Nev. Rev. Stat. § 695A.001 Definitions.
As used in this chapter, unless the context otherwise requires, the words and terms defined in NRS 695A.003 to 695A.044, inclusive, have the meanings ascribed to them in those sections.
FRATERNAL BENEFIT SOCIETIES
Nev. Rev. Stat. 695A
in effectNev. Rev. Stat. § 695A.003 Benefit contract defined.
Benefit contract means an agreement for the provision of any contractual benefit authorized by NRS 695A.180.
Nev. Rev. Stat. § 695A.004 Benefit member defined.
Benefit member means a member of a society who is an adult and who is designated by the laws or rules of the society to be a benefit member under a benefit contract.
Nev. Rev. Stat. § 695A.006 Certificate defined.
Certificate means the document issued as written evidence of the benefit contract.
Nev. Rev. Stat. § 695A.010 Fraternal benefit society defined.
Fraternal benefit society means any incorporated society, order or supreme lodge, without capital stock, including one exempted under the provisions of paragraph (b) of subsection 1 of NRS 695A.570 whether incorporated or not, which:
1. Is conducted solely for the benefit of its members and their beneficiaries and not for profit;
2. Operates on a lodge system with ritualistic form of work;
3. Has a representative form of government; and
4. Provides benefits in accordance with this chapter.
Nev. Rev. Stat. § 695A.014 Insurer defined.
Insurer includes every person engaged as principal and as indemnitor, surety or contractor in the business of entering into contracts of insurance.
Nev. Rev. Stat. § 695A.016 Laws defined.
Laws means the articles of incorporation, charter, constitution and bylaws of the society.
Nev. Rev. Stat. § 695A.018 Lodge defined.
Lodge means a subordinate unit of a society, and includes a camp, court, council, branch or any similar entity by whatever name designated.
Nev. Rev. Stat. § 695A.020 Lodge system defined.
Lodge system means the system under which a society is operating if:
1. The society has a supreme governing body and subordinate lodges into which members are elected, initiated or admitted in accordance with its laws, ritual and rules; and
2. The subordinate lodges are required by the laws of the society to hold regular meetings at least once in each month.
Nev. Rev. Stat. § 695A.023 Medicaid defined.
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.
Nev. Rev. Stat. § 695A.027 Order for medical coverage defined.
Order for medical coverage means an order of a court or administrative tribunal to provide coverage under a certificate for health benefits to a child pursuant to the provisions of 42 U.S.C. § 1396g-1.
Nev. Rev. Stat. § 695A.030 Premiums defined.
Premiums means premiums, rates, dues or other required contributions by whatever name known, which are payable under the certificate.
Nev. Rev. Stat. § 695A.040 Representative form of government defined.
Representative form of government means that form of government which a society has when:
1. It has a supreme governing body which is:
(a) An assembly composed of delegates elected either directly by the members of the society or at intermediate assemblies or conventions of members or their representatives, and such other delegates as prescribed in the laws of the society; or
(b) A board composed of persons elected by the members of the society, either directly or by their representatives in intermediate assemblies, and such other persons as prescribed in the laws of the society.
2. If its supreme governing body is an assembly:
(a) The elected delegates constitute a majority in number, have a majority of the votes and have not less than the number of votes necessary to amend the laws of the society;
(b) The election of delegates is done in person or by mail, as prescribed in the laws of the society;
(c) The assembly is elected and meets not less than once every 4 years;
(d) A board of directors is elected by the assembly to conduct the business of the society in the interim between meetings of the assembly; and
(e) Vacancies on the board of directors are filled in the manner prescribed in the laws of the society.
3. If its supreme governing body is a board:
(a) The persons elected to the board constitute a majority in number, have a majority of the votes and have not less than the number of votes necessary to amend the laws of the society;
(b) The election of the members of the board is done in person or by mail, as prescribed in the laws of the society;
(c) The term of any member of the board does not exceed 4 years;
(d) The board meets not less than quarterly to conduct the business of the society;
(e) Vacancies on the board are filled in the manner prescribed in the laws of the society; and
(f) A person filling the unexpired term of an elected member of the board is considered to be an elected member.
4. The officers of the society are elected either by the supreme governing body or by the board of directors.
5. Only benefit members are eligible for election to the supreme governing body, the board of directors or any intermediate assembly.
6. Each member who is entitled to vote has only one vote, and votes are not cast by proxy.
Nev. Rev. Stat. § 695A.042 Rules defined.
Rules includes all rules, regulations and resolutions adopted by the supreme governing body or board of directors of a society and which generally apply to the members of the society.
Nev. Rev. Stat. § 695A.044 Society defined.
Society means a fraternal benefit society.
Nev. Rev. Stat. § 695A.050 Organization: Preparation and contents of articles of incorporation.
Ten or more citizens of the United States, a majority of whom are citizens of this state, who desire to form a fraternal benefit society, may make, sign and acknowledge before some person competent to take acknowledgment of deeds, articles of incorporation, in which must be stated:
1. The proposed corporate name of the society, which must not so closely resemble the name of any society or insurer as to be misleading or confusing;
2. The purposes for which it is being formed, which must not include more liberal powers than are granted by this chapter;
3. The mode in which its corporate powers are to be exercised; and
4. The names and residences of the incorporators and the names, residences and official titles of all the officers, trustees, directors or other persons who are to have and exercise the general control of the management of the affairs and money of the society for the first year or until the ensuing election at which all officers must be elected by the supreme governing body, which election must be held not later than 1 year after the date of the issuance of the permanent certificate of authority.
Nev. Rev. Stat. § 695A.060 Organization: Filing of documents and bond with Commissioner; preliminary certificate of authority.
1. Duly certified copies of the laws and rules of the society, copies of all proposed forms of certificates, applications therefor, circulars to be issued by the society and a bond conditioned upon the return to applicants of the advanced payments if the organization is not completed within 1 year must be filed with the Commissioner, who may require such further information as the Commissioner deems necessary. The bond must comply with NRS 679B.175 and be in an amount determined by the Commissioner, which must be not less than $300,000 nor more than $1,500,000. All documents filed must be in the English language. If the purposes of the society conform to the requirements of this chapter and all applicable provisions of the law of this state have been complied with, the Commissioner shall so certify, retain and file the articles of incorporation and furnish the incorporators a preliminary certificate of authority for the society to solicit members as provided in this chapter.
2. No preliminary certificate of authority granted under the provisions of this section is valid after 1 year from its date or after such further period, not exceeding 1 year, as may be authorized by the Commissioner upon cause shown, unless 500 applicants have been secured and the organization has been completed as provided in this chapter. The articles of incorporation and all proceedings thereunder are void 1 year after the date of the preliminary certificate of authority, or at the expiration of the extended period, unless the society has completed its organization and received a certificate of authority to do business.
Nev. Rev. Stat. § 695A.070 Organization: Solicitation of members; collection of advance premiums; reports to Commissioner.
1. Upon receipt of a preliminary certificate of authority from the Commissioner, the society:
(a) May solicit members for the purpose of completing its organization;
(b) Shall collect from each applicant the amount of not less than one regular monthly premium in accordance with its table of rates; and
(c) Shall issue to each applicant a receipt for the amount collected.
2. A society shall not incur any liability other than for the return of an advance premium, or issue any certificate, or pay, allow, or offer or promise to pay or allow, any death or disability benefit to any person until:
(a) Actual bona fide applications for benefits have been secured aggregating at least $500,000 on not less than 500 applicants, and all required evidence of insurability has been furnished to and approved by the society;
(b) Not less than 10 subordinate lodges have been established into which the 500 applicants have been admitted;
(c) There has been submitted to the Commissioner, under oath of the president or secretary, or corresponding officer of the society, a list of the applicants, giving their names and addresses, the date each was admitted, the name and number of the subordinate lodge of which each applicant is a member, the amount of benefits to be granted and the premiums therefor; and
(d) It has been shown to the Commissioner, by sworn statement of the treasurer or corresponding officer of the society, that at least 500 applicants have each paid in cash at least one regular monthly premium as provided in this chapter, which premiums in the aggregate must amount to at least $150,000.
3. The advance premiums provided for in subsection 2 must be held in trust during the period of organization and if the society has not qualified for a permanent certificate of authority within 1 year, as provided in this chapter, the premiums must be returned to the applicants.
