USA Statutes : nevada
Title : Title 57 - INSURANCE
Chapter : CHAPTER 695D - PLANS FOR DENTAL CARE
As used in this chapter, unless the
context otherwise requires, the words and terms defined in NRS 695D.020
to 695D.080 , inclusive, have the meanings ascribed to
them in those sections.
(Added to NRS by 1983, 2021)
“Commissioner” means the
Commissioner of Insurance.
(Added to NRS by 1983, 2021)
“Dental care” means the
services ordinarily provided by dentists and includes appliances, drugs,
medicines, supplies, prosthetic appliances, orthodontic appliances, and
metal, ceramic or other restorations customarily used or provided by a
dentist.
(Added to NRS by 1983, 2021)
“Dentist” includes a dental
hygienist.
(Added to NRS by 1983, 2021)
“Member” includes the person
enrolled in a plan for dental care and his dependents who may also be
enrolled in the plan.
(Added to NRS by 1983, 2021)
“Organization for dental care” means any person who agrees to provide
coverage for dental care through one or more plans for dental care.
(Added to NRS by 1983, 2021)
“Plan for dental
care” means any agreement in which a person agrees to provide or arrange
for dental care or pay for or reimburse any part of the cost of that care
and the member agrees to prepay, make periodic payments or pay through
insurance for that care.
(Added to NRS by 1983, 2021; A 1985, 2098)
“Policy” means the document given
to a member which describes the dental care to which he is entitled under
a plan for dental care and his obligations to the organization for dental
care.
(Added to NRS by 1983, 2021)
1. Except as otherwise specifically provided in this chapter or
elsewhere in this title, the provisions of this title other than this
chapter do not apply to organizations for dental care. This exemption
does not apply to any insurer authorized pursuant to any other provision
of this title except with respect to those activities authorized and
regulated by this chapter.
2. The provisions of this chapter do not apply to:
(a) Any person, corporation or organization which must be
authorized by the Commissioner to transact the business of insurance
pursuant to chapter 680A , 695B or 695C of NRS.
(b) Any plan established to provide health and welfare benefits to
employees pursuant to a collective bargaining agreement.
(Added to NRS by 1983, 2021)
An organization for dental care is not exempt from the
provisions of NRS 679B.700 . If an
organization is an admitted health insurer, as that term is defined in
NRS 449.450 , it is not exempt from the
fees imposed pursuant to NRS 449.465 .
(Added to NRS by 1987, 470)
The Commissioner may
adopt any regulations necessary to carry out the provisions of this
chapter.
(Added to NRS by 1983, 2022)
1. The Commissioner shall adopt regulations which require an
organization for dental care to file with the Commissioner, for his
approval, a disclosure summarizing the coverage provided by each plan for
dental care offered by the organization for dental care. 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 policy only, and that the policy itself should be read to
determine the governing contractual provisions.
3. The Commissioner shall not approve any proposed disclosure
submitted to him pursuant to this section which does not comply with the
requirements of this section and the applicable regulations.
(Added to NRS by 1989, 1254)
An organization for dental care shall provide to the group
policyholder to whom it offers a plan for dental care a copy of the
disclosure approved for that plan pursuant to NRS 695D.102 before the policy is issued. An organization
for dental care shall not offer a plan for dental care unless the
disclosure for that plan has been approved by the Commissioner.
(Added to NRS by 1989, 1254)
No person may establish or operate a plan for dental care,
act as an administrator of such a plan or sell or offer to sell such a
plan without first obtaining a certificate of authority from the
Commissioner.
(Added to NRS by 1983, 2022)
Each
application for a certificate of authority must be filed with the
Commissioner on a form prescribed by him, must be verified by an officer
or authorized representative of the organization for dental care and must
include:
1. A copy of any organizational document for the organization and
all amendments to that document.
2. A copy of any bylaws, rules or regulations governing the
internal affairs of the organization.
3. A list of the names, addresses and official positions of the
persons responsible for operating the organization, including the members
of the board of directors, board of trustees, executive committee,
principal officers or partners.
4. A copy of the contracts made or proposed to be made between the
applicant and those persons listed in subsection 3 and the dentists.
5. A statement describing the applicant’s plan for dental care,
its facilities and personnel.
