[Rev. 2/11/2015 11:52:13
AM--2014R2]
CHAPTER 689A - INDIVIDUAL HEALTH INSURANCE
GENERAL PROVISIONS
NRS 689A.010 Short
title.
NRS 689A.020 Scope.
NRS 689A.030 General
requirements.
NRS 689A.035 Contracts
between insurer and provider of health care: Prohibiting insurer from charging
provider of health care fee for inclusion on list of providers given to
insureds; form to obtain information on provider of health care; modification;
providing schedule of fees.
REQUIRED PROVISIONS
NRS 689A.040 Contents
of policy; substitution of provisions; captions; omission or modification of
provisions.
NRS 689A.0403 Procedure
for arbitration of disputes concerning independent medical evaluations.
NRS 689A.04033 Coverage
for treatment received as part of clinical trial or study.
NRS 689A.04036 Coverage
for continued medical treatment.
NRS 689A.0404 Coverage
for use of certain drugs for treatment of cancer.
NRS 689A.04042 Coverage
for screening for colorectal cancer.
NRS 689A.04045 Coverage
for prescription drug previously approved for medical condition of insured.
NRS 689A.0405 Coverage
for cytologic screening test and mammograms for certain women.
NRS 689A.041 Coverage
relating to mastectomy.
NRS 689A.0413 Coverage
for certain gynecological or obstetrical services without authorization or
referral from primary care physician.
NRS 689A.0415 Coverage
for drug or device for contraception and for hormone replacement therapy in
certain circumstances; prohibited actions by insurer; exceptions.
NRS 689A.0417 Coverage
for health care services related to contraceptives and hormone replacement
therapy in certain circumstances; prohibited actions by insurer; exceptions.
NRS 689A.042 Coverage
relating to complications of pregnancy.
NRS 689A.0423 Coverage
for treatment of certain inherited metabolic diseases.
NRS 689A.0425 Individual
health benefit plan that includes coverage for maternity care and pediatric
care: Requirement to allow minimum stay in hospital in connection with
childbirth; prohibited acts.
NRS 689A.0427 Coverage
for management and treatment of diabetes.
NRS 689A.043 Coverage
of newly born and adopted children and children placed for adoption.
NRS 689A.0435 Coverage
for autism spectrum disorders.
NRS 689A.044 Coverage
for human papillomavirus vaccine.
NRS 689A.0445 Coverage
for prostate cancer screening.
NRS 689A.0447 Coverage
for orally administered chemotherapy.
NRS 689A.045 Termination
of coverage on dependent child. [Repealed.]
NRS 689A.0455 Coverage
for treatment of conditions relating to severe mental illness.
NRS 689A.046 Benefits
for treatment of abuse of alcohol or drugs.
NRS 689A.0465 Coverage
of treatment of temporomandibular joint.
REIMBURSEMENT FOR CERTAIN MEDICALLY RELATED TREATMENT AND
SERVICES
NRS 689A.0475 Acupuncture.
NRS 689A.048 Treatment
by licensed psychologist.
NRS 689A.0483 Treatment
by licensed marriage and family therapist or licensed clinical professional
counselor.
NRS 689A.0485 Treatment
by licensed associate in social work, social worker, independent social worker
or clinical social worker.
NRS 689A.0487 Treatment
by licensed podiatrist.
NRS 689A.049 Treatment
by licensed chiropractor; restriction on policy limitations.
NRS 689A.0493 Treatment
by licensed clinical alcohol and drug abuse counselor.
NRS 689A.0495 Services
provided by certain registered nurses; restriction on policy limitations;
exception.
NRS 689A.0497 Provider
of medical transportation.
MISCELLANEOUS PROVISIONS
NRS 689A.050 Entire
contract; changes.
NRS 689A.060 Time
limit on certain defenses.
NRS 689A.070 Grace
period.
NRS 689A.080 Reinstatement.
NRS 689A.090 Notice
of claim.