Nev. Rev. Stat. § 695A.080 Certificate of authority: Issuance and renewal; effect; record; copies; fees.
1. The Commissioner may make such examination and require such further information as the Commissioner deems advisable. Upon presentation of satisfactory evidence that the society has complied with all applicable provisions of law, the Commissioner shall issue to the society a certificate of authority indicating that the society may transact business pursuant to the provisions of this chapter.
2. The certificate of authority is prima facie evidence of the existence of the society on the date of the certificate.
3. The Commissioner shall cause a record of the certificate of authority to be made. A certified copy of the record may be given in evidence with like effect as the original certificate of authority.
4. For the issuance or renewal of a certificate of authority, a society must pay to the Commissioner:
(a) A fee of $250 if the number of outstanding benefit contracts within Nevada of the society is 600 or less;
(b) A fee of $500 if the number of outstanding benefit contracts within Nevada of the society is more than 600 but less than 1,200;
(c) A fee of $2,450 if the number of outstanding benefit contracts within Nevada of the society is 1,200 or more; and
(d) In addition to any other fee or charge, all applicable fees required pursuant to NRS 680C.110 .
Ê Each such certificate or renewal expires on March 1 following its issuance.
5. If a society properly applies for the renewal of its certificate of authority but does not receive approval of its application by March 1, it may continue to transact business pursuant to this chapter unless it receives notice that the application for renewal is specifically denied.
6. A certified copy or duplicate of a certificate of authority is prima facie evidence that the society may lawfully transact business in this state pursuant to the provisions of this chapter during the period stated on the license.
Nev. Rev. Stat. § 695A.090 General powers and duties of society.
A society shall operate for the benefit of its members and their beneficiaries by providing benefits as specified in NRS 695A.180 and may:
1. Operate for any lawful social, intellectual, educational, charitable, benevolent, moral, fraternal, patriotic or religious purpose.
2. Carry out its purposes directly or through subsidiary corporations or affiliated organizations.
3. Create, maintain and operate, or establish organizations to operate, nonprofit institutions to further the societys purposes. Such institutions may charge a reasonable amount for their services.
4. Organize and operate lodges for children under the minimum age for adult membership. Membership and initiation in local lodges must not be required of children, and they must not have a voice or vote in the management of the society.
5. Adopt laws and rules for the government of the society, the admission of its members and the management of its affairs.
6. Amend its laws and rules.
7. Exercise any other power which is necessary and incidental to carrying into effect the objects and purposes of the society and which is not inconsistent with the provisions of this chapter.
Nev. Rev. Stat. § 695A.095 Contracts between society and provider of health care: Prohibiting society from charging provider of health care fee for inclusion on list of providers given to insureds; society required to use form to obtain information on provider of health care; modification; submission by society of schedule of payments to provider.
1. A society 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 society to its insureds.
2. A society shall not contract with a provider of health care to provide health care to an insured unless the society 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 society 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 society upon giving to the provider 45 days written notice of the modification of the societys 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 society contracts with a provider of health care to provide health care to an insured, the society 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. § 695A.110 Unincorporated or voluntary association prohibited from transacting business as society.
No unincorporated or voluntary association may transact business in this state as a fraternal benefit society.
Nev. Rev. Stat. § 695A.120 Location of principal office; meetings of supreme governing body; minutes of certain proceedings; official publications; grievances by benefit members.
1. The principal office of any domestic society must be located in this state.
2. The meetings of its supreme governing body may be held in any state, district, province or territory in which the society has at least five subordinate lodges, and all business transacted at those meetings is as valid in all respects as if the meetings were held in this state.
3. The minutes of the proceedings of the supreme governing body and the board of directors must be written in the English language.
4. A society may provide in its laws for an official publication in which any notice, report or statement which is required by law to be given to a member, including a notice of election, may be published. Such a report, notice or statement must be printed conspicuously in the publication.
5. If the records of a society indicate that two or more benefit members have the same mailing address, an official publication mailed to one member shall be deemed to be mailed to all members at the same address unless a member requests a separate copy.
6. A society may provide in its laws or rules a procedure by which a benefit member may pursue a grievance or complaint against the society, its supreme governing body, officers, directors or other members.
Nev. Rev. Stat. § 695A.130 Consolidation; merger.
1. A domestic society that wishes to consolidate or merge with any other society must file with the Commissioner:
(a) A certified copy of the written contract containing in full the terms and conditions of the consolidation or merger;
(b) A sworn statement by the president and secretary or corresponding officers of each society showing the financial condition thereof on a date fixed by the Commissioner, but not earlier than December 31, next preceding the date of the contract;
(c) The certification of such officers, duly verified by their respective oaths, that the consolidation or merger has been approved by a two-thirds vote of the supreme governing body of each society at a regular or special meeting of such bodies or, if permitted by the laws of the society, by mail; and
(d) Evidence that at least 60 days before the action of the supreme governing body of each society, the text of the contract was furnished to all members of each society either by mail or by publication in full in the official publication of each society.
2. If the Commissioner finds that the contract containing in full the terms and conditions of the consolidation or merger is in conformity with the provisions of this section, that the financial statements are correct and that the consolidation or merger is just and equitable to the members of each society, the Commissioner shall approve the contract and issue a certification of that fact.
3. The contract becomes effective upon approval by the Commissioner unless any society which is a party to the contract is incorporated under the laws of any other state or territory, in which case the consolidation or merger does not become effective unless:
(a) It is approved as provided by the laws of the other state or territory and a certificate of such approval has been filed with the Commissioner of this state; or
(b) If the laws of the other state or territory do not provide for such approval, it is approved by the officer responsible for supervising the business of insurance in the other state or territory and a certificate of such approval has been filed with the Commissioner of this state.
4. Upon the consolidation or merger becoming effective as provided in this chapter, all the rights, franchises and interests of the consolidated or merged societies in and to every species of property, real, personal or mixed, and things in action belonging thereto are vested in the society resulting from or remaining after the consolidation or merger without any other instrument, except that conveyances of real property may be evidenced by proper deeds. The title to any real property or interest therein, vested under the laws of this state in any of the societies consolidated or merged, does not revert and is not in any way impaired by the consolidation or merger but vests absolutely in the society resulting from or remaining after the consolidation or merger.
5. The affidavit of any officer of the society or of anyone authorized by it to mail any notice or document, stating that the notice or document has been duly addressed and mailed, is prima facie evidence that the notice or document has been furnished the addressees.
Nev. Rev. Stat. § 695A.140 Conversion of fraternal benefit society into mutual life insurer.
Any domestic fraternal benefit society may be converted to and licensed as a mutual life insurer by compliance with all the applicable requirements of chapter 693A of NRS if a plan of conversion is:
1. Prepared by the board of directors of the society in writing setting forth in full the terms and conditions of the conversion;
2. Approved by the affirmative vote of two-thirds of all members of the supreme governing body of the society at a regular or special meeting; and
3. Approved by the Commissioner, who may give such approval if the Commissioner finds that the proposed change is in conformity with the laws of this state and not prejudicial to the certificate holders of the society.
Nev. Rev. Stat. § 695A.150 Qualifications for and rights and privileges of membership.
1. Subject to the limitations set forth in subsections 2, 3 and 4, a society shall specify in its laws or rules for each class of membership:
(a) The standards of eligibility and the process for admission to membership in that class; and
(b) The rights and privileges of membership in that class, provided that only benefit members may have the right to vote on the management of the business of the society relating to insurance.
2. If benefits are provided on the lives of children, the minimum age for membership as an adult must be not less than 15 and not greater than 21 years of age.
3. A society may also admit social members, who have no voice or vote in the management of its affairs relating to insurance.
4. Membership rights in the society must not be assignable.
Nev. Rev. Stat. § 695A.151 Effect of eligibility for medical assistance under Medicaid on eligibility for coverage; assignment of rights to state agency.
1. A society shall not, when considering eligibility for coverage or making payments under a certificate for health benefits, consider the availability of, or eligibility of a person for, medical assistance under Medicaid.
2. To the extent that payment has been made by Medicaid for health care, a society:
(a) Shall treat Medicaid as having a valid and enforceable assignment of an insureds benefits regardless of any exclusion of Medicaid or the absence of a written assignment; and
(b) May, as otherwise allowed by its certificate for health benefits, evidence of coverage or contract and applicable law or regulation concerning subrogation, seek to enforce any reimbursement 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 insured.
