Nev. Rev. Stat. § 695B.010 Short title.
This chapter may be cited as the Nonprofit Hospital, Medical and Dental Service Corporation Law.
NONPROFIT CORPORATIONS FOR HOSPITAL, MEDICAL AND DENTAL SERVICE
Nev. Rev. Stat. 695B
in effectNev. Rev. Stat. § 695B.020 Scope.
1. This chapter does not:
(a) Apply to or govern any corporation which is organized for profit, which contemplates any pecuniary gain to its shareholders or members, or which conducts or is authorized by its articles of incorporation to conduct any business whatsoever on a profit basis.
(b) Authorize and must not be construed to authorize, directly or indirectly, any corporation to operate a hospital or a medical or dental service plan on a profit basis.
2. Except as otherwise provided in subsection 3, a corporation subject to the provisions of this chapter shall not own or operate any hospital or engage in any business other than that of establishing, maintaining and operating a nonprofit hospital, medical or dental service plan.
3. A corporation subject to the provisions of this chapter may, with the approval of the Commissioner, engage in any business reasonably and necessarily incidental to the business of a nonprofit hospital, medical or dental service plan.
Nev. Rev. Stat. § 695B.030 Definitions.
As used in this chapter:
1. Dental services means general and special dental services ordinarily provided by dentists licensed under the provisions of chapter 631 of NRS to practice in the State of Nevada in accordance with the generally accepted practices of the community at the time the service is rendered, and the furnishing of necessary appliances, drugs, medicines and supplies, prosthetic appliances, orthodontic appliances, metal, ceramic and other restorations.
2. Hospital services means the furnishing or providing of any or all of the following:
(a) Maintenance and care in the hospital, including but not limited to, nursing care, drugs, medicines, supplies, physiotherapy, transportation and use of facilities and appliances.
(b) Reimbursement of the beneficiary or subscriber for, but without requiring that the beneficiary or subscriber first pay, expenses incurred for any of the items included in paragraph (a).
(c) Reimbursement, at a uniform rate, of the beneficiary or subscriber for, but without requiring that the beneficiary or subscriber first pay, the costs and expenses incurred for medical supplies.
(d) Reimbursement for expenses incurred outside of the hospital for continued care and treatment following the subscribers discharge from the hospital, for nursing service, necessary appliances, drugs, medicines, supplies and any other services which would have been available in the hospital (excluding physicians services), whether or not provided through a hospital.
(e) Reimbursement for ambulance service expenses.
3. Medical services means the furnishing or providing of any or all of the following:
(a) Medical or surgical services, in or out of a hospital, by a physician licensed to practice under the laws of Nevada.
(b) Reimbursement for expenses incurred for nursing services, necessary appliances, drugs, medicines, supplies and any other health care services.
Nev. Rev. Stat. § 695B.035 Contract between corporation and provider of health care: Prohibiting corporation from charging provider of health care fee for inclusion on list of providers given to insureds; corporation required to use form to obtain information on provider of health care; modification; submission by corporation of schedule of payments to provider.
1. A corporation subject to the provisions of this chapter shall not charge a provider of health care a fee to include the name of the provider on a list of providers of health care given by the corporation to its insureds.
2. A corporation specified in subsection 1 shall not contract with a provider of health care to provide health care to an insured unless the corporation uses the form prescribed by the Commissioner pursuant to NRS 629.095 to obtain any information related to the credentials of the provider of health care.
3. A contract between a corporation specified in subsection 1 and a provider of health care may be modified:
(a) At any time pursuant to a written agreement executed by both parties.
(b) Except as otherwise provided in this paragraph, by the corporation upon giving to the provider 45 days written notice of the modification of the corporations schedule of payments, including any changes to the fee schedule applicable to the providers practice. If the provider fails to object in writing to the modification within the 45-day period, the modification becomes effective at the end of that period. If the provider objects in writing to the modification within the 45-day period, the modification must not become effective unless agreed to by both parties as described in paragraph (a).
4. If a corporation specified in subsection 1 contracts with a provider of health care to provide health care to an insured, the corporation shall:
(a) If requested by the provider of health care at the time the contract is made, submit to the provider of health care the schedule of payments applicable to the provider of health care; or
(b) If requested by the provider of health care at any other time, submit to the provider of health care the schedule of payments, including any changes to the fee schedule applicable to the providers practice, specified in paragraph (a) within 7 days after receiving the request.
5. As used in this section, provider of health care means a provider of health care who is licensed pursuant to chapter 630 , 631 , 632 or 633 of NRS.
Nev. Rev. Stat. § 695B.040 Corporations authorized to undertake and operate plans.
Any corporation which is organized under the laws of the State of Nevada, or the laws of any other state, without capital stock, for the purpose of maintaining and operating a hospital, medical or dental service plan, and which does not contemplate pecuniary gain or profit to its members, may undertake and operate a hospital, medical or dental service plan for rendering hospital, medical or dental service to its subscribers under and subject to the provisions of this chapter.
Nev. Rev. Stat. § 695B.050 Manner of incorporation.
Persons desiring to form a nonprofit hospital, medical or dental service corporation shall incorporate pursuant to the provisions of this chapter, and the provisions of the nonprofit corporation laws of the State of Nevada, including NRS 81.410 to 81.540, inclusive, or chapter 82 of NRS, as applicable, so far as the provisions of such laws are applicable and not inconsistent with this chapter.
Nev. Rev. Stat. § 695B.060 Directors: Qualifications.
1. A majority of the board of directors of a corporation providing or rendering hospital services shall be persons who are not duly appointed representatives of hospitals with which the corporation has contracts for the rendering of hospital services.
2. A majority of the board of directors of a corporation providing medical services shall be persons who are not physicians or duly appointed representatives of the physicians who have signed participating agreements with the corporation for the rendering of medical services.
3. A majority of the board of directors of a corporation providing dental services shall be persons who are not dentists or duly appointed representatives of the dentists who have signed participating agreements with the corporation for the rendering of dental services.
4. This section does not apply to any duly appointed representative of a hospital, physician or dentist who is a member of the board of directors of a corporation on July 1, 1977. Such a person may continue to serve as a member of the board of directors until the term of the person expires.
Nev. Rev. Stat. § 695B.070 Merger and consolidation: Procedure.
Any corporation operating under this chapter may merge and consolidate with any other corporation operating or to operate under this chapter as follows:
1. The agreement of merger and consolidation shall be submitted to and approved by a two-thirds vote of the members of the ceding corporation present in person or by proxy at a meeting called to consider that agreement. A written or printed notice of such meeting shall be mailed or personally delivered to each member at least 30 days before the day fixed for the meeting.
2. Before the merger and consolidation is effected, the corporation which proposes to assume the liabilities of the ceding corporation shall submit to its members the question of merger and consolidation and a similar notice shall be given and a similar vote required as in the case of members of the ceding corporation.
3. If the vote in the case of both corporations is in the affirmative by the required majority, a certified copy of all proceedings relating to the proposed merger and consolidation shall be filed with the Commissioner. If the Commissioner finds that the proceedings have been in accordance with law, the Commissioner shall approve the agreement.
4. Upon the approval by the Commissioner of such agreement, the consolidated corporation shall issue certificates of assumption to each and every subscriber of the ceding corporation. Such certificates shall be in a form approved by the Commissioner.
5. The approval of the Commissioner of the agreement of merger and consolidation shall operate to dissolve the ceding corporation, and all its liability upon its insurance contracts or benefit certificates shall thereupon cease, but its officers may thereafter perform any act necessary to close its affairs. The officers of the ceding corporation shall file a certified copy of the agreement in the Office of the Secretary of State. Such certified copy shall be in lieu of any certificate of dissolution required by the provisions of the general corporation law.
6. The consolidated corporation shall be entitled to all the assets of the ceding corporation and shall assume all its liabilities.
Nev. Rev. Stat. § 695B.080 Merger and consolidation: Continuance of contracts and contribution certificates.
In the event of any merger and consolidation as provided by this chapter, contracts and contribution certificates issued in compliance with the provisions of this chapter and outstanding at the time of the date of the merger and consolidation may be continued in force, reinstated, renewed and repaid without change of provisions, except as such change may be necessary or advisable at or following the next renewal or reinstatement.
Nev. Rev. Stat. § 695B.090 Merger and consolidation: Withdrawal of prior deposit of securities.
Upon approval by the Commissioner of any such merger and consolidation, the merged and consolidated corporation may withdraw any securities therefore deposited pursuant to any requirements of this chapter.
Nev. Rev. Stat. § 695B.110 Certificate of authority: Required; fees.
A corporation shall not establish, maintain or operate a nonprofit service plan as authorized by the provisions of this chapter unless it has:
1. Procured a certificate of authority from the Commissioner for the establishment, maintenance and operation of the plan.
2. Paid to the Commissioner the fees required of insurers by NRS 680B.010 for:
(a) The filing of the initial application;
(b) The issuance of the certificate of authority;
(c) Each annual continuation of the certificate of authority; and
(d) The filing of each annual report.
3. Paid, in addition to any other fee or charge, all applicable fees required pursuant to NRS 680C.110 .
Nev. Rev. Stat. § 695B.120 Certificate of authority: Qualifications.
The Commissioner shall not issue or renew a certificate of authority to any corporation proposing to establish, maintain or operate a nonprofit hospital, medical or dental service plan until such corporation establishes:
1. If a nonprofit hospital service corporation, that it has entered into contracts with hospitals in the State of Nevada having an aggregate bed capacity sufficient to render the services contemplated to be furnished under the hospital service plan to persons in the State of Nevada.
2. That the hospital, medical or dental service contract proposed to be entered into by such corporation with those who may become subscribers is not such as will work a fraud or injustice upon such subscribers or any person.
3. That a schedule of the rates, dues, fees or other periodic charges to be paid by subscribers has been filed with the Commissioner and the same are not such as will, after providing for such legal reserves as are required by NRS 695B.140 , result in profit to, or in the accumulation of excessive reserves or surpluses by, such corporation and are such as will enable such corporation to furnish or provide the hospital, medical or dental services which it proposes to make available to its beneficiaries and subscribers without impairment of its legal reserves and without a constant depletion of the assets of such corporation. A reserve or surplus over and above all approved and required reserves in an amount in excess of the average annual gross income of such corporation for the immediately preceding 3 calendar years shall be prima facie an excessive accumulation.
Nev. Rev. Stat. § 695B.130 Certificate of authority: Application; issuance.
1. An application for a certificate of authority must be filed with the Commissioner in writing by the corporation for medical service which is applying for the certificate on forms furnished or accepted by the Commissioner. The application must set forth such information concerning the applicant and its qualifications and in other respects as the Commissioner may reasonably require.
2. The application must be accompanied by:
(a) A copy of the applicants charter or articles of incorporation, certified by the public officer with whom the original is required to be filed in its state of domicile;
(b) A copy of the applicants bylaws, certified by the corporate secretary;
(c) A copy of each contract the applicant has made or proposed to make with hospitals, or physicians or dentists in this state;
(d) A copy of each service contract proposed to be issued to its subscribers in this state;
(e) The schedule of the rates, dues, fees or other periodical charges proposed to be charged for such service contracts; and
(f) All applicable fees for an initial application and the issuance of a certificate of authority.
3. If upon completion of the application the Commissioner determines that the applicant is fully qualified and entitled to a certificate of authority under this chapter, the Commissioner shall promptly issue a certificate of authority to the applicant. If the Commissioner refuses to issue the certificate of authority, the Commissioner shall give the applicant written notice of the refusal setting forth the grounds therefor.
Nev. Rev. Stat. § 695B.135 Certificate of authority: Expiration; renewal.
1. A certificate of authority issued pursuant to this chapter expires on March 1 of the year following its date of issuance or renewal.
2. To renew a certificate of authority a corporation for medical service must:
(a) File a written request for renewal with the Commissioner; and
(b) Pay all applicable fees for renewal for a certificate of authority.
3. The Commissioner may accept a request for renewal received by the Commissioner within 30 days after the expiration of the certificate if the request is accompanied by a fee for renewal of 150 percent of all applicable fees otherwise required, except for any fee required pursuant to NRS 680C.110 .
Nev. Rev. Stat. § 695B.140 Reserve fund: Minimum amounts; computation; contracts with hospitals; participation of physicians or dentists.
1. No corporation subject to the provisions of this chapter may establish, maintain or operate a hospital, medical or dental service plan unless it has and at all times maintains a reserve fund equal to the following minimum amounts in relation to the number of natural persons entitled to hospital, medical or dental services under contracts issued by the corporation:
Amount of
Number of Natural Persons Reserve
Entitled to Benefits Fund
1 to 1,000, inclusive..................................................................................... $100,000
1,001 to 10,000, inclusive............................................................................. 500,000
10,000 or more................................................................................................ 750,000
but such a reserve fund is not required of a corporation acting only as a fiscal administrator of programs funded by public agencies, authorized insurers and other authorized health service plans.
2. In computing the amount of a reserve fund, the Commissioner shall include the amounts agreed to be paid by contracting hospitals to the corporation or its equivalent value of hospital service to be rendered without charge by the contracting hospital to the hospital service corporation.
3. In addition to the reserve fund provided for in this chapter, the Commissioner shall require every corporation subject to this chapter to make, and to maintain in force, such contracts with enough hospitals in the State of Nevada to be adequate, in the opinion of the Commissioner, to provide care for all natural persons entitled to hospital benefits in the State of Nevada under contracts issued by such a corporation.
4. In addition, the Commissioner shall require medical or dental service corporations to give evidence of the participation of a sufficient number of physicians or dentists, in the judgment of the Commissioner, to render the medical or dental services specified under the contract.
Nev. Rev. Stat. § 695B.150 Insolvency; determination of financial condition; actions by Commissioner; review; regulations.
1. A corporation organized under this chapter shall be deemed to be insolvent if:
(a) The corporation fails to meet its obligations as they mature;
(b) The assets of the corporation are less than the sum of its liabilities and the minimum surplus required to be maintained by the corporation under this Code for authority to transact the kinds of insurance transacted; and
(c) The reserve fund of the corporation is less than the amounts set forth in NRS 695B.140 .
2. In addition to the provisions of subsection 1, a corporation organized under this chapter shall be deemed to be insolvent as otherwise expressly provided in this Code.
3. For the purposes of determining insolvency pursuant to subsection 1 or 2 and the financial condition of the corporation, for the purposes of preparation of annual statements, and for all other purposes not otherwise expressly provided for in this chapter, the corporation is subject to all requirements of the laws of the State of Nevada as to assets, liabilities and reserves which are applicable to mutual nonassessable life or health insurers.
4. A corporation organized under this chapter shall be deemed to be impaired if the assets of the corporation are less than the sum of its liabilities and the minimum surplus required to be maintained by the corporation under this Code for authority to transact the kinds of insurance transacted.
5. The Commissioner may adopt regulations to define when a corporation organized under this chapter is considered to be in a hazardous financial condition and to set forth the standards to be considered by the Commissioner in determining whether the continued operation of such a corporation transacting business in this State may be considered to be hazardous to its insureds or creditors or to the general public.
6. If the Commissioner determines after a hearing that any corporation organized under this chapter is in a hazardous financial condition, the Commissioner may, instead of suspending or revoking the certificate of authority of the corporation, limit the certificate of authority as the Commissioner deems reasonably necessary to correct, eliminate or remedy any conduct, condition or ground that is deemed to be a cause of the hazardous financial condition.
7. An order or decision of the Commissioner under this section is subject to review in accordance with NRS 679B.310 to 679B.370 , inclusive, at the request of any party to the proceedings whose interests are substantially affected.
Nev. Rev. Stat. § 695B.160 Annual statement of condition and affairs; annual financial statement; quarterly statement; fees; examination by Commissioner.
1. Every corporation subject to the provisions of this chapter shall annually:
(a) On or before March 1, file in the Office of the Commissioner a statement verified by at least two of the principal officers of the corporation, showing its condition and affairs as of December 31 of the preceding calendar year. The statement must be in the form required by the Commissioner and must contain statements relative to the matters required to be established as a condition precedent to maintaining or operating a nonprofit hospital, medical or dental service plan and to other matters which the Commissioner may prescribe.
(b) Pay all applicable fees for the renewal of a certificate of authority and the fee for the filing of an annual statement.
2. Every corporation subject to the provisions of this chapter shall file a financial statement pursuant to NRS 680A.265 , as required pursuant to paragraph (c) of subsection 1 of NRS 680A.265 .
3. Every corporation subject to the provisions of this chapter shall file with the Commissioner and the National Association of Insurance Commissioners a quarterly statement in the form most recently adopted by the National Association of Insurance Commissioners for that type of insurer. The quarterly statement must be:
(a) Prepared in accordance with the instructions which are applicable to that form, including, without limitation, the required date of submission for the form; and
(b) Filed by electronic means.
4. The Commissioner may examine, as often as the Commissioner deems it desirable, the affairs of every corporation subject to the provisions of this chapter. The Commissioner shall, if practicable, examine each such corporation at least once in every 3 years, and in any event, at least once in every 5 years, as to its condition, fulfillment of its contractual obligations and compliance with applicable laws. The actual expenses of the examination must be paid by the corporation in accordance with the provisions of NRS 679B.290 . The Commissioner shall refuse to issue a certificate of authority or shall revoke a certificate of authority issued to any corporation which neglects or refuses to pay such expenses.
Nev. Rev. Stat. § 695B.165 Annual statement required to include report of net worth.
A corporation which has been issued a certificate of authority pursuant to this chapter shall maintain and report on its statement filed with the Commissioner pursuant to NRS 695B.160 a net worth in an amount which is not less than the greater of:
1. One million five hundred thousand dollars;
2. Two percent of the first $150,000,000 earned as revenue from premiums collected in the preceding 12-month period, plus 1 percent of the amount in excess of $150,000,000 earned as revenue from premiums collected in that same period; or
3. The amount of risk-based capital required by regulations adopted by the Commissioner pursuant to NRS 681B.550 .
Nev. Rev. Stat. § 695B.170 Acquisition costs and administrative expenses; effect of finding of excess costs.
All acquisition costs in connection with the solicitation of subscribers to such hospital, medical or dental service plan shall at all times be subject to the approval of the Commissioner, and the administrative expenses for any calendar year, excluding the first full year of operation, of any such corporation, including acquisition costs, shall be limited to 25 percent of the aggregate amount of rates, dues, fees and other periodic charges actually received during that year. If the Commissioner finds that acquisition costs of any corporation operating under the provisions of this chapter are excessive, or that the administrative expenses exceed the amount above stated, such finding shall be sufficient ground to justify the Commissioner in revoking the consent of the Commissioner to the establishment, maintenance and operation by such corporation of the hospital, medical or dental service plan.
Nev. Rev. Stat. § 695B.176 Contract covering prescription drugs: Provision of notice and information regarding use of formulary.
1. An insurer that offers or issues a contract for hospital or medical services which provides coverage for prescription drugs shall include with any summary, certificate or evidence of that coverage provided to an insured, notice of whether a formulary is used and, if so, of the opportunity to secure information regarding the formulary from the insurer pursuant to subsection 2. The notice required by this subsection must:
(a) Be in a language that is easily understood and in a format that is easy to understand;
(b) Include an explanation of what a formulary is; and
(c) If a formulary is used, include:
(1) An explanation of:
(I) How often the contents of the formulary are reviewed; and
(II) The procedure and criteria for determining which prescription drugs are included in and excluded from the formulary; and
(2) The telephone number of the insurer for making a request for information regarding the formulary pursuant to subsection 2.
2. If an insurer offers or issues a contract for hospital or medical services which provides coverage for prescription drugs and a formulary is used, the insurer shall:
(a) Provide to any insured or participating provider of health care, upon request:
(1) Information regarding whether a specific drug is included in the formulary.
(2) Access to the most current list of prescription drugs in the formulary, organized by major therapeutic category, with an indication of whether any listed drugs are preferred over other listed drugs. If more than one formulary is maintained, the insurer shall notify the requester that a choice of formulary lists is available.
(b) Notify each person who requests information regarding the formulary, that the inclusion of a drug in the formulary does not guarantee that a provider of health care will prescribe that drug for a particular medical condition.
Nev. Rev. Stat. § 695B.180 Required provisions.
A contract for hospital, medical or dental services must not be entered into between a corporation proposing to furnish or provide any one or more of the services authorized under this chapter and a subscriber:
1. Unless the entire consideration therefor is expressed in the contract.
2. Unless the times at which the benefits or services to the subscriber take effect and terminate are stated in a portion of the contract above the evidence of its execution.