NRS 689A.100 Claim
forms: Required provision.
NRS 689A.105 Claim
forms: Uniform billing, claims forms.
NRS 689A.110 Claim
forms: Acceptance of uniform forms.
NRS 689A.120 Time
of payment of claims.
NRS 689A.130 Payment
of claims.
NRS 689A.135 Assignment
of benefits to provider of health care.
NRS 689A.140 Physical
examination and autopsy.
NRS 689A.150 Legal
actions.
NRS 689A.160 Change
of beneficiary.
NRS 689A.170 Right
to examine and return policy.
NRS 689A.180 Optional
provisions.
NRS 689A.190 Extended
disability benefit.
NRS 689A.200 Change
of occupation.
NRS 689A.210 Misstatement
of age.
NRS 689A.220 Coordination
of benefits: Same insurer.
NRS 689A.230 Coordination
of benefits: All coverages.
NRS 689A.240 Relation
of earnings to insurance.
NRS 689A.250 Unpaid
premiums.
NRS 689A.260 Conformity
with state statutes.
NRS 689A.270 Illegal
occupation.
NRS 689A.290 Renewability.
NRS 689A.300 Order
of certain provisions.
NRS 689A.310 Ownership
of policy by person other than insured.
NRS 689A.320 Requirements
of other jurisdictions.
NRS 689A.330 Policies
issued for delivery in another state.
NRS 689A.340 Limitation
on provisions not subject to chapter; effect of violation.
NRS 689A.350 Age
limit.
NRS 689A.370 Health
insurance on franchise plan. [Repealed.]
NRS 689A.380 Definitions
of terms used in policies.
NRS 689A.390 Summary
of coverage: Contents of disclosure; approval by Commissioner.
NRS 689A.400 Summary
of coverage: Copy to be provided before policy issued; policy may not be
offered unless summary approved by Commissioner.
NRS 689A.405 Coverage
for prescription drugs: Provision of notice and information regarding use of
formulary.
NRS 689A.410 Approval
or denial of claims; payment of claims and interest; requests for additional
information; award of costs and attorney’s fees; compliance with requirements.
NRS 689A.413 Insurer
prohibited from denying coverage solely because person was victim of domestic
violence.
NRS 689A.415 Insurer
prohibited from denying coverage solely because insured was intoxicated or
under influence of controlled substance; exceptions.
NRS 689A.417 Insurer
prohibited from requiring or using information concerning genetic testing;
exceptions.
NRS 689A.419 Offering
policy of health insurance for purposes of establishing health savings account.
ELIGIBILITY FOR COVERAGE
NRS 689A.420 Definitions.
NRS 689A.430 Effect
of eligibility for medical assistance under Medicaid; assignment of rights to
state agency.
NRS 689A.440 Insurer
prohibited from asserting certain grounds to deny enrollment of child of
insured pursuant to order.
NRS 689A.450 Certain
accommodations to be made when child is covered under policy of noncustodial
parent.
NRS 689A.460 Insurer
to authorize enrollment of child of parent who is required by order to provide
medical coverage under certain circumstances; termination of coverage of child.
PORTABILITY AND ACCOUNTABILITY
General Provisions
NRS 689A.470 Definitions.
NRS 689A.475 “Affiliated”
defined.
NRS 689A.480 “Basic
health benefit plan” defined. [Repealed.]
NRS 689A.485 “Bona
fide association” defined.
NRS 689A.490 “Church
plan” defined.
NRS 689A.495 “Control”
defined.
NRS 689A.500 “Converted
policy” defined. [Repealed.]
NRS 689A.505 “Creditable
coverage” defined.
NRS 689A.510 “Dependent”
defined.
NRS 689A.515 “Eligible
person” defined. [Repealed.]
NRS 689A.520 “Established
geographic service area” defined. [Replaced in revision by NRS 689A.527.]
NRS 689A.523 “Exclusion
for a preexisting condition” defined.