3. If a state agency is assigned any rights of a person who is:
(a) Eligible for medical assistance under Medicaid; and
(b) Covered by a certificate for health benefits,
Ê the society that issued the health policy shall not impose any requirements upon the state agency except requirements it imposes upon the agents or assignees of other persons covered by the certificate.
4. If a state agency is assigned any rights of an insured who is eligible for medical assistance under Medicaid, a society that issues a certificate for health benefits, evidence of coverage or contract shall:
(a) Upon request of the state agency, provide to the state agency information regarding the insured to determine:
(1) Any period during which the insured, a spouse or dependent of the insured may be or may have been covered by the society; and
(2) The nature of the coverage that is or was provided by the society, including, without limitation, the name and address of the insured and the identifying number of the certificate for health benefits, evidence of coverage or 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 the society 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. § 695A.152 Society required to comply with certain provisions concerning portability and availability of health insurance.
1. To the extent reasonably applicable, a fraternal benefit society shall comply 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 offered by the society to its members. 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 group health plan or carrier must be replaced by fraternal benefit society.
Nev. Rev. Stat. § 695A.153 Society prohibited from asserting certain grounds to deny enrollment of child of insured pursuant to order.
A society shall not deny the enrollment of a child pursuant to an order for medical coverage under a certificate for health benefits 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 societys geographic area of service.
Nev. Rev. Stat. § 695A.155 Certain accommodations required to be made by society when child is covered under policy of noncustodial parent.
If a child has coverage under a certificate for health benefits pursuant to which a noncustodial parent of the child is insured, the society issuing that certificate 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. § 695A.157 Society 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 under a certificate for health benefits for a child and the parent is eligible for coverage of members of the parents family under a certificate for health benefits, the society that issued the certificate:
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 society 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. § 695A.160 Amendment of laws of society: Manner; approval by Commissioner; provision to members.
1. A domestic society may amend its laws in accordance with the provisions thereof by action of its supreme governing body at any regular or special meeting thereof or, if its laws so provide, by referendum. Such a referendum may be held in accordance with the provisions of its laws by the vote of the voting members of the society, by the vote of delegates or representatives of voting members or by the vote of local lodges. A society may provide for voting by mail. No amendment submitted for adoption by referendum may be adopted unless, within 6 months after the date of submission thereof, a majority of all of the voting members of the society have signified their consent to the amendment by one of the methods specified in this section.
2. No amendment to the laws of any domestic society becomes effective unless approved by the Commissioner, who shall approve the amendment if the Commissioner finds that it has been duly adopted and is not inconsistent with any requirement of the laws of this state or with the character, objects and purposes of the society. Unless the Commissioner disapproves an amendment within 60 days after it is filed, such amendment shall be deemed approved. The approval or disapproval of the Commissioner must be in writing and mailed to the secretary or corresponding officer of the society at its principal office. If the Commissioner disapproves an amendment, the reasons therefor must be stated in the written notice.
3. Within 90 days after their approval by the Commissioner, all the amendments, or a synopsis thereof, must be furnished to all members of the society either by mail or by publication in full in the official publication of the society. The affidavit of any officer of the society or of anyone authorized by it to mail any amendments or synopsis thereof, stating facts which show that the amendments or synopsis thereof have been duly addressed and mailed, is prima facie evidence that the amendments or synopsis thereof have been furnished the addressee.
4. Every foreign or alien society authorized to do business in this state shall file with the Commissioner a duly certified copy of all amendments of, or additions to, its laws within 90 days after their enactment.
5. Printed copies of the laws as amended, certified by the secretary or corresponding officer of the society, are prima facie evidence of the legal adoption thereof.
Nev. Rev. Stat. § 695A.180 Scope of contractual benefits.
1. A society authorized to do business in this state may provide the following contractual benefits in any form:
(a) Death benefits;
(b) Endowment benefits;
(c) Annuity benefits;
(d) Temporary or permanent disability benefits;
(e) Hospital, medical or nursing benefits;
(f) Monument or tombstone benefits to the memory of deceased members; and
(g) Any other benefits which life insurance companies are authorized to pay which are not inconsistent with the provisions of this chapter.
2. A society shall specify in its laws or rules those persons who may be issued, or covered by, the contractual benefits set forth in subsection 1, consistent with the purpose of providing benefits to members and their dependents. A society may provide benefits on the lives of children under the minimum age for adult membership upon the application of an adult.
Nev. Rev. Stat. § 695A.184 Benefit contract covering prescription drugs prohibited from limiting or excluding coverage for prescription drug previously approved for medical condition of insured; exception.
1. Except as otherwise provided in this section, a benefit contract 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 society 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 society 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 benefit 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 benefit contract.
3. Any provision of a benefit contract 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. § 695A.188 Approval or denial of claim; payment of claims and interest; request for additional information; payment of claim; 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 society.
1. Except as otherwise provided in subsection 3 and NRS 439B.754 , a society shall approve or deny a claim relating to a certificate of health insurance and, if the society:
(a) Approves the claim, pay the claim within:
(1) Twenty-one days after the society receives the claim, if the claim is submitted electronically; or
(2) Thirty days after the society receives the claim, if the claim is not submitted electronically.
(b) Denies the claim, notify the claimant in writing of the denial within 21 days after the society receives the claim, if the claim is submitted electronically, or 30 days after the society receives the claim, if the claim is not submitted electronically. The notice must include, without limitation:
(1) All reasons for denying the claim, including, without limitation, the specific facts and provisions of the certificate relied upon by the society as a basis to deny the claim;
(2) The criteria by which the society determines whether to approve or deny the claim and a description of the manner in which the society applied those criteria to the claim; and
(3) A summary of any applicable process established pursuant to NRS 687B.820 for challenging the denial of the claim.
2. Except as otherwise provided in this section, if the approved claim is not paid within the period specified by subsection 1, the society shall pay interest on the claim at the rate of 10 percent per annum. The interest must be calculated from the date on which payment of the claim is due pursuant to subsection 1 until the claim is paid.
3. If the society 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 society shall notify the claimant of all the specific reasons for the delay in approving or denying the claim. The society shall approve or deny the claim and, if the society:
(a) Approves the claim, pay the claim within:
(1) Twenty-one days after receiving the additional information, if the information is submitted electronically; or
(2) Thirty days after receiving the additional information, if the information is not submitted electronically.
(b) Denies the claim, provide notice of the denial in the manner prescribed in paragraph (b) of subsection 1 within 21 days after receiving the additional information, if the information is submitted electronically, or 30 days after receiving the information, if the information is not submitted electronically.
4. If a claim approved pursuant to subsection 3 is not paid within the period specified in that subsection, the society shall pay interest on the claim in the manner prescribed in subsection 2.
5. A society 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 society, unless the society 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.
6. A society shall not pay only part of a claim that has been approved and is fully payable.
7. A court shall award costs and reasonable attorneys fees to the prevailing party in an action brought pursuant to this section.
8. 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 society.
9. The Commissioner may require a society to provide evidence which demonstrates that the society 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.
10. If the Commissioner determines that a society 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 society to pay an administrative fine in an amount to be determined by the Commissioner. Upon a second or subsequent determination that a society 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 society.
11. On or before February 1 of each year, a society shall submit to the Commissioner a report concerning the compliance of the society 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 society 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 society pursuant to subsections 2 and 4 during the immediately preceding calendar year.
Nev. Rev. Stat. § 695A.195 Society prohibited from denying coverage solely because claim involves act that constitutes domestic violence or applicant or insured was victim of domestic violence.
A society shall not deny a claim, refuse to issue a benefit contract or cancel a benefit contract 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 benefit 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. § 695A.197 Society 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 society that provides health benefits shall not:
(a) Deny a claim under a benefit 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 a benefit 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 a benefit 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 society from enforcing a provision included in a benefit contract 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 a benefit contract solely because of such a claim; or
(c) Refuse to issue a benefit contract to an eligible applicant solely because of such a claim.
3. The provisions of this section do not apply to a society under a benefit contract that provides coverage for long-term care or disability income.
Nev. Rev. Stat. § 695A.198 Society prohibited from discriminating against person with respect to participation or coverage on basis of gender identity or expression.
