studies that are published in scientific or medical journals,
as defined in 21 C.F.R. § 99.3.
2. The coverage required pursuant to this section:
(a) Includes coverage for any medical services necessary to
administer the drug to the enrollee.
(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. Any evidence of coverage 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 evidence of coverage that
conflicts with the provisions of this section is void.
(Added to NRS by 1999, 761 ; A 2003, 3531 )
1. Except as otherwise provided in this section, evidence of
coverage which provides coverage for prescription drugs must not limit or
exclude coverage for a drug if the drug:
(a) Had previously been approved for coverage by the health
maintenance organization or insurer for a medical condition of an
enrollee and the enrollee’s provider of health care determines, after
conducting a reasonable investigation, that none of the drugs which are
otherwise currently approved for coverage are medically appropriate for
the enrollee; and
(b) Is appropriately prescribed and considered safe and effective
for treating the medical condition of the enrollee.
2. The provisions of subsection 1 do not:
(a) Apply to coverage for any drug that is prescribed for a use
that is different from the use for which that drug has been approved for
marketing by the Food and Drug Administration;
(b) Prohibit:
(1) The health maintenance organization or insurer from
charging a deductible, copayment or coinsurance for the provision of
benefits for prescription drugs to the enrollee or from establishing, by
contract, limitations on the maximum coverage for prescription drugs;
(2) A provider of health care from prescribing another drug
covered by the evidence of coverage that is medically appropriate for the
enrollee; or
(3) The substitution of another drug pursuant to NRS
639.23286 or 639.2583 to 639.2597 , inclusive; or
(c) Require any coverage for a drug after the term of the evidence
of coverage.
3. Any provision of an evidence of coverage subject to the
provisions of this chapter that is delivered, issued for delivery or
renewed on or after October 1, 2001, which is in conflict with this
section is void.
(Added to NRS by 2001, 863 ; A 2003, 2300 )
1. A health maintenance plan 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 health maintenance plan 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, 1891; A 1997, 1730)
1. Notwithstanding any provisions of this title to the contrary,
any evidence of coverage 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 year of coverage and 40 visits for treatment as an
outpatient per year of coverage, 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 evidence of coverage required
to provide coverage for more than 40 days of hospitalization as an
inpatient per year of coverage.
(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 evidence of coverage.
4. The provisions of this section do not apply to any evidence of
coverage:
(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 year for which coverage was provided, the
premiums charged for the evidence of coverage, or a standard grouping of
evidence of coverage, increase by more than 2 percent as a result of
providing the coverage required by this section and the health
maintenance organization obtains an exemption from the Commissioner
pursuant to subsection 5.
5. To obtain the exemption required by paragraph (b) of subsection
4, a health maintenance organization 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 year for which
coverage was provided the amount of premiums charged during the period
immediately preceding that 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. Any evidence of coverage 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 evidence of coverage or the
renewal which is in conflict with this section is void, unless the
evidence of coverage 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, 3104 )
1. The benefits provided by health maintenance plans for treatment
of the abuse of alcohol or drugs as required by subparagraph (5) of
paragraph (b) of subsection 3 of NRS 695C.170 , 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, 1181; A 1983, 2042; 1985, 1571, 1778; 1993,
1922; 1997, 1302; 1999, 1890 ; 2001, 440 )
1. Except as otherwise provided in this section, no evidence of
coverage 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 evidence of
coverage or by a claims settlement practice. An evidence of coverage may
exclude coverage of those methods of treatment which are recognized as
dental procedures, including, but not limited to, the extraction of teeth
and the application of orthodontic devices and splints.
2. The health maintenance organization may limit its liability on
the treatment of the temporomandibular joint to:
(a) No more than 50 percent of the usual and customary charges for
such treatment actually received by an enrollee, but in no case more than
50 percent of the maximum benefits provided by the evidence of coverage
for such treatment; and
(b) Treatment which is medically necessary.
3. Any provision of an evidence of coverage 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, 2139)
Each health care plan must provide benefits for hospice care.