6. A copy of the policy to be issued to its members.
7. A copy of any contract for groups to be issued to employers,
unions, trustees or other organizations.
8. Certified financial statements showing the applicant’s assets,
liabilities and sources of support. A copy of the applicant’s most recent
certified financial statement satisfies this requirement unless the
Commissioner requests additional information from the applicant.
9. A description of the method to be used to market the plan for
dental care, including a financial statement, a projection for the
initial 5 years of operation of the plan and a statement of the sources
of capital for the organization.
10. A power of attorney executed by the applicant or its officers,
which appoints the Commissioner as the attorney for the applicant upon
whom service of process may be made in this State.
11. A statement describing the geographic area or areas to be
served by the applicant.
12. A statement indicating that all the dentists for the plan are
licensed pursuant to chapter 631 of NRS.
13. Any other information requested by the Commissioner.
(Added to NRS by 1983, 2022)
The Commissioner
shall issue a certificate of authority to an organization for dental care
after the organization has paid an application fee of $2,450 and the
Commissioner is satisfied that:
1. The persons responsible for operating the organization are
competent, trustworthy, have not been convicted of a felony and have good
reputations.
2. The plan for dental care includes care which is appropriate for
the plan and the plan is appropriate for providing that care.
3. The organization is financially responsible and may reasonably
be expected to meet its obligations to its members. To determine
financial responsibility the Commissioner may consider:
(a) The organization’s arrangements for dental care and the
schedule of charges to be used;
(b) The agreements with an insurer, government or any other
organizations for ensuring payment for the dental care;
(c) Any provisions for alternative coverage if the plan for dental
care is discontinued; and
(d) The agreements with the dentists providing dental care to the
organization’s members.
4. The appropriate deposits or bonds have been filed with the
Commissioner by the organization and its officers.
(Added to NRS by 1983, 2023; A 1991, 1634)
1. Except as otherwise provided in subsection 2, every
organization issued a certificate of authority by the Commissioner shall
notify him of any change in the information provided to obtain its
certificate of authority within 10 days after the change.
2. Every such organization that wishes to make a change in the
geographic areas which it serves, or to make any other material
modification of the operations described in the information required by
NRS 695D.120 , shall file with the
Commissioner an application for the amendment of the certificate of
authority and pay to him an application fee of $100. If the Commissioner
does not disapprove the application within 30 days after filing, it shall
be deemed approved.
(Added to NRS by 1983, 2023; A 1991, 2205)
A certificate of authority expires at midnight on March 1
following the date it was issued or previously renewed. The Commissioner
shall renew the certificate of any organization for dental care which:
1. Continues to comply with the provisions of this chapter; and
2. Pays the fee for renewal of $2,450.
(Added to NRS by 1983, 2023; A 1987, 470; 1991, 1635; 1993, 614)
If an organization for dental care is a corporation,
its board of directors must include:
1. Dentists who have contracted with the organization to provide
dental care to its members; and
2. Members of the plan for dental care, who must comprise at least
one-third of the membership of the board by the end of its first year of
operation.
(Added to NRS by 1983, 2023)
1. Before a certificate of authority may be issued to an
organization for dental care:
(a) The officers responsible for operating the organization must
file with the Commissioner a collective fidelity bond for $1,000,000; and
(b) The organization must file with the Commissioner a surety bond
in the sum of $250,000 or deposit with the Commissioner cash or
securities acceptable to the Commissioner in the sum of $250,000,
Ê to guarantee the organization’s performance pursuant to this chapter.
2. If the bond is furnished in:
(a) Cash, the Commissioner shall deposit the money in the State
Treasury for credit to the Fund for Bonds of Organizations for Dental
Care which is hereby created as a trust fund.
(b) Negotiable securities, the principal must be placed without
restriction at the disposal of the Commissioner, but any income must
inure to the benefit of the organization.
3. The Commissioner may reduce the organization’s bond or deposit:
(a) To $125,000, if the obligations assumed by the organization
under the plan can be satisfied for less than $125,000.
(b) To any amount if the organization demonstrates that it has
commitments of money from federal, state or municipal governments or
their political subdivisions or other comparable resources which are
sufficient to ensure the ability of the organization to satisfy its
obligations.