A society that issues a benefit contract shall not discriminate against any person with respect to participation or coverage under the contract 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 benefit contract 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 contract 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. § 695A.200 Nonforfeiture benefits, cash surrender values, certificate loans and other options.
1. A society may grant paid-up nonforfeiture benefits, cash surrender values, certificate loans and such other options as its laws may permit.
2. In the case of certificates for which reserves are computed on the Commissioners 1980 Standard Ordinary Mortality Table or such other table of mortality as may be specified by the society and approved by the Commissioner, every paid-up nonforfeiture benefit and the amount of any cash surrender value, loan or other option granted must not be less than the corresponding amount ascertained in accordance with the provisions of the laws of this state applicable to life insurance companies issuing policies containing like insurance benefits based upon those tables.
Nev. Rev. Stat. § 695A.210 Beneficiaries; funeral benefits.
1. The owner of a benefit contract has the right at all times to change any beneficiary in accordance with the laws or rules of the society, unless the owner waives that right by requesting in writing that the owners designation of a beneficiary be irrevocable. Every society by its laws or rules may limit the scope of a designation of a beneficiary and shall provide that a revocable beneficiary does not have or obtain any vested interest in the proceeds of any certificate until the certificate has become due and payable in conformity with the provisions of the benefit contract.
2. A society may provide for the payment of funeral benefits to the extent of such portion of any payment under a certificate as might reasonably appear to be due to any person equitably entitled thereto by reason of having incurred expense occasioned by the burial of a member, but the portion so paid must not exceed $1,000.
3. If, at the death of any person insured under a benefit contract, there is no lawful beneficiary to whom the insurance benefits are payable, the amount of such benefits, except to the extent that funeral benefits may be paid as provided in subsection 2, are payable:
(a) To the estate of the deceased insured; or
(b) To the owner of the certificate if the owner is not the person insured under the benefit contract.
Nev. Rev. Stat. § 695A.220 Benefits not liable to attachment, garnishment or other process.
No money or other benefit, charity, relief or aid to be paid, provided or rendered by any society is liable to attachment, garnishment or other process, or to be seized, taken, appropriated or applied by any legal or equitable process or operation of law to pay any debt or liability of a benefit member or beneficiary, or any other person who may have a right thereunder, either before or after payment by the society.
Nev. Rev. Stat. § 695A.230 Terms and conditions of benefit contracts.
1. Every society authorized to do business in this state shall issue to each owner of a benefit contract a certificate specifying the amount of benefits provided thereby. The certificate, together with any riders or endorsements attached thereto, the laws of the society, the application for membership, the application for insurance and the declaration of insurability, if any, signed by the applicant, and all amendments to each thereof, constitute the agreement, as of the date of issuance, between the society and the member, and the certificate must so state. A copy of the application for insurance and the declaration of insurability, if any, must be endorsed upon or attached to the certificate.
2. All statements on an application for insurance are representations and not warranties. Any waiver of this provision is void.
3. Except with regard to contracts providing benefits payable in variable amounts, any changes, additions or amendments to the laws of the society duly made or enacted after the issuance of the certificate bind the owner and the beneficiaries, and govern and control the benefit contract as though the changes, additions or amendments were in force at the time of the application for insurance, except that no change, addition or amendment may destroy or diminish benefits which the society contracted to give the owner as of the date of issuance.
4. Any person upon whose life a benefit contract is issued before the person attains the age of majority is bound by the terms of the application and certificate and by all the laws and rules of the society as though the age of majority had been attained at the time of application.
5. Copies of any of the documents mentioned in this section, certified by the secretary or corresponding officer of the society, must be received in evidence of the terms and conditions thereof.
6. Except with regard to contracts providing benefits payable in variable amounts, a society shall provide in its laws that if its reserves as to all or any class of certificates become impaired, its supreme governing body or board of directors may require each owner of such certificates to pay to the society the amount of the owners equitable proportion of such deficiency as ascertained by its board, and that if the payment is not made, the owner may elect to:
(a) Let it stand as an indebtedness against the certificate and draw interest at a rate not to exceed that specified for loans made pursuant to the certificates; or
(b) In lieu of, or in combination with paragraph (a), accept a proportionate reduction in benefits under the certificate.
Ê The society may specify the manner of the election and which alternative is to be presumed if no election is made by the owner.
Nev. Rev. Stat. § 695A.232 Society required to offer and issue plan regardless of health status of persons; prohibited acts.
1. A society 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. A society 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. A society 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. As used in this section, health benefit plan has the meaning ascribed to it in NRS 687B.470 .
Nev. Rev. Stat. § 695A.235 Offering policy of health insurance for purposes of establishing health savings account.
A society 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. § 695A.240 Approval and contents of certificates.
1. No certificate may be delivered or issued for delivery in this state unless a copy of the form of the certificate has been filed with and approved by the Commissioner in conformity with the requirements of NRS 687B.120 .
2. The certificate must contain:
(a) A provision stating the amount of premiums which are payable under the certificate;
(b) A provision setting forth the societys laws or rules which, if violated, will result in the termination or reduction of benefits payable under the certificate;
(c) If the laws of the society provide for the expulsion or suspension of a member, a provision that any member who is expelled or suspended, except for nonpayment of a premium or, during the period of contestability, for material misrepresentation in the application for membership or insurance, may maintain the certificate in force by continuing payment of the required premium; and
(d) All standard contractual provisions which are required by the provisions of chapters 687B , 688A , 688B , 689 , 689A and 689B of NRS to be included in similar policies issued by life or health insurers in this state, and which are not inconsistent with the provisions of this chapter.
3. The certificate may contain:
(a) A provision that the member is entitled to a grace period of 1 month in which the payment of any premium after the first may be made.
(b) For a benefit contract issued on the life of a person under the societys minimum age for membership as an adult, a provision governing the transfer of ownership to the insured at an age specified in the certificate. A society may require approval of an application for membership in order to make the transfer, and may provide for the regulation, government and control of such a certificate and all rights, obligations and liabilities incident to the certificate, including rights of ownership before the transfer.
(c) The terms and conditions governing the assignability of the benefit contract.
Nev. Rev. Stat. § 695A.255 Benefit contract covering prescription drugs: Provision of notice and information regarding use of formulary.
1. A society that offers or issues a benefit contract which provides coverage for prescription drugs shall include with any certificate for such a contract provided to a benefit member, notice of whether a formulary is used and, if so, of the opportunity to secure information regarding the formulary from the society 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 society for making a request for information regarding the formulary pursuant to subsection 2.
2. If a society offers or issues a benefit contract which provides coverage for prescription drugs and a formulary is used, the society 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 society 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. § 695A.256 Benefit contract covering prescription drugs: Submission to step therapy protocol for drug to treat psychiatric condition prohibited in certain circumstances.
1. A benefit contract 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 society 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 benefit contract 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 benefit contract offered by a society 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 society. 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 benefit contract provides coverage for the recommended drug.
Nev. Rev. Stat. § 695A.257 Benefit contract covering prescription drugs: Required actions by society 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 society that has issued a benefit contract which provides coverage for prescription drugs shall, notwithstanding any provision of the benefit contract to the contrary:
(a) Waive any provision of the benefit contract 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. § 695A.258 Benefit contract covering prescription drug for treatment of 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 society shall use guidelines based on medical or scientific evidence, if such guidelines are available.
2. A society that offers or issues a benefit contract 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 society 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 society; 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 society shall respond to the request or appeal within 24 hours after the request is made or the appeal is submitted, as applicable.
3. A society 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 society a statement which provides an adequate justification for the exemption and any documentation necessary to support the statement. The society 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 benefit contract 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 benefit contract at the time the attending practitioner selected the drug.
4. If a society 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 society shall immediately authorize coverage for and dispensing of the drug chosen by the attending practitioner for the insured.
6. A benefit contract 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 695A.259 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. § 695A.259 Benefit contract covering prescription drug for treatment of cancer or cancer symptom that is part of step therapy protocol: Society required to allow insured or attending practitioner to apply for exemption from step therapy protocol in certain circumstances; procedure for applying for and granting exemption.