3. If the contract purports to entitle more than one person to benefits or services, except for family contracts issued under NRS 695B.190 , group contracts issued under NRS 695B.200 , and blanket contracts issued under NRS 695B.220 .
4. Unless every printed portion and any endorsement or attached papers are plainly printed in type of which the face is not smaller than 10 points.
5. Except for group contracts and blanket contracts issued under NRS 695B.220 , unless the exceptions of the contract are printed with greater prominence than the benefits to which they apply.
6. Except for group contracts and blanket contracts issued under NRS 695B.230 , unless, if any portion of the contract purports, by reason of the circumstances under which an illness, injury or disablement is incurred to reduce any service to less than that provided for the same illness, injury or disablement incurred under ordinary circumstances, that portion is printed in boldface type and with greater prominence than any other text of the contract.
7. If the contract contains any provisions purporting to make any portion of the charter, constitution or bylaws of a nonprofit corporation a part of the contract unless that portion is set forth in full in the contract.
8. Unless the contract provides benefits for expenses incurred for hospice care.
9. Unless the contract for service in a hospital contains in blackface type, not less than 10 points, the following provisions:
This contract does not restrict or interfere with the right of any person entitled to service and care in a hospital to select the contracting hospital or to make a free choice of an attending physician, who must be the holder of a valid and unrevoked physicians license and a member of, or acceptable to, the attending staff and board of directors of the hospital in which the services are to be provided.
Nev. Rev. Stat. § 695B.181 Provision in contract requiring binding arbitration authorized; procedures for arbitration; declaratory relief.
1. Except as otherwise provided in NRS 695B.182 and subject to the approval of the Commissioner, any contract which is authorized pursuant to this chapter may include a provision which requires the parties to the contract to submit for binding arbitration any dispute between the parties concerning any matter directly or indirectly related to, or associated with, the contract. If such a provision is included in the contract:
(a) A person who elects to be covered by the contract must be given the opportunity to decline to participate in binding arbitration at the time the person elects to be covered by the contract.
(b) It must clearly state that the parties to the contract who have not declined to participate in binding arbitration agree to forego their right to resolve any such dispute in a court of law or equity.
2. Except as otherwise provided in subsection 3, the arbitration must be conducted pursuant to the rules for commercial arbitration established by the American Arbitration Association. The insurer is responsible for any administrative fees and expenses relating to the arbitration, except that the insurer is not responsible for attorneys fees and fees for expert witnesses unless those fees are awarded by the arbitrator.
3. If a dispute required to be submitted to binding arbitration requires an immediate resolution to protect the physical health of a person insured under the contract, any party to the dispute may waive arbitration and seek declaratory relief in a court of competent jurisdiction.
4. If a provision described in subsection 1 is included in a contract, the provision shall not be deemed unenforceable as an unreasonable contract of adhesion if the provision is included in compliance with the provisions of subsection 1.
Nev. Rev. Stat. § 695B.182 Required procedure for arbitration of disputes concerning independent medical, dental or chiropractic evaluations.
1. Each contract for hospital or medical services must include a procedure for binding arbitration to resolve disputes concerning independent medical evaluations pursuant to the rules of the American Arbitration Association.
2. If a corporation subject to the provisions of this chapter, for any final determination of benefits or care, requires an independent evaluation of the medical, dental or chiropractic care of any person for whom such care is covered under a contract for hospital or medical services, only a physician, dentist or chiropractic physician who is certified to practice in the same field of practice as the primary treating physician, dentist or chiropractic physician or who is formally educated in that field may conduct the independent evaluation.
3. The independent evaluation must include a physical examination of the patient, unless the patient is deceased, and a personal review of all X-rays and reports prepared by the primary treating physician, dentist or chiropractic physician. A certified copy of all reports of findings must be sent to the primary treating physician, dentist or chiropractic physician and the insured person within 10 working days after the evaluation. If the insured person disagrees with the finding of the evaluation, the insured person must submit an appeal to the insurer pursuant to the procedure for binding arbitration set forth in the contract for services within 30 days after the insured person receives the finding of the evaluation. Upon its receipt of an appeal, the insurer shall so notify in writing the primary treating physician, dentist or chiropractic physician.
4. The insurer shall not limit or deny coverage for care related to a disputed claim while the dispute is in arbitration, except that, if the insurer prevails in the arbitration, the primary treating physician, dentist or chiropractic physician may not recover any payment from either the insurer, insured person or the patient for services that the primary treating physician, dentist or chiropractic physician provided to the patient after receiving written notice from the insurer pursuant to subsection 3 concerning the appeal of the insured person.
Nev. Rev. Stat. § 695B.183 Insurer required to offer and issue plan regardless of health status of persons; prohibited acts; authority to include wellness program in plan that offers discounts based on health status under certain circumstances.
1. An insurer shall offer and issue a health benefit plan to any person regardless of the health status of the person or any dependent of the person. Such health status includes, without limitation:
(a) Any preexisting medical condition of the person, including, without limitation, any physical or mental illness;
(b) The claims history of the person, including, without limitation, any prior health care services received by the person;
(c) Genetic information relating to the person; and
(d) Any increased risk for illness, injury or any other medical condition of the person, including, without limitation, any medical condition caused by an act of domestic violence.
2. An insurer that offers or issues a health benefit plan shall not:
(a) Deny, limit or exclude a covered benefit based on the health status of an insured; or
(b) Require an insured, as a condition of enrollment or renewal, to pay a premium, deductible, copay or coinsurance based on his or her health status which is greater than the premium, deductible, copay or coinsurance charged to a similarly situated insured who does not have such a health status.
3. An insurer that offers or issues a health benefit plan shall not adjust a premium, deductible, copay or coinsurance for any insured on the basis of genetic information relating to the insured or the covered dependent of the insured.
4. An insurer that offers or issues a health benefit plan may include in the plan a wellness program that reduces a premium, deductible or copayment based on health status if:
(a) An insured who is eligible to participate in the wellness program is given the opportunity to qualify for the discount at least once each year;
(b) The amount of all discounts provided pursuant to such a wellness program does not exceed 30 percent, or if the program is designed to prevent or reduce tobacco use, 50 percent, of the cost of coverage for an insured or an insured and his or her dependents, as applicable, under the plan;
(c) The wellness program is reasonably designed to promote health or prevent disease;
(d) The insurer ensures that the full discount under the wellness program is available to all similarly situated insureds by providing a reasonable alternative standard by which an insured may qualify for the discount which, if based on health status, must accommodate the recommendations of the physician of the insured; and
(e) The plan discloses in all plan materials describing the terms of the wellness program, and in any disclosure that an insured did not satisfy the initial standard to be eligible for the discount, the availability of a reasonable alternative standard described in paragraph (d).
5. As used in this section, health benefit plan has the meaning ascribed to it in NRS 687B.470 .
Nev. Rev. Stat. § 695B.185 Group contract which offers difference of payment between preferred providers of health care and providers who are not preferred: Limitations on deductibles and copayments; circumstances in which service is deemed to be provided by preferred provider; processing of claims of providers who are not preferred.
A group contract for hospital, medical or dental services which offers a difference of payment between preferred providers of health care and providers of health care who are not preferred:
1. May not require a deductible of more than $600 difference per admission to a facility for inpatient treatment which is not a preferred provider of health care.
2. May not require a deductible of more than $500 difference per treatment, other than inpatient treatment at a hospital, by a provider which is not preferred.
3. May not require an insured, another insurer who issues policies of group health insurance, a nonprofit medical service corporation or a health maintenance organization to pay any amount in excess of the deductible or coinsurance due from the insured based on the rates agreed upon with a provider.
4. May not provide for a difference in percentage rates of payment for coinsurance of more than 30 percentage points between the copayment required to be paid by the insured to a preferred provider of health care and the copayment required to be paid by the insured to a provider of health care who is not preferred.
5. Must require that the deductible and payment for coinsurance paid by the insured to a preferred provider of health care be applied to the negotiated reduced rates of that provider.
6. Must provide that if there is a particular service which a preferred provider of health care does not provide and the provider of health care who is treating the insured determines that the use of the service is necessary for the health of the insured, the service shall be deemed to be provided by the preferred provider of health care.
7. Must require the corporation to process a claim of a provider of health care who is not preferred not later than 30 working days after the date on which proof of the claim is received.
Nev. Rev. Stat. § 695B.187 Group contract issued to replace discontinued policy or coverage: Requirements; notice of reduction of benefits; statement of benefits; applicability to self-insured employer.
Except as otherwise provided by the provisions of NRS 689B.340 to 689B.580, inclusive, and chapter 689C of NRS relating to the portability and availability of health insurance:
1. A group contract for hospital, medical or dental services issued by a nonprofit hospital, medical or dental service corporation to replace any discontinued policy or coverage for group health insurance must:
(a) Provide coverage for all persons who were covered under the previous policy or coverage on the date it was discontinued; and
(b) Except as otherwise provided in subsection 2, provide benefits which are at least as extensive as the benefits provided by the previous policy or coverage, except that the benefits may be reduced or excluded to the extent that such a reduction or exclusion was permissible under the terms of the previous policy or coverage,
Ê if that contract is issued within 60 days after the date on which the previous policy or coverage was discontinued.
2. If an employer obtains a replacement contract pursuant to subsection 1 to cover the employees of the employer, any benefits provided by the previous policy or coverage may be reduced if notice of the reduction is given to the employees of the employer pursuant to NRS 608.1577 .
3. Any corporation which issues a replacement contract pursuant to subsection 1 may submit a written request to the insurer which provided the previous policy or coverage for a statement of benefits which were provided under that policy or coverage. Upon receiving such a request, the insurer shall give a written statement to the corporation which indicates what benefits were provided and what exclusions or reductions were in effect under the previous policy or coverage.
4. The provisions of this section apply to a self-insured employer who provides health benefits to the employees of the self-insured employer and replaces those benefits with a group contract for hospital, medical or dental services issued by a nonprofit hospital, medical or dental service corporation.
Nev. Rev. Stat. § 695B.189 Group contract: Required provision permitting continuation of coverage.
A group contract issued by a corporation under the provisions of this chapter must contain a provision which permits the continuation of coverage pursuant to the provisions of NRS 689B.340 to 689B.580, inclusive, and chapter 689C of NRS relating to the portability and availability of health insurance.
Nev. Rev. Stat. § 695B.190 Family contracts.
Family hospital or family medical or dental service contracts may be issued to a family consisting of an individual and one or more persons dependent upon the individual, or of one or more persons dependent upon an individual, and may include a spouse of the individual, whether or not dependent upon the individual. Such contracts shall contain a provision to the effect that to the family originally covered may be added from time to time all new members of the family group eligible for coverage and that the head of the family shall give the corporation notice of the addition to the family of any person eligible for coverage under the contracts.
Nev. Rev. Stat. § 695B.191 Required provision in policy covering mastectomies concerning coverage relating to mastectomy; prohibited acts.
1. A policy of health insurance, issued by a medical service corporation, which provides coverage for the surgical procedure known as a mastectomy must also provide commensurate coverage for:
(a) Reconstruction of the breast on which the mastectomy has been performed;
(b) Surgery and reconstruction of the other breast to produce a symmetrical structure; and
(c) Prostheses and physical complications for all stages of mastectomy, including lymphedemas.
2. The provision of services must be determined by the attending physician and the patient.
3. The plan or issuer may require deductibles and coinsurance payments if they are consistent with those established for other benefits.
4. Written notice of the availability of the coverage must be given upon enrollment and annually thereafter. The notice must be sent to all participants:
(a) In the next mailing made by the plan or issuer to the participant or beneficiary; or
(b) As part of any annual information packet sent to the participant or beneficiary,
Ê whichever is earlier.
5. A plan or issuer may not:
(a) Deny eligibility, or continued eligibility, to enroll or renew coverage, in order to avoid the requirements of subsections 1 to 4, inclusive; or
(b) Penalize, or limit reimbursement to, a provider of care, or provide incentives to a provider of care, in order to induce the provider not to provide the care listed in subsections 1 to 4, inclusive.
6. A plan or issuer may negotiate rates of reimbursement with providers of care.
7. If reconstructive surgery is begun within 3 years after a mastectomy, the amount of the benefits for that surgery must equal those amounts provided for in the policy at the time of the mastectomy. If the surgery is begun more than 3 years after the mastectomy, the benefits provided are subject to all of the terms, conditions and exclusions contained in the policy at the time of the reconstructive surgery.
8. A policy subject to the provisions of this chapter which is delivered, issued for delivery or renewed on or after October 1, 2001, has the legal effect of including the coverage required by this section, and any provision of the policy or the renewal which is in conflict with this section is void.
9. For the purposes of this section, reconstructive surgery means a surgical procedure performed following a mastectomy on one breast or both breasts to re-establish symmetry between the two breasts. The term includes augmentation mammoplasty, reduction mammoplasty and mastopexy.
Nev. Rev. Stat. § 695B.192 Contract containing exclusion, reduction or limitation of coverage relating to complications of pregnancy prohibited; exception.
1. No hospital, medical or dental service contract issued by a corporation pursuant to the provisions of this chapter may contain any exclusion, reduction or other limitation of coverage relating to complications of pregnancy, unless the provision applies generally to all benefits payable under the contract and complies with the provisions of NRS 689B.340 to 689B.580 , inclusive, and chapter 689C of NRS relating to the portability and availability of health insurance.
2. As used in this section, the term complications of pregnancy includes any condition which requires hospital confinement for medical treatment and:
(a) If the pregnancy is not terminated, is caused by an injury or sickness not directly related to the pregnancy or by acute nephritis, nephrosis, cardiac decompensation, missed abortion or similar medically diagnosed conditions; or
(b) If the pregnancy is terminated, results in nonelective cesarean section, ectopic pregnancy or spontaneous termination.
3. A contract subject to the provisions of this chapter which is issued or delivered on or after July 1, 1977, has the legal effect of including the coverage required by this section, and any provision of the contract which is in conflict with this section is void.
Nev. Rev. Stat. § 695B.193 Contract covering family member of subscriber required to include certain coverage for subscribers newly born and adopted children and children placed with subscriber for adoption.
1. All individual and group service or indemnity-type contracts issued by a nonprofit corporation which provide coverage for a family member of the subscriber must as to such coverage provide that the health benefits applicable for children are payable with respect to:
(a) A newly born child of the subscriber from the moment of birth;
(b) An adopted child from the date the adoption becomes effective, if the child was not placed in the home before adoption; and
(c) A child placed with the subscriber for the purpose of adoption from the moment of placement as certified by the public or private agency making the placement. The coverage of such a child ceases if the adoption proceedings are terminated as certified by the public or private agency making the placement.
Ê The contracts must provide the coverage specified in subsection 3, and must not exclude premature births.
2. The contract may require that notification of:
(a) The birth of a newly born child;
(b) The effective date of adoption of a child; or
(c) The date of placement of a child for adoption,
Ê and payments of the required fees, if any, must be furnished to the nonprofit service corporation within 31 days after the date of birth, adoption or placement for adoption in order to have the coverage continue beyond the 31-day period.
3. The coverage for newly born and adopted children and children placed for adoption consists of coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities and, within the limits of the policy, necessary transportation costs from place of birth to the nearest specialized treatment center under major medical policies, and with respect to basic policies to the extent such costs are charged by the treatment center.
4. For covered services provided to the child, the corporation shall reimburse noncontracted providers of health care to an amount equal to the average amount of payment for which the organization has agreements, contracts or arrangements for those covered services.
Nev. Rev. Stat. § 695B.196 Reimbursement for acupuncture.
If any contract for hospital or medical services provides coverage for acupuncture performed by a physician, the insured or a person who is licensed pursuant to chapter 634A of NRS and performs acupuncture on the insured, as applicable, is entitled to reimbursement for the acupuncture performed.
Nev. Rev. Stat. § 695B.197 Reimbursement for treatment by licensed psychologist.
If any contract for hospital or medical service provides coverage for treatment which is within the authorized scope of the practice of a qualified psychologist, the insured or a licensed psychologist who provides such treatment to the insured, as applicable, is entitled to reimbursement for the treatment provided.
Nev. Rev. Stat. § 695B.198 Reimbursement for treatment by chiropractic physician.
1. If any contract for hospital or medical service provides coverage for treatment which is within the authorized scope of practice of a qualified chiropractic physician, the insured or a chiropractic physician who is licensed pursuant to chapter 634 of NRS and who provides such treatment to the insured, as applicable, is entitled to reimbursement for the treatment provided.
2. The terms of the policy must not limit:
(a) Coverage for treatments by a chiropractic physician to a number less than for treatments by other physicians.
(b) Reimbursement for treatments by a chiropractic physician to an amount less than that charged for similar treatments by other physicians.
Nev. Rev. Stat. § 695B.199 Reimbursement for services provided by certain nurses.
1. If any contract for medical service provides coverage for services which are within the authorized scope of practice of a registered nurse who is authorized pursuant to chapter 632 of NRS to perform additional acts in an emergency or under other special conditions as prescribed by the State Board of Nursing, and which are reimbursed when provided by another provider of health care, the insured or a registered nurse who provides such services to the insured, as applicable, is entitled to reimbursement for the services provided.
2. The terms of the contract must not limit:
(a) Coverage for services provided by such a registered nurse to a number of occasions less than for services provided by another provider of health care.
(b) Reimbursement for services provided by such a registered nurse to an amount less than that reimbursed for similar services provided by another provider of health care.
3. An insurer is not required to pay for services provided by such a registered nurse which duplicate services provided by another provider of health care.
Nev. Rev. Stat. § 695B.200 Group contracts written under master contract: Conditions required for issuance.
Group hospital or group medical or dental service contracts written under a master hospital or medical or dental service contract may be issued to cover groups of two or more persons, formed for a purpose other than of obtaining insurance.
Nev. Rev. Stat. § 695B.210 Group master service contract: Required provisions.
Every group master hospital or group medical or dental service contract issued shall contain the following provisions:
1. A provision that the contract, the application of the employer, or executive officer or trustee of any association or trustees, and the individual applications, if any, of the employees or members covered shall constitute the entire contract between the parties, and that all statements made by the employer, or the executive officer, or trustee or trustees, or by the individual employee or member shall, in the absence of fraud, be deemed representations and not warranties, and that no such statement shall be used in defense to a claim under the contract, unless it is contained in a written application.
2. A provision that the corporation will issue to the employer or to the executive officer or trustee of the association or to the trustees, for delivery to each of the employees or members who are covered under such contract, an individual certificate setting forth a statement as to the hospital or medical or dental service to which he or she is entitled.
3. A provision that to the group or class thereof originally covered shall be added from time to time all new employees of the employer or members of the association eligible to and applying for coverage in such group or class.
4. A statement that such contract is not in lieu of workers compensation insurance.
5. Such provisions as may be promulgated by the Commissioner from time to time.
Nev. Rev. Stat. § 695B.220 Blanket service contracts: Issuance to college, school or school personnel; pupils not to be compelled to accept service.
Blanket hospital or blanket medical or dental service contracts may be issued to a college or school or to the head or principal thereof or to the governing board of any school district providing for services to pupils of such schools when such services are required as the result of accident or motor vehicle crash to such pupils while they are required to be in or on buildings or other premises of the school or district during the time they are required to be therein or thereon by reason of their attendance upon a college or regular day school or any regular day school of a school district or while being transported to and from school or other place of instruction. No pupil shall be compelled to accept such service without the consent of a parent or guardian of the pupil.
Nev. Rev. Stat. § 695B.225 Policies of group insurance: Order of benefits.
A policy of group insurance determines its order of benefits using the first of the following which applies:
1. A policy that does not coordinate with other policies is always the primary policy.
2. The benefits of the policy which covers a person as an employee, member or subscriber, other than a dependent, is the primary policy. The policy which covers the person as a dependent is the secondary policy.
3. When more than one policy covers the same child as a dependent of different parents who are not divorced or separated, the primary policy is the policy of the parent whose birthday falls earlier in the year. The secondary policy is the policy of the parent whose birthday falls later in the year. If both parents have the same birthday, the benefits of the policy which covered the parent the longer is the primary policy. The policy which covered the parent the shorter time is the secondary policy.