4. Any final judgment against the organization which is unpaid is
a lien on the bond or deposit and is subject to execution 30 days after
entry of the judgment. Any bond or deposit which is reduced by this lien
must be increased by the organization to the amount required by this
section within 90 days after the judgment is paid.
5. If an organization is dissolved, liquidated or otherwise
terminated:
(a) That amount of the bond or deposit which is necessary to
satisfy the outstanding obligations of the organization may not be
withdrawn for at least 3 years after the certificate of authority has
been terminated.
(b) Any balance remaining after money has been withheld to pay the
organization’s debts and liens must be paid to the organization by the
Commissioner no later than 90 days after the certificate of authority has
been terminated.
(Added to NRS by 1983, 2023)
1. A bond by any organization for dental care or its officers
under this chapter must be payable to the State of Nevada and must be
conditioned on compliance with the provisions of this chapter. The surety
shall pay all damages to any person by reason of any misstatement,
misrepresentation, fraud or deceit, or any wrongful act or omission of
any person or organization made, committed or omitted in the plan for
dental care or caused by any other violation of the provisions of this
chapter.
2. The organization must give notice to the Commissioner at least
90 days before such a bond may be cancelled.
(Added to NRS by 1983, 2024)
Any
director, officer, partner or employee of an organization for dental care
who receives, collects, disburses or invests money in connection with the
activities of that organization is responsible for that money and has a
fiduciary duty and relationship to the members of the organization. Any
dentist who breaches this fiduciary duty or fails to satisfy his
contractual obligation to the organization or the members thereof is
subject to disciplinary action pursuant to NRS 631.350 .
(Added to NRS by 1983, 2024)
1. An organization for dental care shall:
(a) Hold a meeting for all prospective members to review fully the
policy being offered and describe the coverage under the plan for dental
care before any contract is executed between the parties.
(b) Provide to each member a copy of the policy describing his
coverage under the plan for dental care.
2. The Commissioner must approve every policy and amendment to it
before they are distributed to the members or any other person. If the
Commissioner does not disapprove the policy within 30 days after it is
filed with him, it shall be deemed to be approved. If the Commissioner
disapproves a policy, he shall notify the organization of the reasons for
his disapproval. The Commissioner shall grant a hearing on any
disapproval of a policy or amendment within 15 days after the
organization requests, in writing, a hearing on the matter.
3. A policy must contain a clear and complete statement of the
contract between the parties or a summary of the contract which describes:
(a) The dental care and other benefits to which the member is
entitled;
(b) Any limitations on the care to be provided, including any
deductibles or copayments to be paid by a member;
(c) Where information is available and how dental care may be
obtained; and
(d) The member’s obligations for payment under the plan for dental
care.
4. The organization must give notice to the Commissioner and every
member 30 days before any change is made in the member’s policy.
(Added to NRS by 1983, 2025)
1. A group plan for dental care issued by an organization for
dental care to replace any discontinued policy or coverage for dental
care 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 organization for dental care 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. The provisions of this section apply to a self-insured employer
who provides benefits to his employees for dental care and replaces those
benefits with a group plan for dental care.
(Added to NRS by 1987, 851)
1. Each copayment and deductible required to be paid by a member
must be reasonable and reasonably related to the cost of the particular
service.
2. Every organization for dental care shall submit to the
Commissioner for his approval any proposal for copayment or deductible
before it is imposed on the members. The Commissioner shall approve or
disapprove the proposal within 30 days after it is submitted to him. If
the Commissioner disapproves a copayment or deductible, he shall notify
the organization of the reasons for his disapproval. The Commissioner
shall grant a hearing on any such disapproval within 15 days after the
organization requests, in writing, a hearing on the matter.
3. The Commissioner may adopt regulations to define:
(a) “Reasonable” as it relates to copayments and deductibles; and
(b) A “reasonable relationship” between the cost of particular
services and the amount of related copayments and deductibles.
(Added to NRS by 1987, 1783)
1. Any policy which provides coverage for a dependent of a member
must provide that benefits for children are payable for a member’s newly
born child, adopted child or child placed with the member for the purpose
of adoption to the same extent that the coverage applies to other
dependents.
2. The policy may require that to have coverage for the newly born
child, adopted child or child placed for adoption continued beyond 31
days after the child’s birth, adoption or placement, the member must
notify the organization for dental care within 31 days after the birth,
adoption or placement.