(Added to NRS by 1983, 1936; A 1985, 1779; 1989, 1033)
If any evidence of
coverage 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 evidence of coverage 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 evidence of coverage 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, 2134)
If any evidence of coverage 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 evidence of coverage 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 evidence of coverage 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 evidence of coverage 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, 1448)
1. Except as otherwise provided in subsection 3, every evidence of
coverage 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 enrollee or the provider may submit the claim for
reimbursement. The provider shall not demand payment from the enrollee
until after that reimbursement has been granted or denied.
3. Subsection 1 does not apply to any agreement between a health
maintenance organization and a provider of medical transportation for the
direct payment by the organization for the provider’s services.
(Added to NRS by 1989, 1274)
1. No schedule of charges for enrollee coverage for health care
services or amendment thereto may be used in conjunction with any health
care plan until a copy of such schedule or amendment thereto has been
filed with and approved by the Commissioner.
2. Such charges may be established in accordance with actuarial
principles for various categories of enrollees. However the charges shall
not be excessive, inadequate nor unfairly discriminatory. A certification
by a qualified actuary to the adequacy of the charges shall accompany the
filing along with adequate supporting information.
(Added to NRS by 1973, 1251)
1. Except as otherwise provided in subsection 2, a health
maintenance organization shall approve or deny a claim relating to a
health care plan within 30 days after the health maintenance organization
receives the claim. If the claim is approved, the health maintenance
organization 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 health maintenance organization 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 health maintenance organization 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 health maintenance organization
shall notify the provider of health care services of all the specific
reasons for the delay in approving or denying the claim. The health
maintenance organization shall approve or deny the claim within 30 days
after receiving the additional information. If the claim is approved, the
health maintenance organization shall pay the claim within 30 days after
it receives the additional information. If the approved claim is not paid
within that period, the health maintenance organization shall pay
interest on the claim in the manner prescribed in subsection 1.
3. A health maintenance organization shall not request a claimant
to resubmit information that the claimant has already provided to the
health maintenance organization, unless the health maintenance
organization 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 health maintenance organization 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 health maintenance organization.
7. The Commissioner may require a health maintenance organization
to provide evidence which demonstrates that the health maintenance
organization 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 health maintenance
organization is not in substantial compliance with the requirements set
forth in this section, the Commissioner may require the health
maintenance organization to pay an administrative fine in an amount to be
determined by the Commissioner. Upon a second or subsequent determination
that a health maintenance organization 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 health maintenance
organization.
(Added to NRS by 1991, 1331; A 1999, 1651 ; 2001, 2735 ; 2003, 3368 )
1. A health maintenance organization shall not:
(a) Enter into any contract or agreement, or make any other
arrangements, with a provider for the provision of health care; or
(b) Employ a provider pursuant to a contract, an agreement or any
other arrangement to provide health care,
Ê unless the contract, agreement or other arrangement specifically
provides that the health maintenance organization and provider agree to
the schedule for the payment of claims set forth in NRS 695C.185 .
2. Any contract, agreement or other arrangement between a health
maintenance organization and a provider that is entered into or renewed
on or after October 1, 2001, that does not specifically include a
provision concerning the schedule for the payment of claims as required
by subsection 1 shall be deemed to conform with the requirements of
subsection 1 by operation of law.
(Added to NRS by 2001, 2734 )
The Commissioner may require the submission of whatever relevant
information he deems necessary in determining whether to approve or
disapprove a filing made pursuant to NRS 695C.170 to 695C.200 , inclusive.
(Added to NRS by 1973, 1252; A 1985, 1448; 1989, 1274)
1. The Commissioner shall adopt regulations which require a health
maintenance organization to file with the Commissioner, for his approval,
a disclosure summarizing the coverage provided by each health care plan
offered by the health maintenance organization. The disclosure must
include:
(a) Any significant exception, reduction or limitation that applies
to the plan; and
(b) Any other information,
Ê that the Commissioner finds necessary to provide for full and fair
disclosure of the provisions of the plan.