4. If more than one policy covers a person as a dependent child of divorced or separated parents, benefits for the child are determined in the following order:
(a) First, the policy of the parent with custody of the child;
(b) Second, the policy of the spouse of the parent with custody; and
(c) Third, the policy of the parent without custody of the child,
Ê unless the specific terms of a court decree state that one parent is responsible for the health care expenses of the child, in which case, the policy of that parent is the primary policy. A parent responsible for the health care pursuant to a court decree shall notify the insurer of the terms of the decree.
5. The primary policy is the policy which covers a person as an employee who is neither laid off nor retired, or that employees dependent. The secondary policy is the policy which covers that person as a laid off or retired employee, or that employees dependent.
6. If none of the rules in subsections 1 to 5, inclusive, determines the order of benefits, the primary policy is the policy which covered an employee, member or subscriber longer. The secondary policy is the policy which covered that person the shorter time.
Ê When a policy is determined to be a secondary policy it acts to provide benefits in excess of those provided by the primary policy. The secondary policy may not reduce benefits based upon payments by the primary policy, except that this provision does not require duplication of benefits.
Nev. Rev. Stat. § 695B.230 Filing and approval of forms and schedules of premium rates.
If more than one class of risk is included:
1. A hospital or medical or dental service contract or evidence of coverage under a group or nongroup contract must not be issued or delivered in this state until a copy of the form of the contract is filed with the Commissioner and either:
(a) Thirty days expires without notice from the Commissioner after the copy is filed; or
(b) The Commissioner gives written approval before that time.
2. A schedule of premium rates to be paid by subscribers under either a group or nongroup contract must not be issued, delivered or used by any nonprofit hospital, medical or dental service corporation until that corporation files with the Commissioner a copy of the schedule together with any supplementary information required by the Commissioner and either:
(a) Thirty days expires without notice from the Commissioner after the copy is filed; or
(b) The Commissioner gives written approval before that time.
Nev. Rev. Stat. § 695B.240 Provision of group service coverage before approval of forms.
1. A corporation subject to the provisions of this chapter is permitted to provide group hospital or group medical or dental service coverage prior to the approval of the form of the contract or certificate if all the conditions of subsection 2 of this section are met prior thereto and if thereafter it acts as required by subsection 3.
2. The conditions referred to in subsection 1 are that:
(a) The group is one eligible for coverage pursuant to the provisions of this chapter.
(b) An executed memorandum has been or is concurrently delivered to the subscriber containing a provision that unless a group hospital or group medical or dental service certificate, the form of which has been approved by the Commissioner, which is issued under a group hospital or group medical or dental service contract the form of which has been approved by the Commissioner, and which embodies the coverage, has been issued and delivered to the subscriber within 90 days after the date on which the coverage is provided or agreed to be provided, the coverage provided pursuant to such memorandum terminates 120 days after such date. The memorandum shall contain a specification in either complete or summary form of:
(1) The class or classes of employees eligible for coverage.
(2) The benefits to be provided.
(3) The exceptions and reductions to such benefits, if any.
3. A corporation subject to the provisions of this chapter providing coverage pursuant to this section shall:
(a) Within 60 days after the date on which the coverage is provided or agreed to be provided, submit to the Commissioner for approval a form of a group hospital or group medical or dental service contract, and a form of a certificate of individual coverage, drafted to provide the coverage provided by such memorandum and to meet all requirements of law.
(b) Make such revisions in the contract and certificate submitted as the Commissioner may lawfully require.
(c) Terminate such coverage in accordance with the provisions of paragraph (b) of subsection 2 of this section if approval of such contract and certificate is not secured within the time specified therein.
Nev. Rev. Stat. § 695B.250 Extensions of time; automatic approval.
1. Upon written request from the corporation subject to the provisions of this chapter filed within 50 days after the date on which the coverage is provided or agreed to be provided and upon proof satisfactory to the Commissioner that the corporation is acting with due diligence and that hardship will result unless an extension is granted, the Commissioner may extend the time set forth in paragraph (a) of subsection 3 of NRS 695B.240 for a period of not to exceed 30 days. Upon such extension, the corporation with the consent of the subscriber may amend the memorandum referred to in paragraph (b) of subsection 2 of NRS 695B.240 to extend the time within which the certificate must be issued and delivered to the subscriber to 30 days after the date to which the Commissioner has extended the time within which a form of contract and certificate must be submitted to the Commissioner for approval and to extend the date for termination of coverage to 30 days thereafter.
2. A contract and certificate submitted to the Commissioner with a letter from the corporation stating that coverage has been provided in accordance with this section shall be automatically approved unless the Commissioner disapproves the same within 30 days of the date of its submission to the Commissioner.
Nev. Rev. Stat. § 695B.251 Group subscriber contracts required to contain provision for conversion to individual contracts; exceptions.
1. Except as otherwise provided in the provisions of this section, NRS 689B.340 to 689B.580 , inclusive, and chapter 689C of NRS relating to the portability and availability of health insurance, all group subscriber contracts delivered or issued for delivery in this state providing for hospital, surgical or major medical coverage, or any combination of these coverages, on a service basis or an expense-incurred basis, or both, must contain a provision that the employee or member is entitled to have issued to him or her a subscriber contract of health coverage when the employee or member is no longer covered by the group subscriber contract.
2. The requirement in subsection 1 does not apply to contracts providing benefits only for specific diseases or accidental injuries.
3. If an employee or member was a recipient of benefits under the coverage provided pursuant to NRS 695B.1944 , the employee or member is not entitled to have issued to him or her by a replacement insurer a subscriber contract of health coverage unless the employee or member has reported for his or her normal employment for a period of 90 consecutive days after last being eligible to receive any benefits under the coverage provided pursuant to NRS 695B.1944 .
Nev. Rev. Stat. § 695B.252 Conversion privilege available to spouse and children; conditions.
Subject to the conditions set forth in NRS 695B.251 to 695B.259, inclusive, the conversion privilege must also be made available:
1. To the surviving spouse, if any, upon the death of the employee or member, with respect to the spouse and any child whose coverage under the group contract is terminated by reason of such death, or if there is no surviving spouse, to each surviving child whose coverage under the group contract terminates by reason of such death, or, if the group contract provides for continuation of dependents coverage following the employees or members death, at the end of the continued coverage;
2. To the spouse of the employee or member upon termination of coverage of the spouse while the employee or member remains covered under the group contract, if the spouse ceases to be a dependent as defined by the group contract, and to any child whose coverage under the group contract terminates at the same time; or
3. To a child solely with respect to himself or herself upon termination of his or her coverage because the child ceases to be a dependent as defined by the group contract, if a conversion privilege is not otherwise provided with respect to the termination.
Nev. Rev. Stat. § 695B.253 Denial of converted contract because of overinsurance; notice concerning cancellation of other coverage.
1. The medical service corporation is not required to issue a converted contract to any person who:
(a) Is covered for similar benefits by another hospital, surgical, medical or major medical expense insurance policy, a hospital or medical service subscriber contract, a medical practice or other prepayment plan, or by any other kind of plan or program;
(b) Is eligible to be covered for similar benefits under any arrangement of coverage for individuals in a group, whether on an insured or uninsured basis; or
(c) Has similar benefits provided for or available under the requirements of any state or federal law,
Ê if any benefits provided under the sources listed in this subsection, together with the benefits to be provided by the converted contract, would result in overinsurance according to the medical service corporations standards.
2. Before denying a converted contract to an applicant because the applicant has coverage as described in paragraph (a) of subsection 1, the medical service corporation shall notify the applicant that the converted contract will be issued only if the other coverage is cancelled.
Nev. Rev. Stat. § 695B.254 Choice of types of contracts required to be offered.
1. A person who is entitled to a converted contract must be given a choice of at least three types of contracts offering benefits on a service basis or an expense-incurred basis, or both.
2. The converted contract may include major medical or catastrophic benefits if they were provided under the group contract.
3. For those subscribers eligible for Medicare, the medical service corporation may provide for a supplement to Medicare as part of the conversion privilege.
Nev. Rev. Stat. § 695B.255 Benefits exceeding those provided under group contract not required; exclusions and limitations.
A medical service corporation is not required to issue a converted contract which provides benefits in excess of those provided under the group contract from which conversion is made, and a converted contract may contain any exclusion or benefit limitation contained in the group contract.
Nev. Rev. Stat. § 695B.256 Issuance and effective date of converted contract; premiums; persons covered.
The medical service corporation shall:
1. Issue the converted contract without evidence of insurability;
2. Base the premium on the converted policies for the first 12 months, and subsequent renewals, upon the medical service corporations table of premium rates applicable to the age and class of risk of each person to be covered under the contract and to the type and amount of coverage provided. The frequency of premium payments must be the same as is customarily required by the medical service corporation for the contract form and plan selected except that premium payments must not be required more often than quarterly;
3. Provide that the effective date of the converted contract is 12:01 a.m. on the day after the termination of coverage under the group contract; and
4. Provide that the converted contract covers the employee or member and dependents of the employee or member who were covered by the group contract on the date of his or her termination. At the option of the insurer, a separate converted contract may be issued to cover any dependent.
Nev. Rev. Stat. § 695B.257 Notice of conversion privilege.
A notification of the conversion privilege must be included in each certificate of coverage. A written notice of the existence of the conversion privilege must also be given to the employee or member at least 15 days before the expiration of the 31 days permitted a person to make a written application for the converted contract. If written notice of the right to convert is not given as required under this section, an additional period must be allowed the person to apply for the converted contract. The additional period expires 15 days after written notice of the conversion privilege has been given, or 60 days after the expiration of the 31-day period, whichever is earlier.
Nev. Rev. Stat. § 695B.258 Extension of coverage under existing group contract.
The medical service corporation may elect to extend coverage of a subscriber under the existing group contract for a period not to exceed 6 months following the day of the persons eligibility for a converted contract if the conversion privilege is offered upon termination of the extended coverage under the group contract.
Nev. Rev. Stat. § 695B.259 Continuation of identical coverage in lieu of converted contract.
The medical service corporation may continue coverage identical to that provided under the group contract instead of issuing a converted contract. Coverage may be offered by amending the group certificate or by issuing an individual contract and must otherwise comply with every requirement of NRS 695B.251 to 695B.259, inclusive.
Nev. Rev. Stat. § 695B.260 Suspension or revocation of permission to provide coverage before approval of forms.
The Commissioner may suspend or revoke the permission granted by NRS 695B.240 if, after notice and hearing, the Commissioner finds that the corporation has:
1. Misrepresented the conditional nature of the coverage.
2. Neglected or refused either to cancel or otherwise terminate such coverage within the time required by such section.
3. Delivered any such memorandum which did not comply with such section.
4. Shown a lack of diligence in making revisions in the contract or certificate necessary to obtain its approval by the Commissioner.
5. Failed so often in so many important respects in drafting any such contract or certificate to conform to the applicable requirements of the insurance laws that a conclusion of lack of good faith or competency in drafting is reasonably justified.
6. Circulated announcements of coverage to individual subscribers which failed to advise them of the conditional nature of the coverage.
7. In any other manner so negligently or carelessly handled the effecting of group hospital or group medical or dental service coverage under NRS 695B.240 or the administration thereof that the subscriber or the persons covered by the contract or certificate have been misled or exposed to the danger of loss.
Nev. Rev. Stat. § 695B.270 Disapproval of forms; issuance unlawful.
If the Commissioner notifies the corporation, in writing, that the filed form does not comply with the requirements of law, specifying the reasons for his or her opinion, it is unlawful for the corporation thereafter to issue any contract in such form.
Nev. Rev. Stat. § 695B.280 Regulations; limitations.
The Commissioner may adopt such reasonable regulations, not inconsistent with the provisions of this chapter, relating to the substance, form and issuance of any contract covering the furnishing of hospital or medical or dental services and required to be approved by the Commissioner as are necessary or desirable. The regulations may not prohibit the use in any such contract or agreement of:
1. The word subscriber as a designation of the obligee.
2. The phrase a family member as a designation for the members of the family of the obligee.
3. The word contract or agreement as a designation for the undertakings of the hospital or medical or dental service corporation.
4. The phrases furnishing of service or payment of benefits as a designation for the commitments of the hospital or medical or dental service corporation.
5. The phrase the service as a designation for the corporate obligor in any such contract or agreement.
Nev. Rev. Stat. § 695B.285 Use of Uniform Billing and Claims Forms authorized.
Every nonprofit hospital or medical or dental service corporation may utilize the Uniform Billing and Claims Forms established by the American Hospital Association.
Nev. Rev. Stat. § 695B.290 Agents license required.
Any agent of a nonprofit hospital or medical or dental service corporation who acts as such in the solicitation, negotiation, procurement or making of a hospital service or medical or dental care contract shall be qualified, examined and licensed in the same manner and pay the same fees as provided for a producer of insurance in NRS 680B.010 (fee schedule), chapter 683A of NRS and, in addition to any other fee or charge, all applicable fees required pursuant to NRS 680C.110.
Nev. Rev. Stat. § 695B.300 Contracts with agencies or political subdivisions of United States or State of Nevada; acceptance of money; subcontracts.
Any nonprofit hospital or medical or dental service corporation organized and created under the provisions of this chapter and engaged in the operation of a hospital or medical or dental service plan may contract, without regard to the limitations in respect to contracts imposed by this chapter, with any agency, instrumentality or political subdivision of the United States of America or of the State of Nevada for the furnishing of hospital or medical or dental service and care and, in aid or furtherance of such contract, may accept, receive and administer, in trust, funds directly or indirectly made available by such agency, instrumentality or political subdivision. Any such nonprofit hospital or medical or dental service corporation may subcontract with any organization which has contracted with any agency, instrumentality or political subdivision of the United States of America or of the State of Nevada for the furnishing of medical, dental and hospital services, by which subcontract such hospital or medical or dental service corporation undertakes to furnish the hospital or medical or dental services required by the basic contract.
Nev. Rev. Stat. § 695B.310 Corporation subject to same taxes, licenses, fees and supervision as domestic mutual insurer.
Any nonprofit hospital or medical or dental service corporation subject to the provisions of this chapter shall be subject to the same taxes, licenses, fees and, to the extent not regulated by the provisions of this chapter, the same supervision as a mutual insurer organized under the laws of the State of Nevada.
Nev. Rev. Stat. § 695B.315 Provision of information regarding claims by policyholder for renewal of insurance policy required upon request; fee; regulations.
1. If a policyholder requests information for the renewal of the policy of the policyholder, an insurer shall provide to the policyholder information regarding claims paid on behalf of the policyholder. The information must be provided within 30 working days after the insurer receives a written request from the policyholder. The insurer may charge the policyholder a reasonable fee for the information.
2. The Commissioner may adopt regulations to carry out the provisions of subsection 1.
Nev. Rev. Stat. § 695B.316 Corporation prohibited from denying coverage solely because claim involves act that constitutes domestic violence or applicant or insured was victim of domestic violence.
A corporation shall not deny a claim, refuse to issue a contract for hospital, medical or dental services or cancel a contract for hospital, medical or dental services solely because the claim involves an act that constitutes domestic violence pursuant to NRS 33.018, or because the person applying for or covered by the contract was the victim of such an act of domestic violence, regardless of whether the insured or applicant contributed to any loss or injury.
Nev. Rev. Stat. § 695B.317 Corporation that provides health insurance prohibited from requiring or using information concerning genetic testing; exceptions.
1. Except as otherwise provided in subsection 2, a corporation that provides health insurance shall not:
(a) Require an insured person or any member of the family of the insured person to take a genetic test;
(b) Require an insured person to disclose whether the insured person or any member of the family of the insured person has taken a genetic test or any genetic information of the insured person or a member of the family of the insured person; or
(c) Determine the rates or any other aspect of the coverage or benefits for health care provided to an insured person based on whether the insured person or any member of the family of the insured person has taken a genetic test.
2. The provisions of this section do not apply to a corporation that issues a policy of health insurance that provides coverage for long-term care or disability income.
3. As used in this section:
(a) Genetic information means any information that is obtained from a genetic test.
(b) Genetic test means a test, including a laboratory test that uses deoxyribonucleic acid extracted from the cells of a person or a diagnostic test, to determine the presence of abnormalities or deficiencies, including carrier status, that:
(1) Are linked to physical or mental disorders or impairments; or
(2) Indicate a susceptibility to illness, disease, impairment or any other disorder, whether physical or mental.
Nev. Rev. Stat. § 695B.318 Applicability of certain provisions concerning portability and availability of health insurance.
1. Nonprofit hospital, medical or dental service corporations are subject to the provisions of NRS 689B.340 to 689B.580 , 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.580 , inclusive, and chapter 689C of NRS, the provisions of NRS 689B.340 to 689B.580 , inclusive, and chapter 689C of NRS control.
2. For the purposes of subsection 1, unless the context requires that a provision apply only to a group health plan or a carrier that provides coverage under a group health plan, any reference in those sections to:
(a) Carrier must be replaced by corporation.
(b) Group health plan must be replaced by group contract for hospital, medical or dental services.
Nev. Rev. Stat. § 695B.319 Offering policy of health insurance for purposes of establishing health savings account.
A corporation may, subject to regulation by the Commissioner, offer a policy of health insurance that has a high deductible and is in compliance with 26 U.S.C. § 223 for the purposes of establishing a health savings account.
Nev. Rev. Stat. § 695B.320 Applicability of other provisions.
1. Nonprofit hospital and medical or dental service corporations are subject to the provisions of this chapter, and to the provisions of chapters 679A and 679B of NRS, subsections 2, 4, 17, 18 and 30 of NRS 680B.010 , NRS 680B.025 to 680B.060 , inclusive, chapter 681B of NRS, NRS 686A.010 to 686A.315 , inclusive, 686B.010 to 686B.175 , inclusive, 687B.010 to 687B.040 , inclusive, 687B.070 to 687B.140 , inclusive, 687B.150 , 687B.160 , 687B.180 , 687B.200 to 687B.255 , inclusive, 687B.270 , 687B.310 to 687B.380 , inclusive, 687B.410 , 687B.420 , 687B.430 , 687B.500 , 687B.900 to 687B.990 , inclusive, and chapters 692B , 692C , 693A and 696B of NRS, to the extent applicable and not in conflict with the express provisions of this chapter.
2. For the purposes of this section and the provisions set forth in subsection 1, a nonprofit hospital and medical or dental service corporation is included in the meaning of the term insurer.
Nev. Rev. Stat. § 695B.330 Definitions.
As used in NRS 695B.330 to 695B.370, inclusive, unless the context otherwise requires:
1. Contract means a contract for hospital, medical or dental services issued pursuant to this chapter.
2. Corporation means a corporation organized pursuant to this chapter.
3. Medicaid means a program established in any state pursuant to Title XIX of the Social Security Act (42 U.S.C. §§ 1396 et seq.) to provide assistance for part or all of the cost of medical care rendered on behalf of indigent persons.
4. Order for medical coverage means an order of a court or administrative tribunal to provide coverage under a contract to a child pursuant to the provisions of 42 U.S.C. § 1396g-1.
Nev. Rev. Stat. § 695B.340 Effect of eligibility for medical assistance under Medicaid; assignment of rights to state agency.
1. A corporation shall not, when considering eligibility for coverage or making payments under a contract, consider the availability of, or any eligibility of a person for, medical assistance under Medicaid.
2. To the extent that payment has been made by Medicaid for health care, a corporation:
(a) Shall treat Medicaid as having a valid and enforceable assignment of benefits of a subscriber or policyholder or claimant under the subscriber or policyholder regardless of any exclusion of Medicaid or the absence of a written assignment; and
(b) May, as otherwise allowed by the policy, evidence of coverage or contract and applicable law or regulation concerning subrogation, seek to enforce any rights of a recipient of Medicaid against any other liable party if:
(1) It is so authorized pursuant to a contract with Medicaid for managed care; or
(2) It has reimbursed Medicaid in full for the health care provided by Medicaid to its subscriber or policyholder.
3. If a state agency is assigned any rights of a person who is:
(a) Eligible for medical assistance under Medicaid; and
(b) Covered by a contract,
Ê the corporation that issued the contract shall not impose any requirements upon the state agency except requirements it imposes upon the agents or assignees of other persons covered by the same contract.