1. A society that offers or issues a benefit contract 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 society 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 society 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 society 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 society 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 society 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 society approves an application for an exemption from a step therapy protocol pursuant to this section, the society must cover the prescription drug to which the exemption applies in accordance with the terms of the applicable benefit contract. The society 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 society must continue to cover the drug for as long as it is necessary to treat the insured for the cancer or symptom. The society 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 society shall provide a report of the review to the insured.
8. A society shall post in an easily accessible location on an Internet website maintained by the society a form for requesting an exemption pursuant to this section.
9. A benefit contract 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 benefit contract 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. § 695A.261 Benefit contract covering anatomical gifts, organ transplants or treatments or services related to organ transplants: Prohibited acts by society if insured is person with disability.
1. A society that offers or issues a benefit contract 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. § 695A.263 Coverage for dental service provided by qualified dental hygienist required in certain circumstances.
1. A society that offers or issues a benefit contract 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 benefit contract 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.
Nev. Rev. Stat. § 695A.265 Coverage for services provided through telehealth required to same extent as though provided in person or by other means; reimbursement for certain services provided through telehealth required in same amount as though provided in person or by other means; prohibited acts.
1. A benefit contract must include coverage for services provided to an insured through telehealth to the same extent as though provided in person or by other means.
2. A benefit contract 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 society 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 benefit contract 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 benefit contract 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 society 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 society is not otherwise required by law to do so.
6. A benefit contract 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. § 695A.270 Authority to prohibit in societys laws waiver of provisions of societys laws.
The laws of the society may provide that no subordinate body or any of its subordinate officers or members may waive any of the provisions of the laws of the society. Such a provision is binding on the society and every member and beneficiary of a member.
Nev. Rev. Stat. § 695A.280 Reinsurance.
1. Except as otherwise provided in subsection 3, a domestic society may, by a reinsurance agreement, cede any individual risk or risks in whole or in part to an insurer, other than another fraternal benefit society, authorized to provide reinsurance in this state, or if not so authorized, one which is approved in writing by the Commissioner, but no such society may reinsure substantially all of its insurance in force without the written permission of the Commissioner.
2. A society may take credit for the reserves on such ceded risks to the extent reinsured, but no credit may be allowed as an admitted asset or as a deduction from liability to a ceding society for reinsurance made, ceded, renewed or otherwise becoming effective after July 1, 1963, unless the reinsurance is payable by the assuming insurer on the basis of the liability of the ceding society under the benefit contract or contracts reinsured without diminution because of the insolvency of the ceding society.
3. A society may reinsure the risks of another society in a consolidation or merger which is approved by the Commissioner pursuant to NRS 695A.130 .
Nev. Rev. Stat. § 695A.300 Foreign or alien society: License required to transact business; required information.
1. A foreign or alien society shall not transact business in this state without a license issued by the Commissioner.
2. A foreign or alien society may be licensed to transact business in this state upon a showing that its assets are invested in accordance with the provisions of this chapter and upon filing with the Commissioner:
(a) A duly certified copy of its laws, certified by its secretary or corresponding officer;
(b) A power of attorney to the Commissioner as prescribed in NRS 695A.400 ;
(c) A statement of its business under oath of its president and secretary or corresponding officers in a form prescribed by the Commissioner, duly verified by an examination made by the supervising insurance officer of its home state or other state, territory, province or country, satisfactory to the Commissioner of this state;
(d) Certification from the proper officer of its home state, territory, province or country that the society is legally incorporated and licensed to transact business therein;
(e) Copies of its certificate forms; and
(f) Such other information as the Commissioner may deem necessary.
3. Any foreign or alien society desiring admission to this state must comply substantially with the requirements and limitations of this chapter applicable to domestic societies.
Nev. Rev. Stat. § 695A.310 Injunction against, liquidation of or appointment of receiver for domestic society.
1. When the Commissioner upon investigation finds that a domestic society:
(a) Has exceeded its powers;
(b) Has failed to comply with any provision of this chapter;
(c) Is not fulfilling its contracts in good faith;
(d) Has a membership of less than 400 after an existence of 1 year or more; or
(e) Is conducting business fraudulently or in a manner hazardous to its members, creditors, the public or the business,
Ê the Commissioner shall notify the society of his or her findings, state in writing the reasons for the Commissioners dissatisfaction, and issue a written order requiring the society to make the necessary corrections. If the Commissioner finds that the society has failed to comply with the order within 30 days after receiving it, the Commissioner shall notify the society of his or her finding of noncompliance and require the society to show cause on a date named why it should not be enjoined from carrying on any business until the violation complained of has been corrected, or why an action in quo warranto should not be commenced against the society.
2. If on that date the society does not present good and sufficient reasons why it should not be so enjoined or why such action should not be commenced, the Commissioner may present the facts relating thereto to the Attorney General, who shall, if he or she deems the circumstances warrant, commence an action to enjoin the society from transacting business or an action in quo warranto.
3. The court shall thereupon notify the officers of the society of a hearing. If, after a full hearing, it appears that the society should be so enjoined or liquidated or a receiver appointed, the court shall enter the necessary order.
4. A society that is so enjoined shall not do business until:
(a) The Commissioner finds that the violation complained of has been corrected;
(b) The costs of the action have been paid by the society, if the court finds that the society was in default as charged;
(c) The court has dissolved its injunction; and
(d) The Commissioner has reinstated the certificate of authority.
5. If the court orders the society liquidated, it must be enjoined from carrying on any further business, whereupon the receiver of the society shall proceed at once to take possession of the books, papers, money and other assets of the society and, under the direction of the court, proceed forthwith to close the affairs of the society and to distribute its funds to those entitled thereto.
6. No action under this section may be recognized in any court of this state unless brought by the Attorney General upon request of the Commissioner. Whenever a receiver is to be appointed for a domestic society, the court shall appoint the Commissioner as the receiver.
7. The provisions of this section relating to hearing by the Commissioner, action by the Attorney General at the request of the Commissioner, hearing by the court, injunction and receivership apply to a society which voluntarily determines to discontinue business.
Nev. Rev. Stat. § 695A.320 Suspension, revocation or refusal of license of foreign or alien society.
1. When the Commissioner upon investigation finds that a foreign or alien society transacting or applying to transact business in this state:
(a) Has exceeded its powers;
(b) Has failed to comply with any provision of this chapter;
(c) Is not fulfilling its contracts in good faith; or
(d) Is conducting its business fraudulently or in a manner hazardous to its members or creditors or the public,
Ê the Commissioner shall notify the society of his or her findings, state in writing the reasons for the Commissioners dissatisfaction and issue a written order requiring the society to make the necessary corrections. If the Commissioner finds that the society has failed to comply with the order within 30 days after receiving it, the Commissioner shall notify the society of his or her finding of noncompliance and require the society to show cause on a date named why its license should not be suspended, revoked or refused.
2. If on that date the society does not present good and sufficient reason why its authority to do business in this state should not be suspended, revoked or refused, the Commissioner may suspend or refuse the license of the society to do business in this state until satisfactory evidence is furnished to the Commissioner that the suspension or refusal should be withdrawn, or the Commissioner may revoke the authority of the society to do business in this state.
3. Nothing contained in this section prevents a society from continuing in good faith all contracts made in this state during the time the society was legally authorized to transact business in this state.
Nev. Rev. Stat. § 695A.330 Licensing of insurance agents of society; persons exempt from licensing.
1. Every insurance agent of a society must be licensed pursuant to chapter 683A of NRS and any regulations adopted by the Commissioner which apply to health and life insurance agents.
2. No written or other examination is required of a person who held a license as an insurance agent on July 1, 1977, for renewals of his or her license.
3. No examination or license is required of:
(a) Any regular salaried officer or employee of a licensed society who devotes substantially all of his or her services to activities other than the solicitation of fraternal insurance contracts from the public, and who does not receive for the solicitation of such contracts any commission or other compensation directly dependent upon the amount of business obtained; or
(b) Any member of the society who does not write insurance contracts, and whose solicitation or negotiation is incidental to securing new members for the society, and whose only remuneration consists of prizes in the form of merchandise or payments of a nominal amount of money.
Nev. Rev. Stat. § 695A.400 Service of process on society.
1. Every society authorized to do business in this state shall appoint in writing the Commissioner as attorney-in-fact upon whom all lawful process in any action or proceeding against it must be served, and shall agree in the writing that any lawful process against it which is served on the Commissioner is of the same legal force and validity as if served upon the society, and that the authority continues in force so long as any liability remains outstanding in this state. A copy of the appointment, certified by the Commissioner, constitutes sufficient evidence of the appointment and must be admitted in evidence with the same validity as the original.