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 plan only, and that the evidence of coverage 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, 1253)
A health maintenance organization shall provide to the
group policyholder to whom it offers a health care plan a copy of the
disclosure approved for that plan pursuant to NRS 695C.193 before the plan is issued. A health
maintenance organization shall not offer a health care plan unless the
disclosure for that plan has been approved by the Commissioner.
(Added to NRS by 1989, 1253)
The Commissioner
shall within a reasonable period approve any form if the requirements of
NRS 695C.170 are met and any schedule
of charges if the requirements of NRS 695C.180 are met. It is unlawful to issue such form
or to use such schedule of charges until approved. If the Commissioner
disapproves such filing, he shall notify the filer. In the notice, the
Commissioner shall specify the reasons for his disapproval. A hearing
will be granted within 90 days after a request in writing by the person
filing.
(Added to NRS by 1973, 1251)
A health maintenance organization
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 )
A health maintenance organization shall
not deny a claim, refuse to issue a policy or cancel a policy solely
because the claim involves an act that constitutes domestic violence
pursuant to NRS 33.018 , or because the
person applying for or covered by the policy 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 health
maintenance organization shall not:
(a) Deny a claim under a health care plan solely because the claim
involves an injury sustained by an enrollee as a consequence of being
intoxicated or under the influence of a controlled substance.
(b) Cancel participation under a health care plan solely because an
enrollee has made a claim involving an injury sustained by the enrollee
as a consequence of being intoxicated or under the influence of a
controlled substance.
(c) Refuse participation under a health care plan to an eligible
applicant solely because the applicant has made a claim involving an
injury sustained by the applicant as a consequence of being intoxicated
or under the influence of a controlled substance.
2. The provisions of this section do not prohibit a health
maintenance organization from enforcing a provision included in a health
care plan to:
(a) Deny a claim which involves an injury to which a contributing
cause was the insured’s commission of or attempt to commit a felony;
(b) Cancel participation under a health care plan solely because of
such a claim; or
(c) Refuse participation under a health care plan to an eligible
applicant solely because of such a claim.
(Added to NRS by 2005, 2345 , effective July 1, 2006)
1. A health maintenance organization shall not:
(a) Require an enrollee or any member of his family to take a
genetic test;
(b) Require an enrollee to disclose whether he or any member of his
family has taken a genetic test or the genetic information of the
enrollee 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 enrollee based on:
(1) Whether the enrollee or any member of his family has
taken a genetic test; or
(2) Any genetic information of the enrollee or any member of
his family.
2. 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 which
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. Every health maintenance organization shall file with the
Commissioner on or before March 1 of each year a report showing its
financial condition on the last day of the preceding calendar year. The
report must be verified by at least two principal officers of the
organization. The organization shall file a copy of the report with the
State Board of Health.
2. The report must be on forms prescribed by the Commissioner and
must include:
(a) A financial statement of the organization, including its
balance sheet and receipts and disbursements for the preceding calendar
year;
(b) Any material changes in the information submitted pursuant to
NRS 695C.070 ;
(c) The number of persons enrolled during the year, the number of
enrollees as of the end of the year, the number of enrollments terminated
during the year and, if requested by the Commissioner, a compilation of
the reasons for such terminations;
(d) The number and amount of malpractice claims initiated against
the health maintenance organization and any of the providers used by it
during the year broken down into claims with and without form of legal
process, and the disposition, if any, of each such claim, if requested by
the Commissioner;
(e) A summary of information compiled pursuant to paragraph (c) of
subsection 2 of NRS 695C.080 in such
form as required by the State Board of Health; and
(f ) Such other information relating to the performance of the
health maintenance organization as is necessary to enable the
Commissioner to carry out his duties pursuant to this chapter.
3. Every health maintenance organization shall file with the
Commissioner annually an audited financial statement of the organization
prepared by an independent certified public accountant. The statement
must cover the preceding 12-month period and must be filed with the
Commissioner within 120 days after the end of the organization’s fiscal
year. Upon written request, the Commissioner may grant a 30-day extension.
4. If an organization fails to file timely the report or financial
statement required by this section, it shall pay an administrative
penalty of $100 per day until the report or statement is filed, except
that the total penalty must not exceed $3,000. The Attorney General shall
recover the penalty in the name of the State of Nevada.