4. If a state agency is assigned any rights of a subscriber or policyholder who is eligible for medical assistance under Medicaid, a corporation shall:
(a) Upon request of the state agency, provide to the state agency information regarding the subscriber or policyholder to determine:
(1) Any period during which the subscriber or policyholder, the spouse or a dependent of the subscriber or policyholder may be or may have been covered by a contract; and
(2) The nature of the coverage that is or was provided by the corporation, including, without limitation, the name and address of the subscriber or policyholder and the identifying number of the contract;
(b) Not later than 60 days after receiving any inquiry by the state agency regarding a claim for payment for the provision of any medical item or service to the person who is eligible for medical assistance under Medicaid and who the state agency reasonably believes is covered by a contract that is submitted not later than 3 years after the date of the provision of the medical item or service, respond to such inquiry; and
(c) Agree not to deny a claim submitted by the state agency solely on the basis of:
(1) Lack of prior authorization if the state agency authorized the medical item or service; or
(2) The date of submission of the claim, the type or format of the claim form or failure to present proper documentation at the point of sale that is the basis for the claim if:
(I) The claim is submitted by the state agency not later than 3 years after the date of the provision of the medical item or service; and
(II) Any action by the state agency to enforce its rights with respect to such claim is commenced not later than 6 years after the submission of the claim.
Nev. Rev. Stat. § 695B.350 Corporation prohibited from asserting certain grounds to deny enrollment of child of insured pursuant to order.
A corporation shall not deny the enrollment of a child pursuant to an order for medical coverage under a contract pursuant to which a parent of the child is insured, on the ground that the child:
1. Was born out of wedlock;
2. Has not been claimed as a dependent on the parents federal income tax return; or
3. Does not reside with the parent or within the corporations geographic area of service.
Nev. Rev. Stat. § 695B.360 Certain accommodations required to be made when child is covered under policy of noncustodial parent.
If a child has coverage under a contract pursuant to which a noncustodial parent of the child is insured, the corporation issuing that contract shall:
1. Provide to the custodial parent such information as necessary for the child to obtain any benefits under that coverage.
2. Allow the custodial parent or, with the approval of the custodial parent, a provider of health care to submit claims for covered services without the approval of the noncustodial parent.
3. Make payments on claims submitted pursuant to subsection 2 directly to the custodial parent, the provider of health care or an agency of this or another state responsible for the administration of Medicaid.
Nev. Rev. Stat. § 695B.370 Corporation required to authorize enrollment of child of parent who is required by order to provide medical coverage under certain circumstances; termination of coverage of child.
If a parent is required by an order for medical coverage to provide coverage for a child and the parent is eligible for family coverage under a contract, the corporation that issued the contract:
1. Shall, if the child is otherwise eligible for that coverage, allow the parent to enroll the child in that coverage without regard to any restrictions upon periods for enrollment.
2. Shall, if:
(a) The child is otherwise eligible for that coverage; and
(b) The parent is enrolled in that coverage but fails to apply for enrollment of the child,
Ê enroll the child in that coverage upon application by the other parent of the child, or by an agency of this or another state responsible for the administration of Medicaid or a state program for the enforcement of child support established pursuant to 42 U.S.C. §§ 651 et seq., without regard to any restrictions upon periods for enrollment.
3. Shall not terminate the enrollment of the child in that coverage or otherwise eliminate that coverage of the child unless the corporation has written proof that:
(a) The order for medical coverage is no longer in effect; or
(b) The child is or will be enrolled in comparable coverage through another insurer on or before the effective date of the termination of enrollment or elimination of coverage.
Nev. Rev. Stat. § 695B.380 Establishment; approval; requirements; examination.
1. Except as otherwise provided in subsection 4, each insurer that issues a contract for hospital or medical services in this State shall establish a system for resolving any complaints of an insured concerning health care services covered under the policy. The system must be approved by the Commissioner.
2. A system for resolving complaints established pursuant to subsection 1 must include an initial investigation, a review of the complaint by a review board and a procedure for appealing a determination regarding the complaint. The majority of the members on a review board must be insureds who receive health care services pursuant to a contract for hospital or medical services issued by the insurer.
3. The Commissioner may examine the system for resolving complaints established pursuant to subsection 1 at such times as the Commissioner deems necessary or appropriate.
4. Each insurer that issues a contract specified in subsection 1 shall, if the contract provides, delivers, arranges for, pays for or reimburses any cost of health care services through managed care, provide a system for resolving any complaints of an insured concerning those health care services that complies with the provisions of NRS 695G.200 to 695G.310 , inclusive.
Nev. Rev. Stat. § 695B.390 Annual report; insurer required to maintain records of complaints concerning something other than health care services.
1. Each insurer that issues a contract for hospital or medical services in this State shall submit to the Commissioner an annual report regarding its system for resolving complaints established pursuant to subsection 1 of NRS 695B.380 on a form prescribed by the Commissioner which includes, without limitation:
(a) A description of the procedures used for resolving any complaints of an insured;
(b) The total number of complaints and appeals handled through the system for resolving complaints since the last report and a compilation of the causes underlying the complaints filed;
(c) The current status of each complaint and appeal filed; and
(d) The average amount of time that was needed to resolve a complaint and an appeal, if any.
2. Each insurer shall maintain records of complaints filed with it which concern something other than health care services and shall submit to the Commissioner a report summarizing such complaints at such times and in such format as the Commissioner may require.
Nev. Rev. Stat. § 695B.400 Written notice to insured required to be provided by insurer explaining right to file complaint; written notice to insured required when insurer denies coverage of health care service.
1. Following approval by the Commissioner, each insurer that issues a contract for hospital or medical services in this State shall provide written notice to an insured, in clear and comprehensible language that is understandable to an ordinary layperson, explaining the right of the insured to file a written complaint. Such notice must be provided to an insured:
(a) At the time the insured receives a certificate of coverage or evidence of coverage;
(b) Any time that the insurer denies coverage of a health care service or limits coverage of a health care service to an insured; and
(c) Any other time deemed necessary by the Commissioner.
2. Any time that an insurer denies coverage of a health care service to a beneficiary or subscriber, including, without limitation, denying a claim relating to a contract for dental, hospital or medical services pursuant to NRS 695B.2505 , it shall notify the beneficiary or subscriber in writing within:
(a) Twenty-one days after the insurer receives all information necessary to make a determination concerning the claim, if the information is submitted electronically;
(b) Thirty days after the insurer receives all information necessary to make a determination concerning the claim, if the information is not submitted electronically; or
(c) If no claim is received, 10 working days after the insurer denies coverage of the health care service of:
(1) All reasons for denying coverage of the service, including, without limitation, the specific facts and provisions of the contract relied upon by the insurer as a basis to deny coverage for the service;
(2) The criteria by which the insurer determines whether to authorize or deny coverage of the health care service and the manner in which the insurer applied those criteria to the health care service;
(3) A summary of any applicable process established pursuant to NRS 687B.820 for challenging the denial of the claim; and
(4) The right of the beneficiary or subscriber to file a written complaint and the procedure for filing such a complaint.
3. A written notice which is approved by the Commissioner shall be deemed to be in clear and comprehensible language that is understandable to an ordinary layperson.
Nev. Rev. Stat. § 695B.1901 Required provision in certain policies concerning coverage for continued medical treatment; exceptions; regulations.
1. The provisions of this section apply to a policy of health insurance offered or issued by a hospital or medical service corporation if an insured covered by the policy receives health care through a defined set of providers of health care who are under contract with the hospital or medical service corporation.
2. Except as otherwise provided in this section, if an insured who is covered by a policy described in subsection 1 is receiving medical treatment for a medical condition from a provider of health care whose contract with the hospital or medical service corporation is terminated during the course of the medical treatment, the policy must provide that:
(a) The insured may continue to obtain medical treatment for the medical condition from the provider of health care pursuant to this section, if:
(1) The insured is actively undergoing a medically necessary course of treatment; and
(2) The provider of health care and the insured agree that the continuity of care is desirable.
(b) The provider of health care is entitled to receive reimbursement from the hospital or medical service corporation for the medical treatment the provider of health care provides to the insured pursuant to this section, if the provider of health care agrees:
(1) To provide medical treatment under the terms of the contract between the provider of health care and the hospital or medical service corporation with regard to the insured, including, without limitation, the rates of payment for providing medical service, as those terms existed before the termination of the contract between the provider of health care and the hospital or medical service corporation; and
(2) Not to seek payment from the insured for any medical service provided by the provider of health care that the provider of health care could not have received from the insured were the provider of health care still under contract with the hospital or medical service corporation.
3. The coverage required by subsection 2 must be provided until the later of:
(a) The 120th day after the date the contract is terminated; or
(b) If the medical condition is pregnancy, the 45th day after:
(1) The date of delivery; or
(2) If the pregnancy does not end in delivery, the date of the end of the pregnancy.
4. The requirements of this section do not apply to a provider of health care if:
(a) The provider of health care was under contract with the hospital or medical service corporation and the hospital or medical service corporation terminated that contract because of the medical incompetence or professional misconduct of the provider of health care; and
(b) The hospital or medical service corporation did not enter into another contract with the provider of health care after the contract was terminated pursuant to paragraph (a).
5. A policy subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 2003, has the legal effect of including the coverage required by this section, and any provision of the policy or renewal thereof that is in conflict with this section is void.
6. The Commissioner shall adopt regulations to carry out the provisions of this section.
Nev. Rev. Stat. § 695B.1903 Required provision concerning coverage for certain treatment as part of clinical trial or study for treatment of cancer or chronic fatigue syndrome; authority of corporation to require certain information; immunity from liability.
1. A policy of health insurance issued by a medical services corporation must provide coverage for medical treatment which a person insured under the policy receives as part of a clinical trial or study if:
(a) The medical treatment is provided in a Phase I, Phase II, Phase III or Phase IV study or clinical trial for the treatment of cancer or in a Phase II, Phase III or Phase IV study or clinical trial for the treatment of chronic fatigue syndrome;
(b) The clinical trial or study is approved by:
(1) An agency of the National Institutes of Health as set forth in 42 U.S.C. § 281(b);
(2) A cooperative group;
(3) The Food and Drug Administration as an application for a new investigational drug;
(4) The United States Department of Veterans Affairs; or
(5) The United States Department of Defense;
(c) In the case of:
(1) A Phase I clinical trial or study for the treatment of cancer, the medical treatment is provided at a facility authorized to conduct Phase I clinical trials or studies for the treatment of cancer; or
(2) A Phase II, Phase III or Phase IV study or clinical trial for the treatment of cancer or chronic fatigue syndrome, the medical treatment is provided by a provider of health care and the facility and personnel for the clinical trial or study have the experience and training to provide the treatment in a capable manner;
(d) There is no medical treatment available which is considered a more appropriate alternative medical treatment than the medical treatment provided in the clinical trial or study;
(e) There is a reasonable expectation based on clinical data that the medical treatment provided in the clinical trial or study will be at least as effective as any other medical treatment;
(f) The clinical trial or study is conducted in this State; and
(g) The insured has signed, before participating in the clinical trial or study, a statement of consent indicating that the insured has been informed of, without limitation:
(1) The procedure to be undertaken;
(2) Alternative methods of treatment; and
(3) The risks associated with participation in the clinical trial or study, including, without limitation, the general nature and extent of such risks.
2. Except as otherwise provided in subsection 3, the coverage for medical treatment required by this section is limited to:
(a) Coverage for any drug or device that is approved for sale by the Food and Drug Administration without regard to whether the approved drug or device has been approved for use in the medical treatment of the insured person.
(b) The cost of any reasonably necessary health care services that are required as a result of the medical treatment provided in a Phase II, Phase III or Phase IV clinical trial or study or as a result of any complication arising out of the medical treatment provided in a Phase II, Phase III or Phase IV clinical trial or study, to the extent that such health care services would otherwise be covered under the policy of health insurance.
(c) The cost of any routine health care services that would otherwise be covered under the policy of health insurance for an insured participating in a Phase I clinical trial or study.
(d) The initial consultation to determine whether the insured is eligible to participate in the clinical trial or study.
(e) Health care services required for the clinically appropriate monitoring of the insured during a Phase II, Phase III or Phase IV clinical trial or study.
(f) Health care services which are required for the clinically appropriate monitoring of the insured during a Phase I clinical trial or study and which are not directly related to the clinical trial or study.
Ê Except as otherwise provided in NRS 695B.1901 , the services provided pursuant to paragraphs (b), (c), (e) and (f) must be covered only if the services are provided by a provider with whom the medical services corporation has contracted for such services. If the medical services corporation has not contracted for the provision of such services, the medical services corporation shall pay the provider the rate of reimbursement that is paid to other providers with whom the medical services corporation has contracted for similar services and the provider shall accept that rate of reimbursement as payment in full.
3. Particular medical treatment described in subsection 2 and provided to a person insured under the policy is not required to be covered pursuant to this section if that particular medical treatment is provided by the sponsor of the clinical trial or study free of charge to the person insured under the policy.
4. The coverage for medical treatment required by this section does not include:
(a) Any portion of the clinical trial or study that is customarily paid for by a government or a biotechnical, pharmaceutical or medical industry.
(b) Coverage for a drug or device described in paragraph (a) of subsection 2 which is paid for by the manufacturer, distributor or provider of the drug or device.
(c) Health care services that are specifically excluded from coverage under the insureds policy of health insurance, regardless of whether such services are provided under the clinical trial or study.
(d) Health care services that are customarily provided by the sponsors of the clinical trial or study free of charge to the participants in the trial or study.
(e) Extraneous expenses related to participation in the clinical trial or study, including, without limitation, travel, housing and other expenses that a participant may incur.
(f) Any expenses incurred by a person who accompanies the insured during the trial or study.
(g) Any item or service that is provided solely to satisfy a need or desire for data collection or analysis that is not directly related to the clinical management of the insured.
(h) Any costs for the management of research relating to the clinical trial or study.
5. A medical services corporation that delivers or issues for delivery a policy of health insurance specified in subsection 1 may require copies of the approval or certification issued pursuant to paragraph (b) of subsection 1, the statement of consent signed by the insured, protocols for the clinical trial or study and any other materials related to the scope of the clinical trial or study relevant to the coverage of medical treatment pursuant to this section.
6. A medical services corporation that delivers or issues for delivery a policy of health insurance specified in subsection 1 shall:
(a) Include in any disclosure of the coverage provided by the policy notice to each person insured under the policy of the availability of the benefits required by this section.
(b) Provide the coverage required by this section subject to the same deductible, copayment, coinsurance and other such conditions for coverage that are required under the policy.
7. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2006, has the legal effect of including the coverage required by this section, and any provision of the policy that conflicts with this section is void.
8. A medical services corporation that delivers or issues for delivery a policy of health insurance specified in subsection 1 is immune from liability for:
(a) Any injury to the insured caused by:
(1) Any medical treatment provided to the insured in connection with his or her participation in a clinical trial or study described in this section; or
(2) An act or omission by a provider of health care who provides medical treatment or supervises the provision of medical treatment to the insured in connection with his or her participation in a clinical trial or study described in this section.
(b) Any adverse or unanticipated outcome arising out of an insureds 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.
Nev. Rev. Stat. § 695B.1904 Required provision concerning coverage for services provided through telehealth to same extent as though provided in person or by other means; required provision concerning reimbursement for certain services provided through telehealth in same amount as though provided in person or by other means; prohibited acts.
1. A contract for hospital, medical or dental services subject to the provisions of this chapter must include services provided to an insured through telehealth to the same extent as though provided in person or by other means.
2. A contract for hospital, medical or dental services must provide reimbursement for services described in subsection 1 in the same amount as though provided in person or by other means:
(a) If the services:
(1) Are received at an originating site described in 42 U.S.C. § 1395m(m)(4)(C) or furnished by a federally-qualified health center or a rural health clinic; and
(2) Except for services described in paragraph (b), are not provided through audio-only interaction; or
(b) For counseling or treatment relating to a mental health condition or a substance use disorder, including, without limitation, when such counseling or treatment is provided through audio-only interaction.
3. A medical services corporation that issues contracts for hospital, medical or dental services shall not:
(a) Require an insured to establish a relationship in person with a provider of health care or provide any additional consent to or reason for obtaining services through telehealth as a condition to providing the coverage described in subsection 1 or the reimbursement described in subsection 2;
(b) Require a provider of health care to demonstrate that it is necessary to provide services to an insured through telehealth or receive any additional type of certification or license to provide services through telehealth as a condition to providing the coverage described in subsection 1 or the reimbursement described in subsection 2;
(c) Refuse to provide the coverage described in subsection 1 or the reimbursement described in subsection 2 because of:
(1) The distant site from which a provider of health care provides services through telehealth or the originating site at which an insured receives services through telehealth; or
(2) The technology used to provide the services;
(d) Require covered services to be provided through telehealth as a condition to providing coverage for such services; or
(e) Categorize a service provided through telehealth differently for purposes relating to coverage or reimbursement than if the service had been provided in person or through other means.
4. A contract for hospital, medical or dental services must not require an insured to obtain prior authorization for any service provided through telehealth that is not required for the service when provided in person. A contract for hospital, medical or dental services may require prior authorization for a service provided through telehealth if such prior authorization would be required if the service were provided in person or by other means.
5. The provisions of this section do not require a medical services corporation that issues contracts for hospital, medical or dental services to:
(a) Ensure that covered services are available to an insured through telehealth at a particular originating site;
(b) Provide coverage for a service that is not a covered service or that is not provided by a covered provider of health care; or
(c) Enter into a contract with any provider of health care or cover any service if the medical services corporation is not otherwise required by law to do so.
6. A contract for hospital, medical or dental services subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2023, has the legal effect of including the coverage required by this section, and any provision of the contract or the renewal which is in conflict with this section is void.
7. As used in this section:
(a) Distant site has the meaning ascribed to it in NRS 629.515 .
(b) Federally-qualified health center has the meaning ascribed to it in 42 U.S.C. § 1396d(l)(2)(B).
(c) Originating site has the meaning ascribed to it in NRS 629.515 .
(d) Provider of health care has the meaning ascribed to it in NRS 439.820 .
(e) Rural health clinic has the meaning ascribed to it in 42 U.S.C. § 1395x(aa)(2).
(f) Telehealth has the meaning ascribed to it in NRS 629.515 .
Nev. Rev. Stat. § 695B.1905 Contract covering prescription drugs prohibited from limiting or excluding coverage for certain prescription drugs previously approved for medical condition of insured; exceptions.
1. Except as otherwise provided in this section, a contract for hospital or medical services which provides coverage for prescription drugs must not limit or exclude coverage for a drug if the drug:
(a) Had previously been approved for coverage by the insurer for a medical condition of an insured and the insureds provider of health care determines, after conducting a reasonable investigation, that none of the drugs which are otherwise currently approved for coverage are medically appropriate for the insured; and
(b) Is appropriately prescribed and considered safe and effective for treating the medical condition of the insured.
2. The provisions of subsection 1 do not:
(a) Apply to coverage for any drug that is prescribed for a use that is different from the use for which that drug has been approved for marketing by the Food and Drug Administration;
(b) Prohibit:
(1) The insurer from charging a deductible, copayment or coinsurance for the provision of benefits for prescription drugs to the insured or from establishing, by contract, limitations on the maximum coverage for prescription drugs;
(2) A provider of health care from prescribing another drug covered by the contract that is medically appropriate for the insured; or
(3) The substitution of another drug pursuant to NRS 639.23286 or 639.2583 to 639.2597 , inclusive; or
(c) Require any coverage for a drug after the term of the contract.
3. Any provision of a contract for hospital or medical services subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 2001, which is in conflict with this section is void.
Nev. Rev. Stat. § 695B.1906 Required provision in policy covering prescription drugs concerning coverage for prescription drugs irregularly dispensed for purpose of synchronization of chronic medications; prohibited acts; exception.
1. A hospital or medical services corporation who offers or issues a policy of health insurance which provides coverage for prescription drugs:
(a) Must authorize coverage for and may apply a copayment and deductible to a prescription that is dispensed by a pharmacy for less than a 30-day supply if, for the purpose of synchronizing the insureds chronic medications:
(1) The prescriber or pharmacist determines that filling or refilling the prescription in that manner is in the best interest of the insured; and
(2) The insured requests less than a 30-day supply.
(b) May not deny coverage for a prescription described in paragraph (a) which is otherwise approved for coverage by the hospital or medical services corporation.
(c) Unless otherwise provided by a contract or other agreement, may not prorate any pharmacy dispensing fees for a prescription described in paragraph (a).
2. A policy of health insurance subject to the provisions of this chapter which provides coverage for prescription drugs and that is delivered, issued for delivery or renewed on or after January 1, 2017, has the legal effect of providing that coverage subject to the requirements of this section, and any provision of the policy of health insurance or renewal which is in conflict with this section is void.