2. Service of process against a society must be made in accordance with NRS 680A.260 .
3. No such service may require a society to file its answer, pleading or defense in less than 30 days from the date the copy of the service was forwarded to the society.
4. Legal process must not be served upon a society except in the manner provided in this section.
Nev. Rev. Stat. § 695A.410 Injunctions against societies.
No application or petition for injunction against any domestic, foreign or alien society, or any of its lodges, may be recognized in any court of this state unless made by the Attorney General upon request of the Commissioner.
Nev. Rev. Stat. § 695A.420 Judicial review of Commissioners findings and decisions.
All decisions and findings of the Commissioner made under the provisions of this chapter are subject to review by proper proceedings in any court of competent jurisdiction in this state.
Nev. Rev. Stat. § 695A.430 Assets, funds and accounts of society.
1. All assets must be held, invested and disbursed for the use and benefit of the society and no member or beneficiary may have or acquire individual rights therein or become entitled to any apportionment or the surrender of any part thereof, except as provided in the benefit contract.
2. A society may create, maintain, invest, disburse and apply any special fund necessary to carry out any purpose permitted by the laws of the society.
3. A society may, pursuant to a resolution of its supreme governing body and subject to the provisions of NRS 688A.390 , establish and operate one or more separate accounts and issue contracts providing benefits payable in variable amounts. For the purposes of NRS 688A.390 , a society shall be deemed to be a domestic life insurer.
Nev. Rev. Stat. § 695A.440 Investments.
1. A society shall invest its money only in such investments as are authorized by the laws of this state for the investment of assets of life insurers and subject to the limitations thereon.
2. Any foreign or alien society permitted or seeking to do business in this state which invests its money in accordance with the laws of the state, district, territory, country or province in which it is incorporated shall be deemed to meet the requirements of this section for the investment of money.
Nev. Rev. Stat. § 695A.450 Annual statement of financial condition, transactions and affairs: Filing; fee; contents; provision to members; valuation of certificates.
1. Every society transacting business in this state shall annually, on or before the first day of March, unless for cause shown the time has been extended by the Commissioner, file with the Commissioner a true statement of its financial condition, transactions and affairs for the preceding calendar year and pay a filing fee of $25. The statement must be in such general form and context as approved by the National Association of Insurance Commissioners for fraternal benefit societies and as supplemented by additional information required by the Commissioner. The statement must include separately from the societys admitted assets all real or personal property owned, held or leased by the society for the purposes of its nonprofit institutions operated pursuant to NRS 695A.090 .
2. A synopsis of its annual statement providing an explanation of the facts concerning the condition of the society thereby disclosed must be printed and mailed to each benefit member of the society not later than June 1 of each year, or, in lieu thereof, the synopsis may be published in the societys official publication established pursuant to NRS 695A.120 .
3. As a part of the annual statement required by subsection 1, each society shall, on or before the first day of March, file with the Commissioner a valuation of its certificates in force on the preceding December 31. The Commissioner may, in the discretion of the Commissioner for cause shown, extend the time for filing the valuation for not more than 2 calendar months. The valuation must be done pursuant to NRS 695A.490 . The valuation and supporting data must be certified by a qualified actuary or, at the expense of the society, verified by the actuary of the department of insurance of the state in which the society is domiciled.
Nev. Rev. Stat. § 695A.460 Annual statement of financial condition, transactions and affairs: Penalties for failure to file properly.
If a society fails to file the annual statement in the form and within the time provided by NRS 695A.450, it shall pay to the Commissioner $100 for each day that the statement remains unfiled or deficient, and, upon notice by the Commissioner to that effect, its authority to do business in this state ceases until the statement is properly filed.
Nev. Rev. Stat. § 695A.475 Liability of directors, officers, employees, members and volunteers; indemnification and reimbursement of directors, officers, employees and agents.
1. The officers and members of the supreme governing body or any subordinate body of a society are not personally liable for payment of any benefits provided by the society.
2. A person may be indemnified and reimbursed by a society for expenses reasonably incurred by, and liabilities imposed upon, the person in connection with or arising out of any action, suit or proceeding, whether civil, criminal, administrative or investigative, or threat thereof, in which the person may be involved because the person is or was a director, officer, employee or agent of the society or of any firm, corporation or organization which the person served in any capacity at the request of the society.
3. A person may not be so indemnified or reimbursed as to any matter in an action, suit or proceeding, or threat thereof, in which the person is finally adjudged to be guilty of a breach of a duty as a director, officer, employee or agent of the society, or which is made the subject of a compromise settlement, unless:
(a) The person acted in good faith for a purpose the person reasonably believed to be in the best interests of the society; and
(b) If a criminal action, the person had no reasonable cause to believe that his or her conduct was unlawful.
4. The determination of whether the conduct of a person meets the standard required for indemnification and reimbursement may only be made by:
(a) The supreme governing body or board of directors by a majority vote of a quorum consisting of persons who were not parties to the action, suit or proceeding; or
(b) A court of competent jurisdiction.
5. The termination of any action, suit or proceeding by judgment, order, settlement or conviction, or upon a plea of nolo contendere, does not create a conclusive presumption that the person does not meet the standard of conduct required for indemnification and reimbursement.
6. The right of indemnification and reimbursement does not exclude other rights to which the person may be entitled as a matter of law, and inures to the benefit of the persons heirs, executors and administrators.
7. A society may purchase and maintain insurance on behalf of any person who is or was a director, officer, employee or agent of the society, or who is serving or has served at the request of the society as a director, officer, employee or agent of any other firm, corporation or organization, against any liability asserted against and incurred by the person in that capacity or arising out of the status of the person as such, whether or not the society may indemnify the person against liability pursuant to this section.
8. A director, officer, employee, member or volunteer of a society who serves without compensation is not liable, and no cause of action may be brought for damages resulting from his or her exercise of judgment or discretion in carrying out his or her duties or responsibilities on behalf of the society, unless the act or omission involved willful or wanton misconduct.
Nev. Rev. Stat. § 695A.490 Standards of valuation for certificates; excess reserves.
1. The minimum standards of valuation for certificates issued before July 1, 1964, are those provided by the law applicable immediately before July 1, 1963, but not lower than the standards used in the calculating of rates for those certificates.
2. Except as otherwise provided in subsection 4, the minimum standard of valuation for certificates issued on or after July 1, 1964, but before January 1, 1993, is 3.5 percent interest and the following:
(a) For certificates of life insurance, American Men Ultimate Table of Mortality, with Bowermans or Davis Extension thereof or with the consent of the Commissioner, the Commissioners 1941 Standard Ordinary Mortality Table, the Commissioners 1941 Standard Industrial Mortality Table or the Commissioners 1958 Standard Ordinary Mortality Table, using the actual age of the insured for male risks and an age not more than 3 years younger than the actual age of the insured for female risks.
(b) For annuity and pure endowment certificates, excluding any disability and accidental death benefits in those certificates, the 1937 Standard Annuity Mortality Table or the Annuity Mortality Table for 1949, Ultimate, or any modification of either of these tables approved by the Commissioner.
(c) For total and permanent disability benefits in or supplementary to life insurance certificates, Hunters Disability Table, or the Class III Disability Table (1926) modified to conform to the contractual waiting period, or the tables of Period 2 disablement rates and the 1930 to 1950 termination rates of the 1952 Disability Study of the Society of Actuaries with due regard to the type of benefit. Any such table must, for active lives, be combined with a mortality table permitted for calculating the reserves for life insurance certificates.
(d) For accidental death benefits in or supplementary to life insurance certificates, the Inter-Company Double Indemnity Mortality Table or the 1959 Accidental Death Benefits Table. Either table must be combined with a mortality table permitted for calculating the reserves for life insurance certificates.
(e) For noncancellable accident and health benefits, the Class III Disability Table (1926) with conference modifications or, with the consent of the Commissioner, tables based upon the societys own experience.