5. The Commissioner may grant a reasonable extension of time for
filing the report or financial statement required by this section, if the
request for an extension is submitted in writing and shows good cause.
(Added to NRS by 1973, 1252; A 1991, 2204; 1995, 1632, 2681)
All applications, filings and reports required under this
chapter shall be treated as public documents except as otherwise provided
in this chapter.
(Added to NRS by 1973, 1258)
1. Every health maintenance organization subject to this chapter
shall pay to the Commissioner the following fees:
(a) For filing an application for a certificate of authority,
$2,450.
(b) For issuance of a certificate of authority, $250.
(c) For an amendment to a certificate of authority, $100.
(d) For the renewal of a certificate of authority, $2,450.
(e) For filing each annual report, $25.
2. At the time of filing the annual report the health maintenance
organization shall forward to the department of taxation the tax and any
penalty for nonpayment or delinquent payment of the tax in accordance
with the provisions of chapter 680B of NRS.
3. All fees paid pursuant to this section shall be deemed earned
when paid and may not be refunded.
(Added to NRS by 1973, 1257; A 1987, 470; 1991, 1634; 1993, 1923)
Every health maintenance organization shall have available for
inspection the following information:
1. A current statement of financial condition including a balance
sheet and summary of receipts and disbursements;
2. A description of the organizational structure and operation of
the health maintenance organization and a summary of any material changes
since the issuance of the last report;
3. A description of services and information as to where and how
to secure them; and
4. A clear and understandable description of the health
maintenance organization’s method for resolving enrollee complaints.
(Added to NRS by 1973, 1252)
1. After a health maintenance organization has been in operation
24 months, it shall have an annual open enrollment commensurate with
common practices in the area in which it operates.
2. Health maintenance organizations providing services to a
specified group or groups may limit the open enrollment to all members of
such group or groups. “Specified groups” may include:
(a) Employees of one or more specified employers;
(b) Members of one or more specified employee organizations;
(c) Members of one or more specified associations; and
(d) Participants in one or more specified group policies issued by
one or more specified insurers if the insurer is involved in the
operation, management or conduct of the health maintenance organization.
(Added to NRS by 1973, 1252)
Each health maintenance
organization shall establish:
1. A system for resolving complaints which complies with the
provisions of NRS 695G.200 to
695G.230 , inclusive; and
2. A system for conducting external reviews of final adverse
determinations that complies with the provisions of NRS 695G.241 to 695G.310 , inclusive.
(Added to NRS by 1973, 1253; A 1997, 311; 2003, 778 )
1. If a health maintenance organization, 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
provided under the evidence of coverage:
(a) The evidence of coverage must include a procedure for binding
arbitration to resolve disputes concerning independent medical
evaluations pursuant to the rules of the American Arbitration
Association; and
(b) 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.
2. 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 evidence of coverage 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.
3. 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 2 concerning the appeal of the insured person.
(Added to NRS by 1989, 2116)
1. Except as otherwise provided in NRS 695C.265 and subject to the approval of the
Commissioner, a health maintenance organization may include in any
evidence of coverage issued by the organization a provision which
requires an enrollee to whom the evidence of coverage is issued and the
health maintenance organization to submit for binding arbitration any
dispute between the enrollee and the organization concerning any matter
directly or indirectly related to, or associated with, the evidence of
coverage or the health care plan or health care services of the health
maintenance organization. If such a provision is included in the evidence
of coverage:
(a) An enrollee must be given the opportunity to decline to
participate in binding arbitration at the time of his enrollment.
(b) It must clearly state that the health maintenance organization
and an enrollee who has not declined to participate in binding
arbitration agree to forego their right to resolve any such dispute in a
court of law or equity.