3. For covered services provided to the child, the organization
for dental care 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 1983, 2025; A 1989, 742)
1. Except as otherwise provided in subsection 2, an organization
for dental care shall approve or deny a claim relating to a plan for
dental care within 30 days after the organization for dental care
receives the claim. If the claim is approved, the organization for dental
care shall pay the claim within 30 days after it is approved. If the
approved claim is not paid within that period, the organization for
dental care shall pay interest on the claim at the rate of interest
established pursuant to NRS 99.040 . The
interest must be calculated from the date the payment is due until the
claim is paid.
2. If the organization for dental care 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 organization for dental care
shall notify the provider of dental care of the reason for the delay in
approving or denying the claim. The organization for dental care shall
approve or deny the claim within 30 days after receiving the additional
information. If the claim is approved, the organization for dental care
shall pay the claim within 30 days after it receives the additional
information. If the approved claim is not paid within that period, the
organization for dental care shall pay interest on the claim in the
manner prescribed in subsection 1.
(Added to NRS by 1991, 1332)
An
organization for dental care 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, 1097)
[Effective July 1, 2006.]
1. Except as otherwise provided in subsection 2, an organization
for dental care shall not:
(a) Deny a claim under a plan for dental care solely because the
claim involves an injury sustained by a member as a consequence of being
intoxicated or under the influence of a controlled substance.
(b) Cancel participation under a plan for dental care solely
because a member has made a claim involving an injury sustained by the
member as a consequence of being intoxicated or under the influence of a
controlled substance.
(c) Refuse participation under a plan for dental care to an
eligible applicant solely because the applicant has made a claim
involving an injury sustained by the applicant as a consequence of being
intoxicated or under the influence of a controlled substance.
2. The provisions of this section do not prohibit an organization
for dental care from enforcing a provision included in a plan for dental
care 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 plan for dental care solely
because of such a claim; or
(c) Refuse participation under a plan for dental care to an
eligible applicant solely because of such a claim.
(Added to NRS by 2005, 2346 , effective July 1, 2006)
1. The provisions of chapter 683A of
NRS apply to the licensing of agents for an organization for dental care.
2. As used in this section, “agent” means any person who is
associated, directly or indirectly, with the organization and engages in
soliciting or enrolling members.
(Added to NRS by 1983, 2027)
1. Every organization for dental care must submit any advertising,
or other materials to be used to enroll or solicit members, to the
Commissioner for his approval before they are used by the organization.
2. If the Commissioner does not disapprove the advertising or
other materials within 30 days after they are filed with the
Commissioner, they shall be deemed to be approved. If the Commissioner
disapproves any of the advertising or other materials because they are
false, deceptive, or misleading, he shall notify the organization of his
reasons for disapproving them. The Commissioner shall grant a hearing on
the matter within 15 days after the organization requests, in writing, a
hearing on the matter.
3. If any advertising or other materials are circulated, issued,
displayed or used in any manner to enroll or solicit members before they
are approved by the Commissioner or after he has disapproved them, the
Commissioner may withdraw his approval, if any, of the policy and plan
for dental care proposed by the organization or take any other
disciplinary action permitted by this chapter against the organization.
(Added to NRS by 1983, 2025)
1. The organization for dental care shall use not more than 25
percent of its prepaid charges or premiums for marketing and
administrative expenses, including all costs to solicit members or
dentists.
2. The Commissioner may adopt regulations which define “marketing
and administrative expenses” for the purposes of subsection 1.
(Added to NRS by 1983, 2026; A 1993, 2401)
1. An organization for dental care shall set aside a reserve equal
to 3 percent of the premiums collected from its members up to a total of
$500,000. This reserve is in addition to the bond or deposit filed with
the Commissioner.
2. This section does not apply to organizations receiving money
from federal, state or municipal governments or their political
subdivisions or another comparable resource which have had their deposit
or bond reduced by the Commissioner.
3. Every organization shall maintain the reserves required by NRS
681B.080 , unless a larger amount is
required by subsection 1 of this section.
4. The reserve required by subsection 1 is held by the
organization in a fiduciary capacity. The organization must deposit the
reserve in an interest-bearing trust account established in a bank,
credit union or savings and loan association in this state that is
federally insured or insured by a private insurer approved pursuant to
NRS 678.755 . The account must be
separate from all other accounts maintained by the organization.