3. Except as otherwise provided in subsection 4, the minimum standard of valuation for certificates issued on or after January 1, 1993, is:
(a) For certificates of life insurance, the Commissioners 1980 Standard Ordinary Mortality Table or any more recent table made applicable to life insurance companies; and
(b) For annuity and pure endowment certificates, total and permanent disability benefits, accidental death benefits and noncancellable accident and health benefits, such tables as are authorized for use by life insurance companies in this state.
4. A society may value its certificates in accordance with the valuation standards used for policies containing comparable benefits which are issued in this state by life insurance companies.
5. The Commissioner may:
(a) Accept other standards for valuation if the Commissioner finds that the reserves produced thereby will not be less in the aggregate than reserves computed in accordance with the minimum valuation standard prescribed in this section.
(b) Vary the standards of mortality applicable to all benefit contracts on substandard lives or other extra-hazardous lives by any society authorized to do business in this state.
6. Any society, with the consent of the commissioner of insurance of the state of domicile of the society and under such conditions, if any, as he or she may impose, may establish and maintain reserves on its certificates in excess of the reserves required thereunder, but the contractual rights of any benefit member are not affected thereby.
Nev. Rev. Stat. § 695A.500 Examination of societies transacting or applying to transact business in State.
The Commissioner, or any person the Commissioner may appoint, may examine any domestic, foreign or alien society which is transacting business or applying for admission to transact business in this state in the same manner as authorized for the examination of domestic, foreign or alien insurers. For the purposes of this section, the provisions of NRS 679B.230 to 679B.300, inclusive, are applicable to societies.
Nev. Rev. Stat. § 695A.530 Applicability of provisions relating to trade practices and frauds.
A society authorized to do business in this state and its agents are subject to the provisions of chapter 686A of NRS relating to trade practices and frauds, except that nothing in that chapter applies to or affects:
1. The right of a society to determine its eligibility requirements for membership; or
2. The offering of benefits exclusively to members or persons eligible for membership in the society by a subsidiary corporation or affiliated organization of the society.
Nev. Rev. Stat. § 695A.550 Exemption of societies from certain taxes.
Every society organized or licensed under this chapter is hereby declared to be a charitable and benevolent institution, and is exempt from every state, county, district, municipal and school tax other than the commerce tax imposed pursuant to chapter 363C of NRS and taxes on real property and office equipment.
Nev. Rev. Stat. § 695A.555 Nonexemption of societies from certain fees.
Societies are not exempt from the provisions of NRS 679B.700. If a society is an admitted health insurer, as that term is defined in NRS 449.450, it is not exempt from the fees imposed pursuant to NRS 449.465.
Nev. Rev. Stat. § 695A.560 Exemption of societies from other insurance laws; exceptions.
Except as otherwise provided in this chapter or by specific statute, societies are governed by this chapter and are exempt from all other provisions of the insurance laws of this state.
Nev. Rev. Stat. § 695A.570 Applicability of chapter; effect of exemption.
1. Nothing contained in this chapter shall be construed to affect or apply to:
(a) Grand or subordinate lodges of societies, orders or associations now doing business in this state which provide benefits exclusively through local or subordinate lodges;
(b) Orders, societies or associations which admit to membership only persons engaged in one or more crafts or hazardous occupations, in the same or similar lines of business, insuring only their own members and their families and the ladies societies or ladies auxiliaries to such orders, societies or associations;
(c) Domestic societies which limit their membership to employees of a particular city or town, designated firm, business house or corporation which provide for a death benefit of not more than $400 or disability benefits of not more than $350 to any person in any 1 year, or both; or
(d) Domestic societies or associations of a purely religious, charitable or benevolent description, which provide for a death benefit of not more than $400 or for disability benefits of not more than $350 to any one person in any 1 year, or both.
2. Any society or association described in paragraphs (c) or (d) of subsection 1 which provides for death or disability benefits for which benefit certificates are issued, and any such society or association included in paragraph (d) of subsection 1 which has more than 1,000 members, shall not be exempted from the provisions of this chapter but shall comply with all requirements thereof.
3. No society which, by the provisions of this section, is exempt from the requirements of this chapter, except any society described in paragraph (b) of subsection 1, shall give or allow, or promise to give or allow, to any person any compensation for procuring new members.
4. Every society which provides for benefits in case of death or disability resulting solely from accident and which does not obligate itself to pay natural death or sick benefits shall have all of the privileges and be subject to all the applicable provisions and regulations of this chapter, except that the provisions thereof relating to medical examination, valuations of benefit certificates and incontestability shall not apply to such society.
5. The Commissioner may require from any society or association, by examination or otherwise, such information as will enable the Commissioner to determine whether such society or association is exempt from the provisions of this chapter.
6. Societies, exempted under the provisions of this section, shall also be exempt from all other provisions of the insurance laws of this state.
Nev. Rev. Stat. § 695A.580 Penalties.
1. Any person who makes a false or fraudulent statement in or relating to an application for membership or for the purpose of obtaining money from or a benefit in any society is guilty of a gross misdemeanor.
2. Any person who solicits membership for, or in any manner assists in procuring membership in, any society not licensed to do business in this State is subject to an administrative fine, imposed by the Commissioner, of not less than $25 nor more than $500 for each violation. In addition if the person is an insurance agent of the society, the Commissioner may suspend, revoke, limit or refuse to continue his or her license in the manner provided in NRS 683A.451 and 683A.461 .
3. Any person convicted of a willful violation of, or neglect or refusal to comply with, any provision of this chapter for which a penalty is not otherwise prescribed shall be punished by a fine of not more than $1,000 for each violation, and not more than $10,000 for all related violations.
Nev. Rev. Stat. § 695A.1841 Limitation on cost-sharing obligation for insulin covered under benefit contract covering prescription insulin drugs.
1. A society that offers or issues a benefit contract 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 society, 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. § 695A.1843 Coverage for drugs, laboratory testing and certain services related to human immunodeficiency virus and hepatitis C required; reimbursement of certain providers of health care for certain services; prohibited acts.
1. A society that offers or issues a benefit contract shall include in the benefit 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 society;
(b) Laboratory testing that is necessary for therapy that uses 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 society.
2. A society that offers or issues a benefit contract shall reimburse:
(a) A pharmacist who participates in the network plan of the society 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 society 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 society 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 society 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 society.
5. A benefit contract 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 plan 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 benefit contract offered by a society 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 society. 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. § 695A.1844 Coverage for testing, treatment and prevention of sexually transmitted diseases required; coverage for condoms for certain insureds required.
1. A society that offers or issues a benefit contract shall include in the contract:
(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 695A.1843 and 695A.1856 .
(b) Unrestricted coverage of condoms for insureds who are 13 years of age or older.
2. A benefit contract 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 contract that conflicts with the provisions of this section is void.
Nev. Rev. Stat. § 695A.1845 Coverage for certain tests and vaccines relating to human papillomavirus required; prohibited acts.
1. A benefit contract 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, 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. A society 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 society.
3. Except as otherwise provided in subsection 5, a society that offers or issues a benefit contract 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 to obtain any benefit provided in the benefit contract pursuant to subsection 1;
(b) Refuse to issue a benefit contract or cancel a benefit contract 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 benefit contract 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 benefit contract or the renewal which is in conflict with this section is void.
5. Except as otherwise provided in this section and federal law, a society 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 benefit contract offered by a society 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 society. 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. § 695A.1853 Coverage for screening, genetic counseling and testing related to BRCA gene required in certain circumstances.
1. A society that issues a benefit contract 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 society 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 society.
3. A benefit contract 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 plan that conflicts with the provisions of this section is void.
4. As used in this section:
(a) Network plan means a benefit contract offered by a society 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 society. 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. § 695A.1855 Coverage for certain screenings and tests for breast cancer required; prohibited acts.
1. A benefit contract 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. A society 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 society.
3. Except as otherwise provided in subsection 5, a society that offers or issues a benefit contract 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 for coverage to obtain any benefit provided in a benefit contract pursuant to subsection 1;
(b) Refuse to issue a benefit contract or cancel a benefit contract 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 benefit contract 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 benefit contract or the renewal which is in conflict with this section is void.
5. Except as otherwise provided in this section and federal law, a society 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 benefit contract with respect to the deductible of such a benefit contract 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 benefit contract offered by a society 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 society. 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 benefit contract means a benefit contract 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. § 695A.1856 Coverage for examination of person who is pregnant for certain diseases required.