3. The provisions of this section do not apply to unit-of-use packaging for which synchronization is not practicable or to a controlled substance.
4. As used in this section:
(a) Chronic medication means any drug that is prescribed to treat any disease or other condition which is determined to be permanent, persistent or lasting indefinitely.
(b) Synchronization means the alignment of the dispensing of multiple medications by a single contracted pharmacy for the purpose of improving a patients adherence to a prescribed course of medication.
(c) Unit-of-use packaging means medication that is prepackaged by the manufacturer in blister packs, compliance packs, course-of-therapy packs or any other packaging which is designed and intended to be dispensed directly to the patient without modification by the dispensing pharmacy, except for the addition of a prescription label.
Nev. Rev. Stat. § 695B.1907 Required provision in policy covering treatment of colorectal cancer concerning coverage for colorectal cancer screening.
1. A policy of health insurance issued by a hospital or medical service corporation that provides coverage for the treatment of colorectal cancer must provide coverage for colorectal cancer screening in accordance with:
(a) The guidelines concerning colorectal cancer screening which are published by the American Cancer Society; or
(b) Other guidelines or reports concerning colorectal cancer screening which are published by nationally recognized professional organizations and which include current or prevailing supporting scientific data.
2. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 2003, has the legal effect of including the coverage required by this section, and any provision of the policy that conflicts with the provisions of this section is void.
Nev. Rev. Stat. § 695B.1908 Required provision in certain contracts concerning coverage for certain drugs and related services for treatment of cancer.
Except as otherwise provided in NRS 695B.1903:
1. No contract for hospital or medical services that provides coverage for a drug approved by the Food and Drug Administration for use in the treatment of an illness, disease or other medical condition may be delivered or issued for delivery in this state unless the contract includes coverage for any other use of the drug for the treatment of cancer, if that use is:
(a) Specified in the most recent edition of or supplement to:
(1) The United States Pharmacopoeia Drug Information ; or
(2) The American Hospital Formulary Service Drug Information ; or
(b) Supported by at least two articles reporting the results of scientific studies that are published in scientific or medical journals, as defined in 21 C.F.R. § 99.3.
2. The coverage required pursuant to this section:
(a) Includes coverage for any medical services necessary to administer the drug to a person covered under the contract.
(b) Does not include coverage for any:
(1) Experimental drug used for the treatment of cancer if that drug has not been approved by the Food and Drug Administration; or
(2) Use of a drug that is contraindicated by the Food and Drug Administration.
3. A contract for hospital or medical services subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 1999, has the legal effect of including the coverage required by this section, and any provision of the contract that conflicts with the provisions of this section is void.
Nev. Rev. Stat. § 695B.1909 Contract covering treatment of cancer through use of chemotherapy: Prohibited acts related to orally administered chemotherapy.
1. An insurer that offers or issues a contract for hospital or medical service which provides coverage for the treatment of cancer through the use of chemotherapy shall not:
(a) Require a copayment, deductible or coinsurance amount for chemotherapy administered orally by means of a prescription drug in a combined amount that is more than $100 per prescription. The limitation on the amount of the deductible that may be required pursuant to this paragraph does not apply to a health benefit plan, as defined in NRS 687B.470 , if the health benefit plan is a high deductible health plan, as defined in 26 U.S.C. § 223, and the amount of the annual deductible has not been satisfied.
(b) Make the coverage subject to monetary limits that are less favorable for chemotherapy administered orally by means of a prescription drug than the monetary limits applicable to chemotherapy which is administered by injection or intravenously.
(c) Decrease the monetary limits applicable to chemotherapy administered orally by means of a prescription drug or to chemotherapy which is administered by injection or intravenously to meet the requirements of this section.
2. A contract subject to the provisions of this chapter which provides coverage for the treatment of cancer through the use of chemotherapy and that is delivered, issued for delivery or renewed on or after January 1, 2015, has the legal effect of providing that coverage subject to the requirements of this section, and any provision of the contract or renewal which is in conflict with this section is void.
3. Nothing in this section shall be construed as requiring an insurer to provide coverage for the treatment of cancer through the use of chemotherapy administered by injection or intravenously or administered orally by means of a prescription drug.
Nev. Rev. Stat. § 695B.1911 Required provision concerning coverage for screening, genetic counseling and testing related to BRCA gene in certain circumstances.
1. A hospital or medical services corporation that issues a policy of health insurance shall provide coverage for screening, genetic counseling and testing for harmful mutations in the BRCA gene for women under circumstances where such screening, genetic counseling or testing, as applicable, is required by NRS 457.301 .
2. A hospital or medical services corporation shall ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the hospital or medical services corporation.
3. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2022, has the legal effect of including the coverage required by subsection 1, and any provision of the policy that conflicts with the provisions of this section is void.
4. As used in this section:
(a) Network plan means a policy of health insurance offered by a hospital or medical services corporation under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the hospital or medical services corporation. The term does not include an arrangement for the financing of premiums.
(b) Provider of health care has the meaning ascribed to it in NRS 629.031 .
Nev. Rev. Stat. § 695B.1912 Required provision concerning coverage for certain screenings and tests for breast cancer; prohibited acts.
1. An insurer that offers or issues a contract for hospital or medical service must provide coverage for benefits payable for expenses incurred for:
(a) A mammogram to screen for breast cancer annually for insureds who are 40 years of age or older.
(b) An imaging test to screen for breast cancer on an interval and at the age deemed most appropriate, when medically necessary, as recommended by the insureds provider of health care based on personal or family medical history or additional factors that may increase the risk of breast cancer for the insured.
(c) A diagnostic imaging test for breast cancer at the age deemed most appropriate, when medically necessary, as recommended by the insureds provider of health care to evaluate an abnormality which is:
(1) Seen or suspected from a mammogram described in paragraph (a) or an imaging test described in paragraph (b); or
(2) Detected by other means of examination.
2. An insurer must ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the insurer.
3. Except as otherwise provided in subsection 5, an insurer that offers or issues a contract for hospital or medical service shall not:
(a) Except as otherwise provided in subsection 6, require an insured to pay a deductible, copayment, coinsurance or any other form of cost-sharing or require a longer waiting period or other condition to obtain any benefit provided in a contract for hospital or medical service pursuant to subsection 1;
(b) Refuse to issue a contract for hospital or medical service or cancel a contract for hospital or medical service solely because the person applying for or covered by the contract uses or may use any such benefit;
(c) Offer or pay any type of material inducement or financial incentive to an insured to discourage the insured from obtaining any such benefit;
(d) Penalize a provider of health care who provides any such benefit to an insured, including, without limitation, reducing the reimbursement of the provider of health care;
(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 access to any such benefit to an insured; or
(f) Impose any other restrictions or delays on the access of an insured to any such benefit.
4. A contract for hospital or medical service subject to the provisions of this chapter which is delivered, issued for delivery or renewed on or after January 1, 2024, has the legal effect of including the coverage required by subsection 1, and any provision of the contract or the renewal which is in conflict with this section is void.
5. Except as otherwise provided in this section and federal law, an insurer may use medical management techniques, including, without limitation, any available clinical evidence, to determine the frequency of or treatment relating to any benefit required by this section or the type of provider of health care to use for such treatment.
6. If the application of paragraph (a) of subsection 3 would result in the ineligibility of a health savings account of an insured pursuant to 26 U.S.C. § 223, the prohibitions of paragraph (a) of subsection 3 shall apply only for a qualified contract for hospital or medical service with respect to the deductible of such a contract for hospital or medical service after the insured has satisfied the minimum deductible pursuant to 26 U.S.C. § 223, except with respect to items or services that constitute preventive care pursuant to 26 U.S.C. § 223(c)(2)(C), in which case the prohibitions of paragraph (a) of subsection 3 shall apply regardless of whether the minimum deductible under 26 U.S.C. § 223 has been satisfied.
7. As used in this section:
(a) Medical management technique means a practice which is used to control the cost or utilization of health care services or prescription drug use. The term includes, without limitation, the use of step therapy, prior authorization or categorizing drugs and devices based on cost, type or method of administration.
(b) Network plan means a contract for hospital or medical service offered by an insurer under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the insurer. The term does not include an arrangement for the financing of premiums.
(c) Provider of health care has the meaning ascribed to it in NRS 629.031 .
(d) Qualified contract for hospital or medical service means a contract for hospital or medical service that has a high deductible and is in compliance with 26 U.S.C. § 223 for the purposes of establishing a health savings account.
Nev. Rev. Stat. § 695B.1913 Required provision concerning coverage for examination of person who is pregnant for certain diseases.
1. A hospital or medical services corporation that issues a policy of health insurance shall provide coverage for the examination of a person who is pregnant for the discovery of:
(a) Chlamydia trachomatis , gonorrhea, hepatitis B and hepatitis C in accordance with NRS 442.013 .
(b) Syphilis in accordance with NRS 442.010 .
2. The coverage required by this section must be provided:
(a) Regardless of whether the benefits are provided to the insured by a provider of health care, facility or medical laboratory that participates in the network plan of the hospital or medical services corporation; and
(b) Without prior authorization.
3. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2021, has the legal effect of including the coverage required by subsection 1, and any provision of the policy that conflicts with the provisions of this section is void.
4. As used in this section:
(a) Medical laboratory has the meaning ascribed to it in NRS 652.060 .
(b) Network plan means a policy of health insurance offered by a hospital or medical services corporation under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the hospital or medical services corporation. The term does not include an arrangement for the financing of premiums.
(c) Provider of health care has the meaning ascribed to it in NRS 629.031 .
Nev. Rev. Stat. § 695B.1914 Required provision concerning coverage of certain gynecological and obstetrical services without authorization or referral from primary care physician; designation of obstetrician or gynecologist as primary care provider.
1. A contract for hospital or medical service must include a provision authorizing a woman covered by the contract to:
(a) Obtain covered gynecological or obstetrical services without first receiving authorization or a referral from her primary care physician.
(b) Designate as her primary care physician an obstetrician or gynecologist who:
(1) Participates in the network plan of the hospital or medical services corporation;
(2) Satisfies the criteria established by the hospital or medical services corporation for designation as a primary care provider under the contract; and
(3) Agrees to abide by all terms and conditions imposed by the hospital or medical services corporation on other primary care physicians generally.
2. A contract subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2026, has the legal effect of including the coverage required by this section, and any provision of the contract or the renewal which is in conflict with this section is void.
3. As used in this section:
(a) Network plan means a policy of health insurance offered by a hospital or medical services corporation under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the hospital or medical services corporation. The term does not include an arrangement for the financing of premiums.
(b) Primary care physician has the meaning ascribed to it in NRS 695G.060 .
Nev. Rev. Stat. § 695B.1915 Required provision concerning coverage for medically necessary treatment of conditions relating to gender dysphoria and gender incongruence; restriction on refusal to cover certain treatments; authority of corporation to prescribe requirements for covering surgical treatments for minors; determination of medical necessity.
1. Except as otherwise provided in this section, a hospital or medical services corporation that issues a policy of health insurance shall include in the policy coverage for the medically necessary treatment of conditions relating to gender dysphoria and gender incongruence. Such coverage must include coverage of medically necessary psychosocial and surgical intervention and any other medically necessary treatment for such disorders provided by:
(a) Endocrinologists;
(b) Pediatric endocrinologists;
(c) Social workers;
(d) Psychiatrists;
(e) Psychologists;
(f) Gynecologists;
(g) Speech-language pathologists;
(h) Primary care physicians;
(i) Advanced practice registered nurses;
(j) Physician assistants; and
(k) Any other providers of medically necessary services for the treatment of gender dysphoria or gender incongruence.
2. This section does not require a policy of health insurance to include coverage for cosmetic surgery performed by a plastic surgeon or reconstructive surgeon that is not medically necessary.
3. A hospital or medical services corporation that issues a policy of health insurance shall not categorically refuse to cover medically necessary gender-affirming treatments or procedures or revisions to prior treatments if the policy provides coverage for any such services, procedures or revisions for purposes other than gender transition or affirmation.
4. A hospital or medical services corporation that issues a policy of health insurance may prescribe requirements that must be satisfied before the hospital or medical services corporation covers surgical treatment of conditions relating to gender dysphoria or gender incongruence for an insured who is less than 18 years of age. Such requirements may include, without limitation, requirements that:
(a) The treatment must be recommended by a psychologist, psychiatrist or other mental health professional;
(b) The treatment must be recommended by a physician;
(c) The insured must provide a written expression of the desire of the insured to undergo the treatment;
(d) A written plan for treatment that covers at least 1 year must be developed and approved by at least two providers of health care; and
(e) Parental consent is provided for the insured unless the insured is expressly authorized by law to consent on his or her own behalf.
5. When determining whether treatment is medically necessary for the purposes of this section, a hospital or medical services corporation must consider the most recent Standards of Care published by the World Professional Association for Transgender Health, or its successor organization.
6. A hospital or medical services corporation shall make a reasonable effort to ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the hospital or medical services corporation. If, after a reasonable effort, the hospital or medical services corporation is unable to make such benefits available through such a provider of health care, the hospital or medical services corporation may treat the treatment that the hospital or medical services corporation is unable to make available through such a provider of health care in the same manner as other services provided by a provider of health care who does not participate in the network plan of the hospital or medical services corporation.
7. If an insured appeals the denial of a claim or coverage under this section on the grounds that the treatment requested by the insured is not medically necessary, the hospital or medical services corporation must consult with a provider of health care who has experience in prescribing or delivering gender-affirming treatment concerning the medical necessity of the treatment requested by the insured when considering the appeal.
8. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2023, has the legal effect of including the coverage required by subsection 1, and any provision of the policy or renewal which is in conflict with the provisions of this section is void.
9. As used in this section:
(a) Cosmetic surgery:
(1) Means a surgical procedure that:
(I) Does not meaningfully promote the proper function of the body;
(II) Does not prevent or treat illness or disease; and
(III) Is primarily directed at improving the appearance of a person.
(2) Includes, without limitation, cosmetic surgery directed at preserving beauty.
(b) Gender dysphoria means distress or impairment in social, occupational or other areas of functioning caused by a marked difference between the gender identity or expression of a person and the sex assigned to the person at birth which lasts at least 6 months and is shown by at least two of the following:
(1) A marked difference between gender identity or expression and primary or secondary sex characteristics or anticipated secondary sex characteristics in young adolescents.
(2) A strong desire to be rid of primary or secondary sex characteristics because of a marked difference between such sex characteristics and gender identity or expression or a desire to prevent the development of anticipated secondary sex characteristics in young adolescents.
(3) A strong desire for the primary or secondary sex characteristics of the gender opposite from the sex assigned at birth.
(4) A strong desire to be of the opposite gender or a gender different from the sex assigned at birth.
(5) A strong desire to be treated as the opposite gender or a gender different from the sex assigned at birth.
(6) A strong conviction of experiencing typical feelings and reactions of the opposite gender or a gender different from the sex assigned at birth.
(c) Medically necessary means health care services or products that a prudent provider of health care would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that are necessary and:
(1) Provided in accordance with generally accepted standards of medical practice;
(2) Clinically appropriate with regard to type, frequency, extent, location and duration;
(3) Not provided primarily for the convenience of the patient or provider of health care;
(4) Required to improve a specific health condition of a patient or to preserve the existing state of health of the patient; and
(5) The most clinically appropriate level of health care that may be safely provided to the patient.
Ê A provider of health care prescribing, ordering, recommending or approving a health care service or product does not, by itself, make that health care service or product medically necessary.
(d) Network plan means a policy of health insurance offered by a hospital or medical services corporation under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the hospital or medical services corporation. The term does not include an arrangement for the financing of premiums.
(e) Provider of health care has the meaning ascribed to it in NRS 629.031 .
Nev. Rev. Stat. § 695B.1916 Required provision in contract covering prescription drugs or devices concerning coverage of hormone replacement therapy in certain circumstances; prohibited acts; exception.
1. An insurer that offers or issues a contract for hospital or medical service which provides coverage for prescription drugs or devices shall include in the contract coverage for any type of hormone replacement therapy which is lawfully prescribed or ordered and which has been approved by the Food and Drug Administration.
2. An insurer that offers or issues a contract for hospital or medical service that provides coverage for prescription drugs shall not:
(a) Require an insured to pay a higher deductible, any copayment or coinsurance or require a longer waiting period or other condition for coverage for a prescription for hormone replacement therapy;
(b) Refuse to issue a contract for hospital or medical service or cancel a contract for hospital or medical service solely because the person applying for or covered by the contract uses or may use in the future hormone replacement therapy;
(c) Offer or pay any type of material inducement or financial incentive to an insured to discourage the insured from accessing hormone replacement therapy;
(d) Penalize a provider of health care who provides hormone replacement therapy to an insured, including, without limitation, reducing the reimbursement of the provider of health care; or
(e) Offer or pay any type of material inducement, bonus or other financial incentive to a provider of health care to deny, reduce, withhold, limit or delay hormone replacement therapy to an insured.
3. A contract for hospital or medical service subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 1999, has the legal effect of including the coverage required by subsection 1, and any provision of the contract or the renewal which is in conflict with this section is void.
4. The provisions of this section do not require an insurer to provide coverage for fertility drugs.
5. As used in this section, provider of health care has the meaning ascribed to it in NRS 629.031 .
Nev. Rev. Stat. § 695B.1918 Required provision in contract covering outpatient care concerning coverage of health care services related to hormone replacement therapy; prohibited acts.
1. An insurer that offers or issues a contract for hospital or medical service which provides coverage for outpatient care shall include in the contract coverage for any health care service related to hormone replacement therapy.
2. An insurer that offers or issues a contract for hospital or medical service that provides coverage for outpatient care shall not:
(a) Require an insured to pay a higher deductible, any copayment or coinsurance or require a longer waiting period or other condition for coverage for outpatient care related to hormone replacement therapy;
(b) Refuse to issue a contract for hospital or medical service or cancel a contract for hospital or medical service solely because the person applying for or covered by the contract uses or may use in the future hormone replacement therapy;
(c) Offer or pay any type of material inducement or financial incentive to an insured to discourage the insured from accessing hormone replacement therapy;
(d) Penalize a provider of health care who provides hormone replacement therapy to an insured, including, without limitation, reducing the reimbursement of the provider of health care; or
(e) Offer or pay any type of material inducement, bonus or other financial incentive to a provider of health care to deny, reduce, withhold, limit or delay hormone replacement therapy to an insured.
3. A contract for hospital or medical service subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 1999, has the legal effect of including the coverage required by subsection 1, and any provision of the contract or the renewal which is in conflict with this section is void.
4. As used in this section, provider of health care has the meaning ascribed to it in NRS 629.031 .
Nev. Rev. Stat. § 695B.1919 Required provision concerning coverage for drug or device for contraception and related health services; prohibited acts; exceptions.
1. Except as otherwise provided in subsection 8, an insurer that offers or issues a contract for hospital or medical service shall include in the contract coverage for:
(a) Up to a 12-month supply, per prescription, of any type of drug for contraception or its therapeutic equivalent which is:
(1) Lawfully prescribed or ordered;
(2) Approved by the Food and Drug Administration;
(3) Listed in subsection 12; and
(4) Dispensed in accordance with NRS 639.28075 ;
(b) Any type of device for contraception which is:
(1) Lawfully prescribed or ordered;
(2) Approved by the Food and Drug Administration; and
(3) Listed in subsection 12;
(c) Self-administered hormonal contraceptives dispensed by a pharmacist pursuant to NRS 639.28078 ;
(d) Insertion of a device for contraception or removal of such a device if the device was inserted while the insured was covered by the same contract for hospital or medical service;
(e) Education and counseling relating to the initiation of the use of contraception and any necessary follow-up after initiating such use;
(f) Management of side effects relating to contraception; and
(g) Voluntary sterilization for women.
2. An insurer shall provide coverage for any services listed in subsection 1 which are within the authorized scope of practice of a pharmacist when such services are provided by a pharmacist who is employed by or serves as an independent contractor of an in-network pharmacy and in accordance with the applicable provider network contract. Such coverage must be provided to the same extent as if the services were provided by another provider of health care, as applicable to the services being provided. The terms of the policy must not limit:
(a) Coverage for services listed in subsection 1 and provided by such a pharmacist to a number of occasions less than the coverage for such services when provided by another provider of health care.