2. Except as otherwise provided in subsection 3, the arbitration
must be conducted pursuant to the rules for commercial arbitration
established by the American Arbitration Association. The health
maintenance organization is responsible for any administrative fees and
expenses relating to the arbitration, except that the health maintenance
organization 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 an
enrollee, 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 any
evidence of coverage issued by a health maintenance organization, 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, 2559)
Each health maintenance
organization shall furnish a surety bond in an amount satisfactory to the
Commissioner or deposit with the Commissioner cash or securities
acceptable to him in at least the same amount as a guarantee that the
obligations to the enrollees will be performed. The Commissioner may
waive this requirement whenever satisfied that the assets of the
organization and its contracts with insurers, governments, or other
organizations are sufficient to reasonably assure the performance of its
obligations.
(Added to NRS by 1973, 1253)
1. To the extent authorized by federal law, the Commissioner shall
adopt regulations for the licensing of provider-sponsored organizations
in this State.
2. As used in this section, “provider-sponsored organization” has
the meaning ascribed to it in 42 U.S.C. § 1395w-25(d).
(Added to NRS by 1999, 2817 )
The Commissioner may adopt such
reasonable regulations as are necessary to provide for the licensing of
agents or brokers. An agent is a person directly or indirectly associated
with a health care plan who engages in solicitation or enrollment. A
broker is a person who is directly involved with the insured in the
manner provided in chapter 683A of NRS.
(Added to NRS by 1973, 1254; A 1981, 107; 1993, 2401)
1. An insurance company licensed in this State may either directly
or through a subsidiary or affiliate organize and operate a health
maintenance organization under the provisions of this chapter.
Notwithstanding any other law which may be inconsistent herewith, any two
or more such insurance companies or subsidiaries or affiliates thereof
may jointly organize and operate a health maintenance organization. The
business of insurance is deemed to include the providing of health care
by a health maintenance organization owned or operated by an insurer or a
subsidiary thereof.
2. An insurer may contract with a health maintenance organization
to provide insurance or similar protection against the cost of care
provided through health maintenance organizations and to provide coverage
in the event of the failure of the health maintenance organization to
meet its obligations. Among other things, under such contracts the
insurer may make benefit payments to health maintenance organizations for
health care services rendered by providers pursuant to the health care
plan.
(Added to NRS by 1973, 1254)
1. No health maintenance organization or representative thereof
may cause or knowingly permit the use of advertising which is untrue or
misleading, solicitation which is untrue or misleading or any form of
evidence of coverage which is deceptive. For purposes of this chapter:
(a) A statement or item of information shall be deemed to be untrue
if it does not conform to fact in any respect which is or may be
significant to an enrollee of, or person considering enrollment in, a
health care plan.
(b) A statement or item of information shall be deemed to be
misleading, whether or not it may be literally untrue if, in the total
context in which such statement is made or such item of information is
communicated, such statement or item of information may be reasonably
understood by a reasonable person not possessing special knowledge
regarding health care coverage, as indicating any benefit or advantage or
the absence of any exclusion, limitation or disadvantage of possible
significance to an enrollee of, or person considering enrollment in, a
health care plan if such benefit or advantage or absence of limitation,
exclusion or disadvantage does not in fact exist.
(c) An evidence of coverage shall be deemed to be deceptive if the
evidence of coverage taken as a whole, and with consideration given to
typography and format as well as language, shall be such as to cause a
reasonable person not possessing special knowledge regarding health care
plans and evidences of coverage therefor to expect benefits, services,
charges or other advantages which the evidence of coverage does not
provide or which the health care plan issuing such evidence of coverage
does not regularly make available for enrollees covered under such
evidence of coverage.
2. NRS 686A.010 to 686A.310
, inclusive, shall be construed to
apply to health maintenance organizations, health care plans and
evidences of coverage except to the extent that the nature of health
maintenance organizations, health care plans and evidences of coverage
render the sections therein clearly inappropriate.
3. An enrollee may not be cancelled or not renewed except for the
failure to pay the charge for such coverage or for cause as determined in
the master contract.
4. No health maintenance organization, unless licensed as an
insurer, may use in its name, contracts, or literature any of the words
“insurance,” “casualty,” “surety,” “mutual” or any other words
descriptive of the insurance, casualty or surety business or deceptively
similar to the name or description of any insurance or surety corporation
doing business in this State.