1. A society that issues a benefit contract 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 society; and
(b) Without prior authorization.
3. A benefit 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 subsection 1, and any provision of the contract 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 benefit contract offered by a society 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 society. 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. § 695A.1857 Benefit contract covering maternity care: Prohibited acts by society if insured is acting as gestational carrier; child deemed child of intended parent for purposes of benefit contract.
1. A society that offers or issues a benefit contract 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 benefit contract.
3. As used in this section, gestational carrier has the meaning ascribed to it in NRS 126.580 .
Nev. Rev. Stat. § 695A.1859 Coverage for biomarker testing for diagnosis, treatment, management and monitoring of cancer required 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 society that issues a benefit contract shall include in the contract 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 society 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 society.
3. If a society requires an insured to obtain prior authorization for a biomarker test described in subsection 1, the society 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 society 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 society; 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 benefit contract 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 benefit contract 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 gene mutation or characteristic; 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 benefit contract offered by a society 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 society. 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. § 695A.1865 Coverage for drug or device for contraception and related health services required in benefit contract covering prescription drugs or devices; prohibited acts; exceptions.
1. Except as otherwise provided in subsection 8, a society that offers or issues a benefit contract which provides coverage for prescription drugs or devices 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 11; 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 11;
(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 benefit contract;
(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. A society 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. A society 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 society.
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 society.
5. Except as otherwise provided in subsections 9, 10 and 12, a society that offers or issues a benefit contract 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 any benefit included in the benefit contract pursuant to subsection 1;
(b) Refuse to issue a benefit contract or cancel a benefit contract 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 benefit contract 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. A society that offers or issues a benefit contract and which is affiliated with a religious organization is not required to provide the coverage required by subsection 1 if the society objects on religious grounds. Such a society shall, before the issuance of a benefit contract and before the renewal of such a contract, provide to the prospective insured written notice of the coverage that the society refuses to provide pursuant to this subsection.
9. A society 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.
10. For each of the 18 methods of contraception listed in subsection 11 that have been approved by the Food and Drug Administration, a benefit contract 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 society may charge a deductible, copayment or coinsurance for any other drug or device that provides the same method of contraception. If the society charges a copayment or coinsurance for a drug for contraception, the society 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.
11. 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.
12. Except as otherwise provided in this section and federal law, a society 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.
13. A society 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 11 at a hospital immediately after an insured gives birth.
14. A society 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 society to obtain any benefit required by this section without a higher deductible, copayment or coinsurance.
15. As used in this section:
(a) In-network pharmacy means a pharmacy that has entered into a contract with a society to provide services to insureds through a network plan offered or issued by the society.
(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 benefit contract offered by a society 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 society. The term does not include an arrangement for the financing of premiums.
(d) Provider network contract means a contract between a society and a provider of health care or pharmacy specifying the rights and responsibilities of the society 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. § 695A.1866 Coverage for procedure or service for preservation of fertility required in certain circumstances; exemption. [Effective January 1, 2027.]
1. Except as otherwise provided in subsection 4, a society that issues a benefit contract shall include in the contract 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 society 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 society.
4. A society that is affiliated with a religious organization is not required to provide the coverage required by subsection 1 if the society objects on religious grounds. Such a society shall, before the issuance of a benefit contract that is subject to the requirements of subsection 1 and before the renewal of such a contract, provide to the insured or prospective insured, as applicable, written notice of the coverage that the society refuses to provide pursuant to this subsection.
5. A benefit contract 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 contract or the renewal that conflicts with the provisions of this section is void.
6. As used in this section:
(a) Network plan means a benefit contract offered by a society 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 society. 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. § 695A.1867 Coverage for medically necessary treatment of conditions relating to gender dysphoria and gender incongruence required; restriction on refusal to cover certain treatments; authority of society to prescribe requirements for covering surgical treatment for minors; determination of medical necessity.
1. Except as otherwise provided in this section, a society that issues a benefit contract shall include in the benefit contract 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 benefit contract to include coverage for cosmetic surgery performed by a plastic surgeon or reconstructive surgeon that is not medically necessary.
3. A society that issues a benefit contract shall not categorically refuse to cover medically necessary gender-affirming treatments or procedures or revisions to prior treatments if the contract provides coverage for any such services, procedures or revisions for purposes other than gender transition or affirmation.
4. A society that issues a benefit contract may prescribe requirements that must be satisfied before the society 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 society must consider the most recent Standards of Care published by the World Professional Association for Transgender Health, or its successor organization.
6. A society 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 society. If, after a reasonable effort, the society is unable to make such benefits available through such a provider of health care, the society may treat the treatment that the society 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 society.
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 society 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 benefit contract 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 benefit contract 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 benefit contract offered by a society 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 society. 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. § 695A.1873 Coverage for management and treatment of sickle cell disease and its variants required; coverage for medically necessary prescription drugs to treat sickle cell disease and its variants required in benefit contract covering prescription drugs.
1. A society that issues a benefit contract shall include in the benefit contract 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 society that issues a benefit contract which provides coverage for prescription drugs shall include in the benefit contract coverage for medically necessary prescription drugs to treat sickle cell disease and its variants.
3. A society 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. § 695A.1874 Coverage for certain drugs and services related to substance use disorder and opioid use disorder required; reimbursement of pharmacists and pharmacies for certain services; prohibited acts.
1. A society that offers or issues a benefit contract shall include in the contract 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 society. 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 society that offers or issues a benefit contract shall reimburse a pharmacist or pharmacy that participates in the network plan of the society 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 society 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 society.
4. Except as otherwise provided in this subsection, a society shall not subject the benefits required by paragraphs (a), (b) and (c) of subsection 1 to medical management techniques, other than step therapy. A society 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 society 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 society 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 society.
7. A benefit contract 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 contract 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 benefit contract offered by a society 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 society. 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. § 695A.1875 Coverage for certain services, screenings and tests relating to wellness required; prohibited acts.
1. A society that offers or issues a benefit contract 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) Hormone replacement therapy;
(e) Such prenatal screenings and tests as recommended by the American College of Obstetricians and Gynecologists or its successor organization;
(f) 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;
(g) Screening for cervical cancer at such intervals as are recommended by the American College of Obstetricians and Gynecologists or its successor organization;
(h) Screening for depression;
(i) 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;
(j) 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;
(k) 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
(l) 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. A society 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 society.
3. Except as otherwise provided in subsection 5, a society that offers or issues a benefit contract 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 benefit contract pursuant to subsection 1;
(b) Refuse to issue a benefit contract or cancel a benefit contract 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 benefit contract 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 benefit contract or the renewal which is in conflict with this section is void.
5. Except as otherwise provided in this section and federal law, a society 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 benefit contract offered by a society 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 society. 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. § 695A.18445 Coverage for certain gynecological or obstetrical services required without prior authorization or referral from primary care physician; designation of obstetrician or gynecologist as primary care physician.
1. A society that offers or issues a benefit contract shall include in the contract a provision authorizing a woman covered by the plan 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 society;
(2) Satisfies the criteria established by the society for designation as a primary care provider under the benefit contract; and
(3) Agrees to abide by all terms and conditions imposed by the society on other primary care physicians generally.
2. A benefit 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 benefit contract or renewal of the benefit contract which is in conflict with this section is void.
3. As used in this section:
(a) Network plan means a benefit contract offered by a society 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 society. 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. § 695A.18565 Coverage for noninvasive prenatal screening required.
1. A society that offers or issues a benefit contract shall include in the contract coverage for noninvasive prenatal screening at any time during pregnancy. Such coverage must be provided without prior authorization.
2. A benefit 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 subsection 1, and any provision of the contract 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. § 695A.18575 Coverage for screening for lung cancer required in benefit contract providing coverage for treatment for lung cancer.
1. A society that offers a benefit contract 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 benefit 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 that conflicts with the provisions of this section is void.
Nev. Rev. Stat. § 695A.18735 Coverage for habilitative speech-language pathology and rehabilitative speech-language pathology as treatment for stuttering required for certain persons; prohibited acts.
1. A society that offers or issues a benefit contract shall include in the contract 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 society 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 benefit 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 subsection 1, and any provision of the contract 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.
Source: NV Statutes (Official Site)URL: https://www.leg.state.nv.us/nrs/NRS-695A.htmlFetched: 10/4/2026