(b) Reimbursement for services listed in subsection 1 and provided by such a pharmacist to an amount less than the amount reimbursed for similar services provided by a physician, physician assistant or advanced practice registered nurse.
3. An insurer that offers or issues a contract for hospital or medical services must ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the insurer.
4. If a covered therapeutic equivalent listed in subsection 1 is not available or a provider of health care deems a covered therapeutic equivalent to be medically inappropriate, an alternate therapeutic equivalent prescribed by a provider of health care must be covered by the insurer.
5. Except as otherwise provided in subsections 10, 11 and 13, an insurer that offers or issues a contract for hospital or medical service shall not:
(a) Require an insured to pay a higher deductible, any copayment or coinsurance or require a longer waiting period or other condition to obtain any benefit included in the contract for hospital or medical service pursuant to subsection 1;
(b) Refuse to issue a contract for hospital or medical service or cancel a contract for hospital or medical service solely because the person applying for or covered by the contract uses or may use any such benefit;
(c) Offer or pay any type of material inducement or financial incentive to an insured to discourage the insured from obtaining any such benefit;
(d) Penalize a provider of health care who provides any such benefit to an insured, including, without limitation, reducing the reimbursement to the provider of health care;
(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 access to any such benefit to an insured; or
(f) Impose any other restrictions or delays on the access of an insured to any such benefit.
6. Coverage pursuant to this section for the covered dependent of an insured must be the same as for the insured.
7. Except as otherwise provided in subsection 8, a contract for hospital or medical service subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2024, has the legal effect of including the coverage required by this section, and any provision of the contract or the renewal which is in conflict with this section is void.
8. An insurer that offers or issues a contract for hospital or medical service and which is affiliated with a religious organization is not required to provide the coverage required by subsection 1 if the insurer objects on religious grounds. Such an insurer shall, before the issuance of a contract for hospital or medical service and before the renewal of such a contract, provide to the prospective insured written notice of the coverage that the insurer refuses to provide pursuant to this subsection.
9. If an insurer refuses, pursuant to subsection 8, to provide the coverage required by subsection 1, an employer may otherwise provide for the coverage for the employees of the employer.
10. An insurer may require an insured to pay a higher deductible, copayment or coinsurance for a drug for contraception if the insured refuses to accept a therapeutic equivalent of the drug.
11. For each of the 18 methods of contraception listed in subsection 12 that have been approved by the Food and Drug Administration, a contract for hospital or medical service must include at least one drug or device for contraception within each method for which no deductible, copayment or coinsurance may be charged to the insured, but the insurer may charge a deductible, copayment or coinsurance for any other drug or device that provides the same method of contraception. If the insurer charges a copayment or coinsurance for a drug for contraception, the insurer may only require an insured to pay the copayment or coinsurance:
(a) Once for the entire amount of the drug dispensed for the plan year; or
(b) Once for each 1-month supply of the drug dispensed.
12. The following 18 methods of contraception must be covered pursuant to this section:
(a) Voluntary sterilization for women;
(b) Surgical sterilization implants for women;
(c) Implantable rods;
(d) Copper-based intrauterine devices;
(e) Progesterone-based intrauterine devices;
(f) Injections;
(g) Combined estrogen- and progestin-based drugs;
(h) Progestin-based drugs;
(i) Extended- or continuous-regimen drugs;
(j) Estrogen- and progestin-based patches;
(k) Vaginal contraceptive rings;
(l) Diaphragms with spermicide;
(m) Sponges with spermicide;
(n) Cervical caps with spermicide;
(o) Female condoms;
(p) Spermicide;
(q) Combined estrogen- and progestin-based drugs for emergency contraception or progestin-based drugs for emergency contraception; and
(r) Ulipristal acetate for emergency contraception.
13. Except as otherwise provided in this section and federal law, an insurer that offers or issues a contract for hospital or medical services may use medical management techniques, including, without limitation, any available clinical evidence, to determine the frequency of or treatment relating to any benefit required by this section or the type of provider of health care to use for such treatment.
14. An insurer shall not:
(a) Use medical management techniques to require an insured to use a method of contraception other than the method prescribed or ordered by a provider of health care;
(b) Require an insured to obtain prior authorization for the benefits described in paragraphs (a) and (c) of subsection 1; or
(c) Refuse to cover a contraceptive injection or the insertion of a device described in paragraph (c), (d) or (e) of subsection 12 at a hospital immediately after an insured gives birth.
15. An insurer must provide an accessible, transparent and expedited process which is not unduly burdensome by which an insured, or the authorized representative of the insured, may request an exception relating to any medical management technique used by the insurer to obtain any benefit required by this section without a higher deductible, copayment or coinsurance.
16. As used in this section:
(a) In-network pharmacy means a pharmacy that has entered into a contract with an insurer to provide services to insureds through a network plan offered or issued by the insurer.
(b) Medical management technique means a practice which is used to control the cost or utilization of health care services or prescription drug use. The term includes, without limitation, the use of step therapy, prior authorization or categorizing drugs and devices based on cost, type or method of administration.
(c) Network plan means a contract for hospital or medical service offered by an insurer under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the insurer. The term does not include an arrangement for the financing of premiums.
(d) Provider network contract means a contract between an insurer and a provider of health care or pharmacy specifying the rights and responsibilities of the insurer and the provider of health care or pharmacy, as applicable, for delivery of health care services pursuant to a network plan.
(e) Provider of health care has the meaning ascribed to it in NRS 629.031 .
(f) Therapeutic equivalent means a drug which:
(1) Contains an identical amount of the same active ingredients in the same dosage and method of administration as another drug;
(2) Is expected to have the same clinical effect when administered to a patient pursuant to a prescription or order as another drug; and
(3) Meets any other criteria required by the Food and Drug Administration for classification as a therapeutic equivalent.
Nev. Rev. Stat. § 695B.1923 Required provision concerning coverage for treatment of certain inherited metabolic diseases.
1. A contract for hospital or medical service must provide coverage for:
(a) Enteral formulas for use at home that are prescribed or ordered by a physician as medically necessary for the treatment of inherited metabolic diseases characterized by deficient metabolism, or malabsorption originating from congenital defects or defects arising shortly after birth, of amino acid, organic acid, carbohydrate or fat; and
(b) At least $2,500 per year for special food products which are prescribed or ordered by a physician as medically necessary for the treatment of a person described in paragraph (a).
2. The coverage required by subsection 1 must be provided whether or not the condition existed when the contract was purchased.
3. A contract subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2021, has the legal effect of including the coverage required by this section, and any provision of the contract or the renewal which is in conflict with this section is void.
4. As used in this section:
(a) Enteral formula includes, without limitation, a formula that is ingested orally.
(b) Inherited metabolic disease means a disease caused by an inherited abnormality of the body chemistry of a person.
(c) 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.
Nev. Rev. Stat. § 695B.1924 Required provision concerning coverage for drugs, laboratory testing and certain services related to human immunodeficiency virus and hepatitis C; reimbursement of certain providers of health care for certain services; prohibited acts.
1. A hospital or medical services corporation that offers or issues a policy of health insurance shall include in the policy coverage for:
(a) All drugs approved by the United States Food and Drug Administration for preventing the acquisition of human immunodeficiency virus or treating human immunodeficiency virus or hepatitis C in the form recommended by the prescribing practitioner, regardless of whether the drug is included in the formulary of the hospital or medical services organization;
(b) Laboratory testing that is necessary for therapy using a drug to prevent the acquisition of human immunodeficiency virus;
(c) Any service to test for, prevent or treat human immunodeficiency virus or hepatitis C provided by a provider of primary care if the service is covered when provided by a specialist and:
(1) The service is within the scope of practice of the provider of primary care; or
(2) The provider of primary care is capable of providing the service safely and effectively in consultation with a specialist and the provider engages in such consultation; and
(d) The services described in NRS 639.28085 , when provided by a pharmacist who participates in the network plan of the hospital or medical services corporation.
2. A hospital or medical services corporation that offers or issues a policy of health insurance shall reimburse:
(a) A pharmacist who participates in the network plan of the hospital or medical services corporation for the services described in NRS 639.28085 at a rate equal to the rate of reimbursement provided to a physician, physician assistant or advanced practice registered nurse for similar services.
(b) An advanced practice registered nurse or a physician assistant who participates in the network plan of the hospital or medical services corporation for any service to test for, prevent or treat human immunodeficiency virus or hepatitis C at a rate equal to the rate of reimbursement provided to a physician for similar services.
3. A hospital or medical services corporation shall not:
(a) Subject the benefits required by subsection 1 to medical management techniques, other than step therapy;
(b) Limit the covered amount of a drug described in paragraph (a) of subsection 1;
(c) Refuse to cover a drug described in paragraph (a) of subsection 1 because the drug is dispensed by a pharmacy through mail order service; or
(d) Prohibit or restrict access to any service or drug to treat human immunodeficiency virus or hepatitis C on the same day on which the insured is diagnosed.
4. A hospital or medical services corporation shall ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the hospital or medical services corporation.
5. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2024, has the legal effect of including the coverage required by subsection 1, and any provision of the policy that conflicts with the provisions of this section is void.
6. As used in this section:
(a) Medical management technique means a practice which is used to control the cost or use of health care services or prescription drugs. The term includes, without limitation, the use of step therapy, prior authorization and categorizing drugs and devices based on cost, type or method of administration.
(b) Network plan means a policy of health insurance offered by a hospital or medical services corporation under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the hospital or medical services corporation. The term does not include an arrangement for the financing of premiums.
(c) Primary care means the practice of family medicine, pediatrics, internal medicine, obstetrics and gynecology and midwifery.
(d) Provider of health care has the meaning ascribed to it in NRS 629.031 .
Nev. Rev. Stat. § 695B.1925 Required provision concerning coverage for certain tests and vaccines relating to human papillomavirus; prohibited acts.
1. An insurer that offers or issues a contract for hospital or medical service must provide coverage for benefits payable for expenses incurred for:
(a) Deoxyribonucleic acid testing for high-risk strains of human papillomavirus every 3 years for women 30 years of age and older; and
(b) Administering the human papillomavirus vaccine at such ages as recommended for vaccination by a competent authority, including, without limitation, the Centers for Disease Control and Prevention of the United States Department of Health and Human Services, the Food and Drug Administration or the manufacturer of the vaccine.
2. An insurer must ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the insurer.
3. Except as otherwise required by subsection 5, an insurer that offers or issues a contract for hospital or medical service shall not:
(a) Require an insured to pay a higher deductible, any copayment or coinsurance or require a longer waiting period or other condition to obtain any benefit provided in the contract for hospital or medical service pursuant to subsection 1;
(b) Refuse to issue a contract for hospital or medical service or cancel a contract for hospital or medical service solely because the person applying for or covered by the contract uses or may use any such benefit;
(c) Offer or pay any type of material inducement or financial incentive to an insured to discourage the insured from obtaining any such benefit;
(d) Penalize a provider of health care who provides any such benefit to an insured, including, without limitation, reducing the reimbursement of the provider of health care;
(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 access to any such benefit to an insured; or
(f) Impose any other restrictions or delays on the access of an insured to any such benefit.
4. A contract for hospital or medical service subject to the provisions of this chapter which is delivered, issued for delivery or renewed on or after January 1, 2018, has the legal effect of including the coverage required by subsection 1, and any provision of the contract or the renewal which is in conflict with this section is void.
5. Except as otherwise provided in this section and federal law, an insurer may use medical management techniques, including, without limitation, any available clinical evidence, to determine the frequency of or treatment relating to any benefit required by this section or the type of provider of health care to use for such treatment.
6. As used in this section:
(a) Human papillomavirus vaccine means the Quadrivalent Human Papillomavirus Recombinant Vaccine or its successor which is approved by the Food and Drug Administration for the prevention of human papillomavirus infection and cervical cancer.
(b) Medical management technique means a practice which is used to control the cost or utilization of health care services or prescription drug use. The term includes, without limitation, the use of step therapy, prior authorization or categorizing drugs and devices based on cost, type or method of administration.
(c) Network plan means a contract for hospital or medical service offered by an insurer under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the insurer. The term does not include an arrangement for the financing of premiums.
(d) Provider of health care has the meaning ascribed to it in NRS 629.031 .
Nev. Rev. Stat. § 695B.1926 Required provision concerning coverage for testing, treatment and prevention of sexually transmitted diseases; required provision concerning coverage for condoms for certain insureds.
1. A hospital or medical services corporation that offers or issues a policy of health insurance shall include in the policy:
(a) Coverage of testing for and the treatment and prevention of sexually transmitted diseases, including, without limitation, Chlamydia trachomatis , gonorrhea, syphilis, human immunodeficiency virus and hepatitis B and C, for all insureds, regardless of age. Such coverage must include, without limitation, the coverage required by NRS 695B.1913 and 695B.1924 .
(b) Unrestricted coverage of condoms for insureds who are 13 years of age or older.
2. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2024, has the legal effect of including the coverage required by subsection 1, and any provision of the policy that conflicts with the provisions of this section is void.
Nev. Rev. Stat. § 695B.1927 Required provision in contract covering hospital, medical or surgical expenses concerning coverage for management and treatment of diabetes.
1. No contract for hospital or medical service that provides coverage for hospital, medical or surgical expenses may be delivered or issued for delivery in this state unless the contract includes coverage for the management and treatment of diabetes, including, without limitation, coverage for the self-management of diabetes.
2. An insurer who delivers or issues for delivery a contract specified in subsection 1:
(a) Shall include in any disclosure of the coverage provided by the contract notice to each policyholder or subscriber covered under the contract of the availability of the benefits required by this section.
(b) Except as otherwise provided in NRS 695B.19055 , shall provide the coverage required by this section subject to the same deductible, copayment, coinsurance and other such conditions for coverage that are required under the contract.
3. A contract for hospital or medical service subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 1998, has the legal effect of including the coverage required by this section, and any provision of the contract that conflicts with this section is void.
4. As used in this section:
(a) Coverage for the management and treatment of diabetes includes coverage for medication, equipment, supplies and appliances that are medically necessary for the treatment of diabetes.
(b) Coverage for the self-management of diabetes includes:
(1) The training and education provided to a person covered under the contract after the person is initially diagnosed with diabetes which is medically necessary for the care and management of diabetes, including, without limitation, counseling in nutrition and the proper use of equipment and supplies for the treatment of diabetes;
(2) Training and education which is medically necessary as a result of a subsequent diagnosis that indicates a significant change in the symptoms or condition of the person covered under the contract and which requires modification of the persons 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.
Nev. Rev. Stat. § 695B.1929 Required provision of coverage for management and treatment of sickle cell disease and its variants; policy covering prescription drugs required to provide coverage for medically necessary prescription drugs to treat sickle cell disease and its variants.
1. A hospital or medical service corporation that issues a policy of health insurance shall include in the policy coverage for:
(a) Necessary case management services for an insured who has been diagnosed with sickle cell disease and its variants; and
(b) Medically necessary care for an insured who has been diagnosed with sickle cell disease and its variants.
2. A hospital or medical service corporation that issues a policy of health insurance which provides coverage for prescription drugs shall include in the policy coverage for medically necessary prescription drugs to treat sickle cell disease and its variants.
3. A hospital or medical service corporation may use medical management techniques, including, without limitation, any available clinical evidence, to determine the frequency of or treatment relating to any benefit required by this section or the type of provider of health care to use for such treatment.
4. As used in this section:
(a) Case management services means medical or other health care management services to assist patients and providers of health care, including, without limitation, identifying and facilitating additional resources and treatments, providing information about treatment options and facilitating communication between providers of services to a patient.
(b) Medical management technique means a practice which is used to control the cost or utilization of health care services. The term includes, without limitation, the use of step therapy, prior authorization or categorizing drugs and devices based on cost, type or method of administration.
(c) Medically necessary has the meaning ascribed to it in NRS 695G.055 .
(d) Sickle cell disease and its variants has the meaning ascribed to it in NRS 439.4927 .
Nev. Rev. Stat. § 695B.1931 Contract prohibited from excluding coverage relating to treatment of temporomandibular joint; exception.
1. Except as otherwise provided in this section, no contract for hospital or medical service may be delivered or issued for delivery in this state if it contains an exclusion of coverage of the treatment of the temporomandibular joint whether by specific language in the contract or by a claims settlement practice. A contract for hospital or medical service may exclude coverage of those methods of treatment which are recognized as dental procedures, including, but not limited to, the extraction of teeth and the application of orthodontic devices and splints.
2. Pursuant to a contract for hospital or medical service, a corporation may limit its liability on the treatment of the temporomandibular joint to:
(a) No more than 50 percent of the usual and customary charges for such treatment actually received by a subscriber, but in no case more than 50 percent of the maximum benefits provided by the contract for such treatment; and
(b) Treatment which is medically necessary.
3. Any provision of a contract subject to the provisions of this chapter and issued or delivered on or after January 1, 1990, which is in conflict with this section is void.
Nev. Rev. Stat. § 695B.1932 Policy covering prescription drugs: Denial of coverage prohibited for early refills of otherwise covered topical ophthalmic products.
1. A hospital or medical service corporation which offers or issues a policy of health insurance that provides coverage for prescription drugs shall not deny coverage for a topical ophthalmic product which is otherwise approved for coverage by the hospital or medical service corporation when the insured, pursuant to NRS 639.2395 , receives a refill of the product:
(a) After 21 days or more but before 30 days after receiving any 30-day supply of the product;
(b) After 42 days or more but before 60 days after receiving any 60-day supply of the product; or
(c) After 63 days or more but before 90 days after receiving any 90-day supply of the product.
2. The provisions of this section do not affect any deductibles, copayments or coinsurance authorized or required pursuant to the policy of health insurance.
3. A policy of health insurance subject to the provisions of this chapter which provides coverage for prescription drugs and that is delivered, issued for delivery or renewed on or after January 1, 2016, has the legal effect of including the coverage required by this section, and any provision of the policy or renewal which is in conflict with this section is void.
4. As used in this section, topical ophthalmic product means a liquid prescription drug which is applied directly to the eye from a bottle or by means of a dropper.
Nev. Rev. Stat. § 695B.1942 Required provision in contract covering treatment of prostate cancer concerning coverage for prostate cancer screening; prohibited act.
1. A policy of health insurance issued by a hospital or medical service corporation that provides coverage for the treatment of prostate cancer must provide coverage for prostate cancer screening in accordance with:
(a) The guidelines concerning prostate cancer screening which are published by the American Cancer Society; or
(b) Other guidelines or reports concerning prostate cancer screening which are published by nationally recognized professional organizations and which include current or prevailing supporting scientific data.
2. A policy of health insurance issued by a hospital or medical service corporation that provides coverage for the treatment of prostate cancer must not require an insured to obtain prior authorization for any service provided pursuant to subsection 1.
3. A policy of health insurance issued by a hospital or medical service corporation that provides coverage for the treatment of prostate cancer which is delivered, issued for delivery or renewed on or after July 1, 2007, 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.
Nev. Rev. Stat. § 695B.1944 Required provision in certain group contracts concerning continuing coverage for employee or member on leave without pay as result of total disability.
1. As used in this section, total disability and totally disabled mean the continuing inability of the employee or member, because of an injury or illness, to perform substantially the duties related to his or her employment for which the employee or member is otherwise qualified.
2. No group subscriber contract for hospital, medical or dental service may be delivered or issued for delivery in this state unless it provides continuing coverage for an employee or member and dependents of the employee or member who are otherwise covered by the policy while the employee or member is on leave without pay as a result of a total disability. The coverage must be for any injury or illness suffered by the employee or member which is not related to the total disability or for any injury or illness suffered by a dependent of the employee or member. The coverage for such injury or illness must be equal to or greater than the coverage otherwise provided by the policy.
3. The coverage required pursuant to subsection 2 must continue until:
(a) The date on which the employment of the employee or member is terminated;
(b) The date on which the employee or member obtains another policy of health insurance;
(c) The date on which the group subscriber contract is terminated; or
(d) After a period of 12 months in which benefits under such coverage are provided to the employee or member,
Ê whichever occurs first.
Nev. Rev. Stat. § 695B.1948 Contract covering maternity care: Prohibited acts by insurer if insured is acting as gestational carrier; child deemed child of intended parent for purposes of contract.
1. An insurer that offers or issues a contract for hospital or medical services that includes coverage for maternity care shall not deny, limit or seek reimbursement for maternity care because the insured is acting as a gestational carrier.