5. No person not certificated under this chapter shall use in its
name, contracts or literature the phrase “health maintenance
organization” or the initials “HMO.”
(Added to NRS by 1973, 1253)
1. The Commissioner shall make an examination of the affairs of
any health maintenance organization and providers with whom such
organization has contracts, agreements or other arrangements pursuant to
its health care plan as often as he deems it necessary for the protection
of the interests of the people of this State. An examination must be made
not less frequently than once every 3 years.
2. The State Board of Health shall make an examination concerning
the quality of health care services of any health maintenance
organization and providers with whom such organization has contracts,
agreements or other arrangements pursuant to its health care plan as
often as it deems necessary for the protection of the interests of the
people of this State. An examination must be made not less frequently
than once every 3 years.
3. Every health maintenance organization and provider shall submit
its books and records relating to the health care plan to an examination
made pursuant to subsection 1 or 2 and in every way facilitate the
examination. Medical records of natural persons and records of physicians
providing service pursuant to a contract to the health maintenance
organization are not subject to such examination, although the records
are subject to subpoena upon a showing of good cause. For the purpose of
examinations, the Commissioner and the State Board of Health may
administer oaths to, and examine the officers and agents of the health
maintenance organization and the principals of such providers concerning
their business.
4. The expenses of examinations pursuant to this section must be
assessed against the organization being examined and remitted to the
Commissioner or the State Board of Health, whichever is appropriate.
5. In lieu of such examination, the Commissioner may accept the
report of an examination made by the insurance commissioner or the state
board of health of another state.
(Added to NRS by 1973, 1255; A 1991, 2036)
1. For the purpose of determining its financial condition,
fulfillment of its contractual obligations and compliance with law, the
Commissioner shall, as often as he deems advisable, examine the affairs,
transactions, accounts, records and assets of a health maintenance
organization and of any person as to any matter relevant to the financial
affairs of the health maintenance organization or to the examination.
Except as otherwise provided in this Code, the Commissioner shall examine
each health maintenance organization at least once every 3 years.
2. The Commissioner shall examine each health maintenance
organization applying for an initial certificate of authority.
3. In lieu of making his own examination, the Commissioner may, in
his discretion, accept a full report of the last recent examination of a
foreign or alien health maintenance organization, certified to by the
supervisory officer of insurance of another state.
4. To the extent that it is practical, the examination of a
foreign or alien health maintenance organization must be made in
cooperation with the insurance supervisory officers of other states in
which the organization transacts business.
(Added to NRS by 1991, 2035)
1. If the Commissioner determines to examine a health maintenance
organization pursuant to NRS 695C.311 , he shall designate one or more examiners
and instruct them as to the scope of the examination. The examiner shall,
upon demand, exhibit his official credentials to the health maintenance
organization being examined.
2. The Commissioner shall conduct each examination in an
expeditious, fair and impartial manner.
3. The Commissioner, or the examiner if he is authorized in
writing by the Commissioner, may administer oaths and examine under oath
any person concerning any matter relevant to the examination.
4. Every health maintenance organization and its officers,
attorneys, employees, agents and representatives shall make available to
the Commissioner or his examiners the accounts, records, documents,
files, information, assets and matters of the health maintenance
organization in his possession or control relating to the subject of the
examination and shall facilitate the examination.
5. If the Commissioner or examiner finds any accounts or records
to be inadequate or inadequately kept or posted, he shall so notify the
health maintenance organization and give the health maintenance
organization a reasonable opportunity to reconstruct, rewrite, post or
balance the account or record. If the health maintenance organization
fails to maintain, complete or correct the records or accounting after
the Commissioner or examiner has given the health maintenance
organization written notice and a reasonable opportunity to do so, the
Commissioner may employ experts to reconstruct, rewrite, post or balance
the account or record at the expense of the health maintenance
organization being examined.
6. The Commissioner or an examiner shall not remove any record,
account, document, file or other property of the health maintenance
organization being examined from the office or place of business of the
health maintenance organization unless the Commissioner or examiner has
the written consent of an officer of the health maintenance organization
before the removal or pursuant to an order of court. This provision does
not prohibit the Commissioner or examiner from making or removing copies
or abstracts of a record, account, document or file.