5. Any person who diverts or appropriates reserves held in a
fiduciary capacity pursuant to this section for his own use is guilty of
embezzlement.
6. The Commissioner may adopt reasonable regulations related to
the adequacy of a reserve required by this section and the establishment
and maintenance of a trust account pursuant to this section.
(Added to NRS by 1983, 2026; A 1993, 2401; 1999, 1554 )
1. Every organization for dental care shall file with the
Commissioner on or before March 1 of each year a report covering its
activities for the preceding calendar year. The report must be verified
by at least two officers of the organization.
2. The report must be on a form 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 given in the previous
report.
(c) The number of members enrolled in that year, the number of
members whose coverage has been terminated in that year and the total
number of members at the end of the year.
(d) The costs of all goods, services and dental care provided that
year.
(e) Any other information relating to the plan for dental care
requested by the Commissioner.
3. Every organization for dental care shall file with the
Commissioner annually an audited financial statement prepared by an
independent certified public accountant. The statement must cover the
most recent fiscal year of the organization and must be filed with the
Commissioner within 120 days after the end of that fiscal year.
4. 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.
6. The organization shall pay the Department of Taxation the
annual tax, any penalty for nonpayment or delinquent payment of the tax
imposed in chapter 680B of NRS, and a
filing fee of $25 to the Commissioner, at the time the annual report is
filed.
(Added to NRS by 1983, 2026; A 1987, 471; 1991, 2206; 1993, 1923;
1995, 1633, 2682)
1. The Commissioner shall, once:
(a) Every 6 months for the first 3 years after an organization for
dental care receives its certificate of authority; and
(b) Each year thereafter,
Ê conduct an examination of the organization pursuant to NRS 679B.250
to 679B.300 , inclusive.
2. The Commissioner may examine any organization which holds a
certificate of authority from this state or another state at any other
time he deems necessary. For those organizations transacting business in
this state which are not organized in this state, the Commissioner may
accept a full report of the last examination of the organization
certified by the state officer who supervises those organizations in the
other state, if that examination is equivalent to an examination
conducted by the Commissioner.
3. The Commissioner shall, in like manner, examine all
organizations applying for a certificate of authority.
(Added to NRS by 1983, 2027)
Any
rehabilitation, liquidation or conservation of an organization for dental
care shall be deemed to be the rehabilitation, liquidation or
conservation of an insurer and must be conducted pursuant to chapter 696B
of NRS.
(Added to NRS by 1983, 2027)
The provisions of NRS
686A.010 to 686A.310 , inclusive, relating to trade practices and
frauds apply to organizations for dental care.
(Added to NRS by 1983, 2027)
1. The Commissioner may suspend or revoke any certificate of
authority issued to an organization for dental care or impose a fine of
not more than $500 for each violation if he finds that:
(a) The organization is operating contrary to the information it
submitted to him for its certificate of authority;
(b) The organization issued a policy to a member which was not
approved by the Commissioner;
(c) The plan for dental care does not provide basic services
appropriate for such a plan;
(d) The organization can no longer meet its obligations to members
or prospective members;
(e) The organization or any person on its behalf has advertised its
plan in an untrue, misleading, deceptive or unfair manner; or
(f) The organization has failed to comply substantially with this
chapter or the regulations of the Commissioner.
2. If the certificate of authority of an organization is
suspended, the organization shall not, during the period of the
suspension, accept any new members and shall not advertise for or solicit
any new members.
3. If the certificate of authority of an organization is revoked,
the organization shall proceed, immediately following the order, to
terminate its affairs and shall conduct no other business. The
Commissioner, by written order, may approve the continued operation of
the organization for a specified time if the Commissioner finds that the
members need that time to obtain coverage for dental care from another
organization or insurer.
(Added to NRS by 1983, 2027)
1. If the Commissioner believes that grounds for denying a
certificate of authority or for suspending or revoking a certificate
exist, he shall notify the organization for dental care in writing,
specifying the grounds for the denial, suspension or revocation and fix a
time for a hearing on the matter within 30 days after the notice.
2. After the hearing or upon the failure of the organization to
appear at the hearing, the Commissioner shall enter a written order of
his decision which must be mailed by certified mail to the organization.
(Added to NRS by 1983, 2028)