2. If an insured acts as a gestational carrier, the child shall be deemed to be a child of the intended parent, as defined in NRS 126.590 , for purposes related to the contract for hospital or medical services.
3. As used in this section, gestational carrier has the meaning ascribed to it in NRS 126.580 .
Nev. Rev. Stat. § 695B.1949 Contract covering anatomical gifts, organ transplants or treatments or services related to organ transplants: Prohibited acts by insurer if insured is person with disability.
1. An insurer that offers or issues a contract for hospital or medical services that includes coverage for anatomical gifts, organ transplants or treatments or services related to an organ transplant shall not:
(a) Deny, limit or seek reimbursement from an insured for care related to an organ transplant because the insured is a person with a disability;
(b) Deny a person with a disability eligibility or continued eligibility to enroll or renew coverage to avoid providing coverage in accordance with this section;
(c) Reduce or limit the reimbursement of or otherwise penalize a provider of medical or related services because the provider of medical or related services acted in accordance with NRS 460.160 ; or
(d) Provide monetary or nonmonetary incentives for a provider of medical or related services to induce the provider of medical or related services to provide care to an insured in a manner inconsistent with NRS 460.160 .
2. As used in this section:
(a) Anatomical gift has the meaning ascribed to it in NRS 451.513 .
(b) Disability has the meaning ascribed to it in 42 U.S.C. § 12102(1).
(c) Provider of medical or related services has the meaning ascribed to it in NRS 460.160 .
Nev. Rev. Stat. § 695B.1951 Reimbursement for treatment by podiatrist.
1. If any contract for hospital or medical services provides coverage for treatment which is within the authorized scope of practice of a qualified podiatrist, the insured or a podiatrist who is licensed pursuant to chapter 635 of NRS and who provides such treatment to the insured, as applicable, is entitled to reimbursement for the treatment provided.
2. The terms of the policy must not limit:
(a) Coverage for treatments by a podiatrist to a number less than for treatments by other physicians.
(b) Reimbursement for treatments by a podiatrist to an amount less than that reimbursed for similar treatments by other physicians.
Nev. Rev. Stat. § 695B.1955 Reimbursement for treatment by licensed clinical alcohol and drug counselor.
If any contract for hospital or medical service provides coverage for treatment which is within the authorized scope of practice of a licensed clinical alcohol and drug counselor, the insured or a clinical alcohol and drug counselor who is licensed pursuant to chapter 641C of NRS and who provides such treatment to the insured, as applicable, is entitled to reimbursement for the treatment provided, including, without limitation, if the clinical alcohol and drug counselor must be directly reimbursed pursuant to:
1. An assignment of benefits described in NRS 687B.409 ; or
2. Any other applicable assignment of benefits.
Nev. Rev. Stat. § 695B.1973 Reimbursement for treatment by licensed marriage and family therapist or licensed clinical professional counselor.
If any contract for hospital or medical service provides coverage for treatment which is within the authorized scope of practice of a licensed marriage and family therapist or licensed clinical professional counselor, the insured or a marriage and family therapist or clinical professional counselor who is licensed pursuant to chapter 641A of NRS and who provides such treatment to the insured, as applicable, is entitled to reimbursement for the treatment provided.
Nev. Rev. Stat. § 695B.1975 Reimbursement for treatment by licensed associate in social work, social worker, master social worker, independent social worker or clinical social worker.
If any contract for hospital or medical service provides coverage for treatment which is within the authorized scope of the practice of a licensed associate in social work, social worker, master social worker, independent social worker or clinical social worker, the insured or an associate in social work, social worker, master social worker, independent social worker or clinical social worker who is licensed pursuant to chapter 641B of NRS and who provides such treatment to the insured, as applicable, is entitled to reimbursement for the treatment provided.
Nev. Rev. Stat. § 695B.1995 Reimbursement to provider of medical transportation.
1. Except as otherwise provided in subsection 3, every contract for medical service amended, delivered or issued for delivery in this State after October 1, 1989, that provides coverage for medical transportation, must contain a provision for the direct reimbursement of a provider of medical transportation for covered services if that provider does not receive reimbursement from any other source.
2. The subscriber or the provider may submit the claim for reimbursement. The provider shall not demand payment from the subscriber until after that reimbursement has been granted or denied.
3. Subsection 1 does not apply to any agreement between a corporation for medical service and a provider of medical transportation for the direct payment by the corporation for the providers services.
Nev. Rev. Stat. § 695B.1997 Assignment of benefits by insured to provider of health care.
1. A person insured under a contract for hospital, medical or dental services may assign his or her right to benefits to the provider of health care who provided the services covered by the contract. The nonprofit hospital, medical or dental service corporation shall pay all the benefits or the part of the benefits assigned by the insured to the person designated by the insured. A payment made pursuant to this subsection discharges the obligation of the corporation to pay those benefits.
2. If the insured makes an assignment under this section, but the corporation after receiving a copy of the assignment pays the benefits to the insured, the corporation shall also pay those benefits to the provider of health care who received the assignment as soon as the corporation receives notice of the incorrect payment.
3. For the purpose of this section, provider of health care has the meaning ascribed to it in NRS 629.031 .
Nev. Rev. Stat. § 695B.2505 Approval or denial of claims; payment of claims and interest; requests for additional information; award of costs and attorneys fees; compliance with requirements; imposition of administrative fine or suspension or revocation of certificate of authority for failure to comply; report of compliance by corporation.
1. Except as otherwise provided in subsection 2 and NRS 439B.754 , a corporation subject to the provisions of this chapter shall approve or deny a claim relating to a contract for dental, hospital or medical services within 21 days after the corporation receives the claim, if the claim is submitted electronically, or 30 days after the corporation receives the claim, if the claim is not submitted electronically. If the claim is approved, the corporation shall also pay the claim within that period. Except as otherwise provided in this section, if the approved claim is not paid within that period, the corporation shall pay interest on the claim at a rate of 10 percent per annum. The interest must be calculated from the date on which the payment of the claim is due pursuant to this subsection until the date on which the claim is paid.
2. If the corporation requires additional information to determine whether to approve or deny the claim, it shall notify the claimant of its request for the additional information within 20 working days after it receives the claim. The corporation shall notify the claimant of all the specific reasons for the delay in approving or denying the claim. The corporation shall approve or deny the claim within 21 days after receiving the additional information, if the additional information is submitted electronically, or 30 days after receiving the additional information, if the information is not submitted electronically. If the claim is approved, the corporation shall pay the claim within that period. If the approved claim is not paid within that period, the corporation shall pay interest on the claim in the manner prescribed in subsection 1.
3. A corporation shall not:
(a) Deny a claim without a reasonable basis for the denial.
(b) Request a claimant to resubmit information that the claimant has already provided to the corporation, unless the corporation provides a legitimate reason for the request and the purpose of the request is not to delay the payment of the claim, harass the claimant or discourage the filing of claims.
4. A corporation shall not pay only part of a claim that has been approved and is fully payable.
5. A court shall award costs and reasonable attorneys fees to the prevailing party in an action brought pursuant to this section.
6. The payment of interest provided for in this section for the late payment of an approved claim may be waived only if the payment was delayed because of an act of God or another cause beyond the control of the corporation.
7. The Commissioner may require a corporation to provide evidence which demonstrates that the corporation has substantially complied with the requirements set forth in this section, including, without limitation, payment within the time periods specified by this section of at least 95 percent of approved claims or at least 90 percent of the total dollar amount for approved claims.
8. If the Commissioner determines that a corporation is not in substantial compliance with the requirements set forth in this section or has failed to approve or deny a claim or pay an approved claim within 60 working days after receiving the claim, the Commissioner may require the corporation to pay an administrative fine in an amount to be determined by the Commissioner. Upon a second or subsequent determination that a corporation is not in substantial compliance with the requirements set forth in this section or has failed to approve or deny a claim or pay an approved claim within 60 working days after receiving the claim, the Commissioner may suspend or revoke the certificate of authority of the corporation.
9. On or before February 1 of each year, a corporation shall submit to the Commissioner a report concerning the compliance of the corporation with the requirements of this section during the immediately preceding calendar year. The report must include, without limitation:
(a) The number of claims for which the corporation failed to comply with the requirements of subsections 1 and 3 during the immediately preceding calendar year; and
(b) The total amount of interest paid by the corporation pursuant to subsections 1 and 2 during the immediately preceding calendar year.
Nev. Rev. Stat. § 695B.2555 Benefits payable under converted contract authorized to be reduced by amount payable under group contract; limitation.
A converted contract may provide that any hospital, surgical or medical benefits payable under it may be reduced by the amount of any benefits payable under the group contract after his or her termination. A converted contract may provide that during the first contract year the benefits payable under it, together with the benefits payable under the group contract, must not exceed those that would have been payable if the subscribers coverage under the group contract had remained in effect.
Nev. Rev. Stat. § 695B.2565 Renewal of converted contract: Request for information on sources of other benefits; grounds for refusal to renew; notice concerning cancellation of other coverage.
1. A converted contract issued under NRS 695B.251 may include a provision permitting the medical service corporation to request from the applicant, in advance of any premium due date, information as to whether the applicant is covered for similar benefits under any of the sources listed in NRS 695B.253 .
2. The medical service corporation may not refuse to renew the contract or the coverage of any person unless:
(a) Benefits provided under the sources listed in subsection 1 of NRS 695B.253 , together with the benefits provided by the converted contract would result in overinsurance according to the medical service corporations standards;
(b) The holder of the converted contract has refused to provide requested information as to such sources; or
(c) Fraud was committed in applying for any benefits under the converted contract.
3. Before refusing to renew a converted contract because of overinsurance, the medical service corporation shall notify the subscriber that the converted contract will be renewed only if the other coverage is cancelled.
Nev. Rev. Stat. § 695B.2575 Converted contract delivered outside Nevada: Form.
A converted contract which is to be delivered outside this state must be in such form as would be deliverable in the other jurisdiction as a converted contract if the group contract had been issued in that jurisdiction.
Nev. Rev. Stat. § 695B.2585 Provision of group coverage in lieu of converted individual contract.
The medical service corporation may elect to provide group coverage in lieu of the issuance of a converted individual contract.
Nev. Rev. Stat. § 695B.3165 Corporation prohibited from denying coverage solely because applicant or insured was intoxicated or under the influence of controlled substance; exceptions.
1. Except as otherwise provided in subsection 2, a medical services corporation that issues contracts for hospital, medical or dental services shall not:
(a) Deny a claim under such a contract solely because the claim involves an injury sustained by an insured as a consequence of being intoxicated or under the influence of a controlled substance.
(b) Cancel such a contract solely because an insured has made a claim involving an injury sustained by the insured as a consequence of being intoxicated or under the influence of a controlled substance.
(c) Refuse to issue such a contract to an eligible applicant solely because the applicant has made a claim involving an injury sustained by the applicant as a consequence of being intoxicated or under the influence of a controlled substance.
2. The provisions of subsection 1 do not prohibit a medical services corporation from enforcing a provision included in a contract for hospital, medical or dental services to:
(a) Deny a claim which involves an injury to which a contributing cause was the insureds commission of or attempt to commit a felony;
(b) Cancel such a contract solely because of such a claim; or
(c) Refuse to issue such a contract to an eligible applicant solely because of such a claim.
3. The provisions of this section do not apply to a medical services corporation under a contract for hospital, medical or dental services that provides coverage for long-term care or disability income.
Nev. Rev. Stat. § 695B.3167 Corporation prohibited from discriminating against person with respect to participation or coverage on basis of gender identity or expression.
A hospital or medical services corporation that issues a policy of health insurance shall not discriminate against any person with respect to participation or coverage under the policy on the basis of actual or perceived gender identity or expression. Prohibited discrimination includes, without limitation:
1. Denying, cancelling, limiting or refusing to issue or renew a policy of health insurance on the basis of the actual or perceived gender identity or expression of a person or a family member of the person;
2. Imposing a payment or premium that is based on the actual or perceived gender identity or expression of an insured or a family member of the insured;
3. Designating the actual or perceived gender identity or expression of a person or a family member of the person as grounds to deny, cancel or limit participation or coverage; and
4. Denying, cancelling or limiting participation or coverage on the basis of actual or perceived gender identity or expression, including, without limitation, by limiting or denying coverage for health care services that are:
(a) Related to gender transition, provided that there is coverage under the policy for the services when the services are not related to gender transition; or
(b) Ordinarily or exclusively available to persons of any sex.
Nev. Rev. Stat. § 695B.19045 Policy covering prescription drugs: Required actions by corporation related to acquisition of prescription drugs for certain insureds residing in area for which emergency or disaster has been declared.
1. If the Governor or the Legislature proclaims the existence of a state of emergency or issues a declaration of disaster pursuant to NRS 414.070 , a hospital or medical services corporation who has issued a policy of health insurance which provides coverage for prescription drugs shall, notwithstanding any provision of the policy to the contrary:
(a) Waive any provision of the policy restricting the time within which an insured may refill a covered prescription if the insured:
(1) Has not exceeded the number of refills authorized by the prescribing practitioner;
(2) Resides in the area for which the emergency or disaster has been declared; and
(3) Requests the refill not later than the end of the state of emergency or disaster or 30 days after the issuance of the proclamation or declaration, whichever is later; and
(b) Authorize payment for, and may apply a copayment, coinsurance or deductible to, a supply of a covered prescription drug for up to 30 days for an insured who requests a refill pursuant to paragraph (a).
2. The Commissioner may extend the time periods prescribed by subsection 1 in increments of 15 or 30 days as he or she determines to be necessary.
3. As used in this section, practitioner has the meaning ascribed to it in NRS 639.0125 .
Nev. Rev. Stat. § 695B.19046 Policy covering prescription drugs: Submission to step therapy protocol for drug to treat psychiatric condition prohibited in certain circumstances.
1. A policy of health insurance offered or issued by a hospital or medical services corporation which provides coverage for prescription drugs must not require an insured to submit to a step therapy protocol before covering a drug approved by the Food and Drug Administration that is prescribed to treat a psychiatric condition of the insured, if:
(a) The drug has been approved by the Food and Drug Administration with indications for the psychiatric condition of the insured or the use of the drug to treat that psychiatric condition is otherwise supported by medical or scientific evidence;
(b) The drug is prescribed by:
(1) A psychiatrist;
(2) A physician assistant under the supervision of a psychiatrist;
(3) An advanced practice registered nurse who has the psychiatric training and experience prescribed by the State Board of Nursing pursuant to NRS 632.120 ; or
(4) A primary care provider that is providing care to an insured in consultation with a practitioner listed in subparagraph (1), (2) or (3), if the closest practitioner listed in subparagraph (1), (2) or (3) who participates in the network plan of the hospital or medical services corporation is located 60 miles or more from the residence of the insured; and
(c) The practitioner listed in paragraph (b) who prescribed the drug knows, based on the medical history of the insured, or reasonably expects each alternative drug that is required to be used earlier in the step therapy protocol to be ineffective at treating the psychiatric condition.
2. Any provision of a policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2023, which is in conflict with this section is void.
3. As used in this section:
(a) Medical or scientific evidence has the meaning ascribed to it in NRS 695G.053 .
(b) Network plan means a policy of health insurance offered by a hospital or medical services corporation under which the financing and delivery of medical care is provided, in whole or in part, through a defined set of providers under contract with the hospital or medical services corporation. The term does not include an arrangement for the financing of premiums.
(c) Step therapy protocol means a procedure that requires an insured to use a prescription drug or sequence of prescription drugs other than a drug that a practitioner recommends for treatment of a psychiatric condition of the insured before his or her policy of health insurance offered or issued by a hospital or medical services corporation provides coverage for the recommended drug.
Nev. Rev. Stat. § 695B.19047 Policy covering prescription drug for medical condition that is part of step therapy protocol: Use of certain guidelines required; establishment of process to request exemption from step therapy protocol required; granting of request; applicability of provisions.
1. When developing a step therapy protocol, a hospital or medical services corporation shall use guidelines based on medical or scientific evidence, if such guidelines are available.
2. A hospital or medical services corporation that offers or issues a policy of health insurance which includes coverage for a prescription drug for the treatment of any medical condition that is part of a step therapy protocol shall:
(a) Establish a clear, convenient and readily accessible process by which an insured and his or her attending practitioner may:
(1) Request an exemption for the insured from the step therapy protocol; and
(2) Appeal a decision made by the hospital or medical services corporation concerning a request for an exemption from the step therapy protocol pursuant to subparagraph (1);
(b) Make the process described in paragraph (a) accessible through an Internet website maintained by the hospital or medical services corporation; and
(c) Except as otherwise provided in this paragraph, respond to a request made or an appeal submitted pursuant to paragraph (a) not later than 2 business days after the request is made or the appeal is submitted, as applicable. If the attending practitioner indicates that exigent circumstances exist, the hospital or medical services corporation shall respond to the request or appeal within 24 hours after the request is made or the appeal is submitted, as applicable.
3. A hospital or medical services corporation shall grant a request to exempt an insured from a step therapy protocol made in accordance with the process established pursuant to subsection 2 if the attending practitioner for the insured submits to the hospital or medical services corporation a statement which provides an adequate justification for the exemption and any documentation necessary to support the statement. The hospital or medical services corporation shall determine whether such justification exists if the statement and documentation demonstrate that:
(a) Each prescription drug that is required to be used earlier in the step therapy protocol:
(1) Is contraindicated or will likely cause an adverse reaction or physical or mental harm to the insured;
(2) Is expected to be ineffective based on the known clinical characteristics of the insured and the known characteristics of the required prescription drug;
(3) Has been tried by the insured, regardless of whether the insured was covered by the current policy of health insurance at the time, and was discontinued due to lack of efficacy or effectiveness, diminished effect or an adverse event relating to the prescription drug; or
(4) Is not in the best interest of the insured, based on medical necessity; or
(b) The insured is stable on a prescription drug selected by his or her attending practitioner for the medical condition under consideration, regardless of whether the insured was covered by his or her current policy of health insurance at the time the attending practitioner selected the drug.
4. If a hospital or medical services corporation does not respond to a request for an exemption from a step therapy protocol or an appeal concerning a decision relating to such a request within the time frame prescribed by paragraph (c) of subsection 2, the request shall be deemed to have been granted.
5. If a request for an exemption from a step therapy protocol is granted pursuant to subsection 3 or deemed granted pursuant to subsection 4, the hospital or medical services corporation shall immediately authorize coverage for and dispensing of the drug chosen by the attending practitioner for the insured.
6. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2024, has the legal effect of including the coverage required by this section, and any provisions of the policy that conflict with the provisions of this section is void.
7. The provisions of this section do not apply to any prescription drug to which the provisions of NRS 695B.19085 apply.
8. As used in this section:
(a) Attending practitioner means the practitioner, as defined in NRS 639.0125 , who has primary responsibility for the treatment of the medical condition of an insured for which a prescription drug is prescribed.
(b) Medical or scientific evidence has the meaning ascribed to it in NRS 695G.053 .
Nev. Rev. Stat. § 695B.19055 Limitation on cost-sharing obligation for insulin covered under policy covering prescription insulin drugs prohibited from imposing certain cost-sharing obligations.
1. A hospital or medical services corporation that offers or issues a policy of health insurance which provides coverage for prescription insulin drugs shall not impose against an insured a deductible, copayment, coinsurance or other cost-sharing obligation that is greater than $35 for a 30-day supply of a prescription insulin drug which is prescribed to the insured and covered by the hospital or medical services corporation, regardless of the amount or type of prescription insulin drug prescribed.
2. As used in this section:
(a) Diabetes includes type I, type II and gestational diabetes.
(b) Prescription insulin drug means a prescription drug that contains insulin and is used to control blood glucose levels for the purpose of treating diabetes.
Nev. Rev. Stat. § 695B.19065 Required provision concerning coverage for screening for lung cancer in policy that provides coverage for treatment of lung cancer.
1. A hospital or medical services corporation that offers a policy of health insurance that provides coverage for the treatment of lung cancer must provide coverage for screening for lung cancer in accordance with:
(a) The guidelines concerning screening for lung cancer which are published by the American Cancer Society; or
(b) Other guidelines or reports concerning screening for lung cancer which are published by nationally recognized professional organizations and which are based on current or prevailing supporting scientific data.
2. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2026, has the legal effect of including the coverage required by this section, and any provision of the policy that conflicts with the provisions of this section is void.