7. Any person who, without just cause, refuses to be examined
under oath or who willfully obstructs or interferes with an examiner in
the exercise of his authority is guilty of a misdemeanor.
(Added to NRS by 1991, 2035)
1. The health maintenance organization being examined shall pay
the expense of an examination. The expenses to be paid include only the
reasonable and proper travel and lodging expenses of the Commissioner and
his examiners and assistants, including expert assistance, reasonable
compensation to the examiners and assistants and incidental expenses as
necessarily incurred in the examination. The Commissioner shall consider
the scales and limitations recommended by the National Association of
Insurance Commissioners regarding the expense and compensation for an
examination.
2. The health maintenance organization shall promptly pay to the
Commissioner the expenses of the examination upon presentation by the
Commissioner of a reasonably detailed written statement thereof.
(Added to NRS by 1991, 2036)
The Commissioner shall use the procedures required by:
1. NRS 679B.230 to 679B.290
, inclusive, when conducting an
examination of a health maintenance organization.
2. NRS 679B.310 to 679B.370
, inclusive, when conducting a hearing
involving a health maintenance organization.
(Added to NRS by 1991, 2036)
Any
rehabilitation, liquidation or conservation of a health maintenance
organization shall be deemed to be the rehabilitation, liquidation or
conservation of an insurance company and shall be conducted under the
supervision of the Commissioner pursuant to the law governing the
rehabilitation, liquidation, or conservation of insurance companies.
(Added to NRS by 1973, 1256)
A health
maintenance organization may offer to a small employer who has not less
than 2 and not more than 50 employees, a health care plan that has a high
deductible and that is in compliance with 26 U.S.C. § 220 for the
purposes of establishing medical savings accounts for any person insured
by the health care plan.
(Added to NRS by 1997, 2957)
1. The Commissioner may suspend or revoke any certificate of
authority issued to a health maintenance organization pursuant to the
provisions of this chapter if he finds that any of the following
conditions exist:
(a) The health maintenance organization is operating significantly
in contravention of its basic organizational document, its health care
plan or in a manner contrary to that described in and reasonably inferred
from any other information submitted pursuant to NRS 695C.060 , 695C.070 and 695C.140 , unless any amendments to those submissions
have been filed with and approved by the Commissioner;
(b) The health maintenance organization issues evidence of coverage
or uses a schedule of charges for health care services which do not
comply with the requirements of NRS 695C.1691 to 695C.200 , inclusive, or 695C.207 ;
(c) The health care plan does not furnish comprehensive health care
services as provided for in NRS 695C.060 ;
(d) The State Board of Health certifies to the Commissioner that
the health maintenance organization:
(1) Does not meet the requirements of subsection 2 of NRS
695C.080 ; or
(2) Is unable to fulfill its obligations to furnish health
care services as required under its health care plan;
(e) The health maintenance organization is no longer financially
responsible and may reasonably be expected to be unable to meet its
obligations to enrollees or prospective enrollees;
(f) The health maintenance organization has failed to put into
effect a mechanism affording the enrollees an opportunity to participate
in matters relating to the content of programs pursuant to NRS 695C.110
;
(g) The health maintenance organization has failed to put into
effect the system required by NRS 695C.260 for:
(1) Resolving complaints in a manner reasonably to dispose
of valid complaints; and
(2) Conducting external reviews of final adverse
determinations that comply with the provisions of NRS 695G.241 to 695G.310 , inclusive;
(h) The health maintenance organization or any person on its behalf
has advertised or merchandised its services in an untrue,
misrepresentative, misleading, deceptive or unfair manner;
(i) The continued operation of the health maintenance organization
would be hazardous to its enrollees;
(j) The health maintenance organization fails to provide the
coverage required by NRS 695C.1691 ;
or
(k) The health maintenance organization has otherwise failed to
comply substantially with the provisions of this chapter.
2. A certificate of authority must be suspended or revoked only
after compliance with the requirements of NRS 695C.340 .