Nev. Rev. Stat. § 695B.19085 Policy covering prescription drug for treatment of cancer or cancer symptom that is part of step therapy protocol: Corporation required to allow insured or attending practitioner to apply exemption from step therapy protocol in certain circumstances; procedure for applying for and granting exemption.
1. A hospital or medical services corporation that offers or issues a policy of health insurance which provides coverage of a prescription drug for the treatment of cancer or any symptom of cancer that is part of a step therapy protocol shall allow an insured who has been diagnosed with stage 3 or 4 cancer or the attending practitioner of the insured to apply for an exemption from the step therapy protocol. The application process for such an exemption must:
(a) Allow the insured or attending practitioner, or a designated advocate for the insured or attending practitioner, to present to the hospital or medical services corporation the clinical rationale for the exemption and any relevant medical information.
(b) Clearly prescribe the information and supporting documentation that must be submitted with the application, the criteria that will be used to evaluate the request and the conditions under which an expedited determination pursuant to subsection 4 is warranted.
(c) Require the review of each application by at least one physician, registered nurse or pharmacist.
2. The information and supporting documentation required pursuant to paragraph (b) of subsection 1:
(a) May include, without limitation:
(1) The medical history or other health records of the insured demonstrating that the insured has:
(I) Tried other drugs included in the pharmacological class of drugs for which the exemption is requested without success; or
(II) Taken the requested drug for a clinically appropriate amount of time to establish stability in relation to the cancer and the guidelines of the prescribing practitioner; and
(2) Any other relevant clinical information.
(b) Must not include any information or supporting documentation that is not necessary to make a determination about the application.
3. Except as otherwise provided in subsection 4, a hospital or medical services corporation that receives an application for an exemption pursuant to subsection 1 shall:
(a) Make a determination concerning the application if the application is complete or request additional information or documentation necessary to complete the application not later than 72 hours after receiving the application; and
(b) If it requests additional information or documentation, make a determination concerning the application not later than 72 hours after receiving the requested information or documentation.
4. If, in the opinion of the attending practitioner, a step therapy protocol may seriously jeopardize the life or health of the insured, a hospital or medical services corporation that receives an application for an exemption pursuant to subsection 1 must make a determination concerning the application as expeditiously as necessary to avoid serious jeopardy to the life or health of the insured.
5. A hospital or medical services corporation shall disclose to the insured or attending practitioner who submits an application for an exemption from a step therapy protocol pursuant to subsection 1 the qualifications of each person who will review the application.
6. A hospital or medical services corporation must grant an exemption from a step therapy protocol in response to an application submitted pursuant to subsection 1 if:
(a) Any treatment otherwise required under the step therapy or any drug in the same pharmacological class or having the same mechanism of action as the drug for which the exemption is requested has not been effective at treating the cancer or symptom of the insured when prescribed in accordance with clinical indications, clinical guidelines or other peer-reviewed evidence;
(b) Delay of effective treatment would have severe or irreversible consequences for the insured and the treatment otherwise required under the step therapy is not reasonably expected to be effective based on the physical or mental characteristics of the insured and the known characteristics of the treatment;
(c) Each treatment otherwise required under the step therapy:
(1) Is contraindicated for the insured or has caused or is likely, based on peer-reviewed clinical evidence, to cause an adverse reaction or other physical harm to the insured; or
(2) Has prevented or is likely to prevent the insured from performing the responsibilities of his or her occupation or engaging in activities of daily living, as defined in 42 C.F.R. § 441.505;
(d) The condition of the insured is stable while being treated with the prescription drug for which the exemption is requested and the insured has previously received approval for coverage of that drug; or
(e) Any other condition for which such an exemption is required by regulation of the Commissioner is met.
7. If a hospital or medical services corporation approves an application for an exemption from a step therapy protocol pursuant to this section, the hospital or medical services corporation must cover the prescription drug to which the exemption applies in accordance with the terms of the applicable policy of health insurance. The hospital or medical services corporation may initially limit the coverage to a 1-week supply of the drug for which the exemption is granted. If the attending practitioner determines after 1 week that the drug is effective at treating the cancer or symptom for which it was prescribed, the hospital or medical services corporation must continue to cover the drug for as long as it is necessary to treat the insured for the cancer or symptom. The hospital or medical services corporation may conduct a review not more frequently than once each quarter to determine, in accordance with available medical evidence, whether the drug remains necessary to treat the insured for the cancer or symptom. The hospital or medical services corporation shall provide a report of the review to the insured.
8. A hospital or medical services corporation shall post in an easily accessible location on an Internet website maintained by the hospital or medical services corporation a form for requesting an exemption pursuant to this section.
9. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2022, has the legal effect of including the coverage required by this section, and any provision of the policy that conflicts with this section is void.
10. As used in this section, attending practitioner means the practitioner, as defined in NRS 639.0125 , who has primary responsibility for the treatment of the cancer or any symptom of such cancer of an insured.
Nev. Rev. Stat. § 695B.19087 Required provision concerning coverage for biomarker testing for diagnosis, treatment, management and monitoring of cancer in certain circumstances; establishment of process to request exception or appeal denial of coverage; time for responding to request for prior authorization.
1. Subject to the limitations prescribed by subsection 4, a hospital or medical service corporation that issues a policy of health insurance shall include in the policy coverage for medically necessary biomarker testing for the diagnosis, treatment, appropriate management and ongoing monitoring of cancer when such biomarker testing is supported by medical and scientific evidence. Such evidence includes, without limitation:
(a) The labeled indications for a biomarker test or medication that has been approved or cleared by the United States Food and Drug Administration;
(b) The indicated tests for a drug that has been approved by the United States Food and Drug Administration or the warnings and precautions included on the label of such a drug;
(c) A national coverage determination or local coverage determination, as those terms are defined in 42 C.F.R. § 400.202; or
(d) Nationally recognized clinical practice guidelines or consensus statements.
2. A hospital or medical service corporation shall:
(a) Provide the coverage required by subsection 1 in a manner that limits disruptions in care and the need for multiple specimens;
(b) Establish a clear and readily accessible process for an insured or provider of health care to:
(1) Request an exception to a policy excluding coverage for biomarker testing for the diagnosis, treatment, management or ongoing monitoring of cancer; or
(2) Appeal a denial of coverage for such biomarker testing; and
(c) Make the process described in paragraph (b) available on an Internet website maintained by the hospital or medical service corporation.
3. If a hospital or medical service corporation requires an insured to obtain prior authorization for a biomarker test described in subsection 1, the hospital or medical service corporation shall respond to a request for such prior authorization:
(a) Within 24 hours after receiving an urgent request; or
(b) Within 72 hours after receiving any other request.
4. The provisions of this section do not require a hospital or medical service corporation to provide coverage of biomarker testing:
(a) For screening purposes;
(b) Conducted by a provider of health care for whom the biomarker testing is not within his or her scope of practice, training and experience;
(c) Conducted by a provider of health care or a facility that does not participate in the network plan of the hospital or medical service corporation; or
(d) That has not been determined to be medically necessary by a provider of health care for whom such a determination is within his or her scope of practice, training and experience.
5. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 2023, has the legal effect of including the coverage required by this section, and any provision of the policy or renewal which is in conflict with the provisions of this section is void.
6. As used in this section:
(a) Biomarker means a characteristic that is objectively measured and evaluated as an indicator of a normal biological process, a pathogenic process or a pharmacological response to a specific therapeutic intervention and includes, without limitation:
(1) An interaction between a gene and a drug that is being used by or considered for use by the patient;
(2) A mutation or characteristic of a gene; and
(3) The expression of a protein.
(b) Biomarker testing means the analysis of the tissue, blood or other biospecimen of a patient for the presentation of a biomarker and includes, without limitation, single-analyte tests, multiplex panel tests and whole genome, whole exome and whole transcriptome sequencing.
(c) Consensus statement means a statement aimed at a specific clinical circumstance that is:
(1) Made for the purpose of optimizing the outcomes of clinical care;
(2) Made by an independent, multidisciplinary panel of experts that has established a policy to avoid conflicts of interest;
(3) Based on scientific evidence; and
(4) Made using a transparent methodology and reporting procedure.
(d) Medically necessary means health care services or products that a prudent provider of health care would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that are necessary and:
(1) Provided in accordance with generally accepted standards of medical practice;
(2) Not primarily provided for the convenience of the patient or provider of health care; and
(3) Significant in guiding and informing the provider of health care in providing the most appropriate course of treatment for the patient in order to prevent, delay or lessen the magnitude of an adverse health outcome.
(e) Nationally recognized clinical practice guidelines means evidence-based guidelines establishing standards of care that include, without limitation, recommendations intended to optimize care of patients and are:
(1) Informed by a systemic review of evidence and an assessment of the risks and benefits of alternative options for care; and
(2) Developed using a transparent methodology and reporting procedure by an independent organization or society of medical professionals that has established a policy to avoid conflicts of interest.
(f) Network plan means a policy of health insurance offered by a hospital or medical service corporation under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the hospital or medical service corporation. The term does not include an arrangement for the financing of premiums.
(g) Provider of health care has the meaning ascribed to it in NRS 629.031 .
Nev. Rev. Stat. § 695B.19155 Required provision concerning coverage for habilitative speech-language pathology and rehabilitative speech-language pathology as treatment for stuttering for certain persons; prohibited acts.
1. A hospital or medical services corporation that offers or issues a policy of health insurance shall include in the policy coverage for habilitative speech-language pathology and rehabilitative speech-language pathology as a treatment for stuttering for insureds who are less than 26 years of age.
2. A hospital or medical services corporation shall not:
(a) Set a maximum annual limit on the benefits described in subsection 1, including, without limitation, a limit on the number of annual visits to a speech-language pathologist;
(b) Limit the benefits described in subsection 1 based on the cause of the stuttering; or
(c) Subject the benefits described in subsection 1 to medical management techniques.
3. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2026, has the legal effect of including the coverage required by subsection 1, and any provision of the policy that conflicts with the provisions of this section is void.
4. As used in this section:
(a) Habilitative speech-language pathology means services that constitute the practice of speech-language pathology which help a person keep, learn or improve skills and functioning for daily living.
(b) Medical management technique means a practice which is used to control the cost or use of health care services or prescription drugs. The term includes, without limitation, the use of step therapy, prior authorization and categorizing drugs and devices based on cost, type or method of administration.
(c) Practice of speech-language pathology has the meaning ascribed to it in NRS 637B.060 .
(d) Rehabilitative speech-language pathology means services that constitute the practice of speech-language pathology which help a person restore or improve skills and functioning for daily living that have been lost or impaired.
Nev. Rev. Stat. § 695B.19192 Required provision concerning coverage for procedure or service for preservation of fertility in certain circumstances; exemption. [Effective January 1, 2027.]
1. Except as otherwise provided in subsection 4, a hospital or medical services corporation that issues a policy of health insurance shall include in the policy coverage for any procedure or service for the preservation of fertility consistent with established medical practice or any guidelines published by the American Society for Reproductive Medicine or the American Society of Clinical Oncology, or their successor organizations, that is medically necessary to preserve fertility because the insured has been diagnosed with breast or ovarian cancer and:
(a) The cancer may, in the judgment of a provider of health care, directly or indirectly cause infertility; or
(b) The insured is expected to receive medical treatment for the cancer and such treatment may directly or indirectly cause infertility.
2. For the purposes of subsection 1, a medical treatment may directly or indirectly cause infertility if the treatment has a potential side effect of impaired fertility, as established by the American Society of Clinical Oncology or the American Society for Reproductive Medicine, or their successor organizations.
3. A hospital or medical services corporation shall ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the hospital or medical services corporation.
4. A hospital or medical services corporation that is affiliated with a religious organization is not required to provide the coverage required by subsection 1 if the hospital or medical services corporation objects on religious grounds. Such a hospital or medical services corporation shall, before the issuance of a policy of health insurance that is subject to the requirements of subsection 1 and before the renewal of such a policy, provide to the insured or prospective insured, as applicable, written notice of the coverage that the hospital or medical services corporation refuses to provide pursuant to this subsection.
5. A policy of health insurance that is subject to the provisions of this chapter and is delivered, issued for delivery or renewed on or after January 1, 2026, has the legal effect of including the coverage required by subsection 1, and any provision of the policy or the renewal that conflicts with the provisions of this section is void.
6. As used in this section:
(a) Network plan means a policy of health insurance offered by a hospital or medical services corporation under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the hospital or medical services corporation. The term does not include an arrangement for the financing of premiums.
(b) Provider of health care has the meaning ascribed to it in NRS 629.031 .
Nev. Rev. Stat. § 695B.19195 Required provision concerning coverage for certain services, screenings and tests relating to wellness; prohibited acts.
1. An insurer that offers or issues a contract for hospital or medical service shall include in the contract coverage for:
(a) Counseling, support and supplies for breastfeeding, including breastfeeding equipment, counseling and education during the antenatal, perinatal and postpartum period for not more than 1 year;
(b) Screening and counseling for interpersonal and domestic violence for women at least annually with initial intervention services consisting of education, strategies to reduce harm, supportive services or a referral for any other appropriate services;
(c) Behavioral counseling concerning sexually transmitted diseases from a provider of health care for sexually active women who are at increased risk for such diseases;
(d) Such prenatal screenings and tests as recommended by the American College of Obstetricians and Gynecologists or its successor organization;
(e) Screening for blood pressure abnormalities and diabetes, including gestational diabetes, after at least 24 weeks of gestation or as ordered by a provider of health care;
(f) Screening for cervical cancer at such intervals as are recommended by the American College of Obstetricians and Gynecologists or its successor organization;
(g) Screening for depression;
(h) Screening and counseling for the human immunodeficiency virus consisting of a risk assessment, annual education relating to prevention and at least one screening for the virus during the lifetime of the insured or as ordered by a provider of health care;
(i) Smoking cessation programs for an insured who is 18 years of age or older consisting of not more than two cessation attempts per year and four counseling sessions per year;
(j) All vaccinations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention of the United States Department of Health and Human Services or its successor organization; and
(k) Such well-woman preventative visits as recommended by the Health Resources and Services Administration, which must include at least one such visit per year beginning at 14 years of age.
2. An insurer must ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the insurer.
3. Except as otherwise provided in subsection 5, an insurer that offers or issues a contract for hospital or medical service shall not:
(a) Require an insured to pay a higher deductible, any copayment or coinsurance or require a longer waiting period or other condition to obtain any benefit provided in the contract for hospital or medical service pursuant to subsection 1;
(b) Refuse to issue a contract for hospital or medical service or cancel a contract for hospital or medical service solely because the person applying for or covered by the contract uses or may use any such benefit;
(c) Offer or pay any type of material inducement or financial incentive to an insured to discourage the insured from obtaining any such benefit;
(d) Penalize a provider of health care who provides any such benefit to an insured, including, without limitation, reducing the reimbursement of the provider of health care;
(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 access to any such benefit to an insured; or
(f) Impose any other restrictions or delays on the access of an insured to any such benefit.
4. A contract for hospital or medical service subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2018, has the legal effect of including the coverage required by subsection 1, and any provision of the contract or the renewal which is in conflict with this section is void.
5. Except as otherwise provided in this section and federal law, an insurer may use medical management techniques, including, without limitation, any available clinical evidence, to determine the frequency of or treatment relating to any benefit required by this section or the type of provider of health care to use for such treatment.
6. As used in this section:
(a) Medical management technique means a practice which is used to control the cost or utilization of health care services or prescription drug use. The term includes, without limitation, the use of step therapy, prior authorization or categorizing drugs and devices based on cost, type or method of administration.
(b) Network plan means a contract for hospital or medical service offered by an insurer under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the insurer. The term does not include an arrangement for the financing of premiums.
(c) Provider of health care has the meaning ascribed to it in NRS 629.031 .
Nev. Rev. Stat. § 695B.19197 Required provision concerning coverage for certain drugs and services related to substance use disorder and opioid use disorder; reimbursement of pharmacists and pharmacies for certain services; prohibited acts.
1. A hospital or medical services corporation that offers or issues a policy of health insurance shall include in the policy coverage for:
(a) All drugs approved by the United States Food and Drug Administration to support safe withdrawal from substance use disorder, including, without limitation, lofexidine.
(b) All drugs approved by the United States Food and Drug Administration to provide medication-assisted treatment for opioid use disorder, including, without limitation, buprenorphine, methadone and naltrexone.
(c) The services described in NRS 639.28079 when provided by a pharmacist or pharmacy that participates in the network plan of the hospital or medical services corporation. The Commissioner shall adopt regulations governing the provision of reimbursement for such services.
(d) Any service for the treatment of substance use disorder provided by a provider of primary care if the service is covered when provided by a specialist and:
(1) The service is within the scope of practice of the provider of primary care; or
(2) The provider of primary care is capable of providing the service safely and effectively in consultation with a specialist and the provider engages in such consultation.
2. A hospital or medical services corporation that offers or issues a policy of health insurance shall reimburse a pharmacist or pharmacy that participates in the network plan of the hospital or medical services corporation for the services described in NRS 639.28079 at a rate equal to the rate of reimbursement provided to a physician, physician assistant or advanced practice registered nurse for similar services.
3. A hospital or medical services corporation shall provide the coverage required by paragraphs (a) and (b) of subsection 1 regardless of whether the drug is included in the formulary of the hospital or medical services corporation.
4. Except as otherwise provided in this subsection, a hospital or medical services corporation shall not subject the benefits required by paragraphs (a), (b) and (c) of subsection 1 to medical management techniques, other than step therapy. A hospital or medical services corporation may subject the benefits required by paragraphs (b) and (c) of subsection 1 to other reasonable medical management techniques when the benefits are provided by a pharmacist in accordance with NRS 639.28079 .
5. A hospital or medical services corporation shall not:
(a) Limit the covered amount of a drug described in paragraph (a) or (b) of subsection 1; or
(b) Refuse to cover a drug described in paragraph (a) or (b) of subsection 1 because the drug is dispensed by a pharmacy through mail order service.
6. A hospital or medical services corporation shall ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the hospital or medical services corporation.
7. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2024, has the legal effect of including the coverage required by subsection 1, and any provision of the policy that conflicts with the provisions of this section is void.
8. As used in this section:
(a) Medical management technique means a practice which is used to control the cost or use of health care services or prescription drugs. The term includes, without limitation, the use of step therapy, prior authorization and categorizing drugs and devices based on cost, type or method of administration.
(b) Network plan means a policy of health insurance offered by a hospital or medical services corporation under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the hospital or medical services corporation. The term does not include an arrangement for the financing of premiums.
(c) Primary care means the practice of family medicine, pediatrics, internal medicine, obstetrics and gynecology and midwifery.
(d) Provider of health care has the meaning ascribed to it in NRS 629.031 .
Nev. Rev. Stat. § 695B.19199 Required provision concerning coverage for noninvasive prenatal screening.
1. A hospital or medical services corporation that offers or issues a policy of group health insurance shall include in the policy coverage for noninvasive prenatal screening at any time during pregnancy. Such coverage must be provided without prior authorization.
2. A policy of group health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2026, has the legal effect of including the coverage required by subsection 1, and any provision of the policy that conflicts with the provisions of this section is void.
3. As used in this section, noninvasive prenatal screening means drawing blood from a person who is pregnant to perform laboratory analysis on the deoxyribonucleic acid circulating in the maternal blood stream for the purpose of detecting chromosomal abnormalities in the fetus.
Nev. Rev. Stat. § 695B.19305 Required provision concerning coverage for dental service provided by qualified dental hygienist in certain circumstances.
1. An insurer that offers or issues a contract for dental services which includes coverage for a dental service that a qualified dental hygienist is authorized to provide without the supervision of a dentist shall provide coverage for that service when provided by such a qualified dental hygienist without the supervision of a dentist to the same extent as if provided by a qualified dental hygienist under the supervision of a dentist.
2. A contract for dental services subject to the provisions of this chapter which provides coverage for a dental service described in subsection 1 and that is delivered, issued for delivery or renewed on or after October 1, 2025, has the legal effect of including the coverage required by this section, and any provision of the contract that conflicts with the provisions of this section is void.
3. As used in this section, qualified dental hygienist means a dental hygienist who holds a special endorsement issued by the Board of Dental Examiners of Nevada pursuant to NRS 631.287 , is employed by a nonprofit organization and provides services within the scope of that employment.
Source: NV Statutes (Official Site)URL: https://www.leg.state.nv.us/nrs/NRS-695B.htmlFetched: 10/4/2026