3. If the certificate of authority of a health maintenance
organization is suspended, the health maintenance organization shall not,
during the period of that suspension, enroll any additional groups or new
individual contracts, unless those groups or persons were contracted for
before the date of suspension.
4. If the certificate of authority of a health maintenance
organization is revoked, the organization shall proceed, immediately
following the effective date of the order of revocation, to wind up its
affairs and shall conduct no further business except as may be essential
to the orderly conclusion of the affairs of the organization. It shall
engage in no further advertising or solicitation of any kind. The
Commissioner may, by written order, permit such further operation of the
organization as he may find to be in the best interest of enrollees to
the end that enrollees are afforded the greatest practical opportunity to
obtain continuing coverage for health care.
(Added to NRS by 1973, 1255; A 1985, 1448; 1997, 745, 1462, 1629;
1999, 417 , 419 , 761 , 2004 ; 2001, 141 , 144 ; 2003, 778 , 1336 , 3369 , 3532 )
1. When the Commissioner has cause to believe that grounds for the
denial of an application for a certificate of authority exist, or that
grounds for the suspension or revocation of a certificate of authority
exist, he shall notify the health maintenance organization and the State
Board of Health in writing specifically stating the grounds for denial,
suspension or revocation and fixing a time at least 30 days thereafter
for a hearing on the matter.
2. The State Board of Health or its delegated representative shall
be in attendance at the hearing and shall participate in the proceedings.
The recommendation and findings of the State Board of Health with respect
to matters relating to the quality of health maintenance services
provided in connection with any decision regarding denial, suspension or
revocation of a certificate of authority are conclusive and binding upon
the Commissioner. After the hearing, or upon the failure of the health
maintenance organization to appear at the hearing, the Commissioner shall
take action as is deemed advisable on written findings which must be
mailed to the health maintenance organization with a copy thereof to the
State Board of Health. The action of the Commissioner and the
recommendation and findings of the State Board of Health are subject to
review by the First Judicial District Court of the State of Nevada in and
for Carson City. The court may, in disposing of the issue before it,
modify, affirm or reverse the order of the Commissioner in whole or in
part.
(Added to NRS by 1973, 1256; A 1981, 107)
1. The Commissioner may, in lieu of suspension or revocation of a
certificate of authority under NRS 695C.330 , levy an administrative penalty in an amount
not more than $2,500 for each act or violation, if reasonable notice in
writing is given of the intent to levy the penalty.
2. Any person who violates the provisions of this chapter is
guilty of a misdemeanor.
3. If the Commissioner or the State Board of Health for any reason
have cause to believe that any violation of this chapter has occurred or
is threatened, the Commissioner or the State Board of Health may give
notice to the health maintenance organization and to the representatives,
or other persons who appear to be involved in the suspected violation, to
arrange a conference with the alleged violators or their authorized
representatives to attempt to determine the facts relating to the
suspected violation, and, if it appears that any violation has occurred
or is threatened, to arrive at an adequate and effective means of
correcting or preventing the violation.
4. The proceedings conducted pursuant to the provisions of
subsection 3 must not be governed by any formal procedural requirements,
and may be conducted in such manner as the Commissioner or the State
Board of Health may deem appropriate under the circumstances.
5. The Commissioner may issue an order directing a health
maintenance organization or a representative of a health maintenance
organization to cease and desist from engaging in any act or practice in
violation of the provisions of this chapter.
6. Within 30 days after service of the order to cease and desist,
the respondent may request a hearing on the question of whether acts or
practices in violation of this chapter have occurred. The hearing must be
conducted pursuant to the provisions of chapter 233B of NRS and judicial review must be available as
provided therein.
7. In the case of any violation of the provisions of this chapter,
if the Commissioner elects not to issue a cease and desist order, or in
the event of noncompliance with a cease and desist order issued pursuant
to subsection 5, the Commissioner may institute a proceeding to obtain
injunctive relief, or seek other appropriate relief in the district court
of the judicial district of the county in which the violator resides.
(Added to NRS by 1973, 1257; A 1999, 2817 )