NRS 689A.525 “Geographic
rating area” defined.
NRS 689A.527 “Geographic
service area” defined.
NRS 689A.530 “Governmental
plan” defined.
NRS 689A.535 “Group
health plan” defined.
NRS 689A.540 “Health
benefit plan” defined.
NRS 689A.545 “Health
status-related factor” defined. [Repealed.]
NRS 689A.550 “Individual
carrier” defined.
NRS 689A.555 “Individual
health benefit plan” defined.
NRS 689A.560 “Individual
reinsuring carrier” defined. [Repealed.]
NRS 689A.565 “Individual
risk-assuming carrier” defined. [Repealed.]
NRS 689A.570 “Plan
for coverage of a bona fide association” defined.
NRS 689A.575 “Plan
of operation” defined. [Repealed.]
NRS 689A.580 “Plan
sponsor” defined.
NRS 689A.585 “Preexisting
condition” defined.
NRS 689A.590 “Producer”
defined.
NRS 689A.595 “Program
of Reinsurance” defined. [Repealed.]
NRS 689A.600 “Provision
for a restricted network” defined.
NRS 689A.605 “Standard
health benefit plan” defined. [Repealed.]
NRS 689A.610 Applicability;
ceding arrangement prohibited in certain circumstances. [Repealed.]
NRS 689A.615 Certain
plan, fund or program to be treated as employee welfare benefit plan which is
group health plan; partnership deemed employer of each partner.
NRS 689A.620 Certain
person with break in coverage deemed eligible person. [Repealed.]
Individual Carriers
NRS 689A.630 Requirement
to renew coverage at option of individual; exceptions; discontinuation of form
of product of health benefit plan; discontinuation of health benefit plan
available through bona fide association.
NRS 689A.635 Coverage
offered through network plan not required to be offered to person who does not
reside or work in geographic service area or geographic rating area.
NRS 689A.637 Coverage
offered through plan that provides for restricted network: Contracts with
certain federally qualified health centers.
NRS 689A.640 Each
health benefit plan marketed in this State required to be offered to eligible
persons. [Repealed.]
NRS 689A.645 Coverage
to eligible person who does not reside in established geographic service area
not required; coverage within certain areas not required. [Repealed.]
NRS 689A.650 Coverage
to eligible persons not required under certain circumstances; notice to
Commissioner of and prohibition on writing new business after election not to
offer new coverage required. [Repealed.]
NRS 689A.655 Requirement
to file basic and standard health benefit plans with Commissioner; disapproval
of plan. [Repealed.]
NRS 689A.660 Prohibited
acts concerning preexisting conditions and modification of health benefit plan.
[Repealed.]
NRS 689A.665 Certain
health carriers not required to offer health benefit insurance coverage to
individuals. [Repealed.]
NRS 689A.670 Election
to operate as individual risk-assuming carrier or individual reinsuring
carrier: Notice to Commissioner; effective date; change in status. [Repealed.]
NRS 689A.675 Election
to act as individual risk-assuming carrier: Suspension by Commissioner;
applicable statutes. [Repealed.]
NRS 689A.680 Rates
for individual health benefit plans to be developed based on rating
characteristics: Prohibited characteristics; health status as rating factor.
[Repealed.]
NRS 689A.685 Amount
of change in rate of single block of business; plan with provision for
restricted network; involuntary transfer of individual or dependent prohibited;
premiums adjusted for block of business. [Repealed.]
NRS 689A.690 Information
required to be disclosed as part of solicitation and sales materials;
information required to be maintained at place of business.
NRS 689A.695 Information
and documents to be made available to Commissioner; proprietary information.
NRS 689A.700 Regulations
regarding rates.
NRS 689A.705 Regulations
concerning reissuance of health benefit plan.
NRS 689A.710 Prohibited
acts; denial of application for coverage; regulations; violation may constitute
unfair trade practice; applicability of section.
Individual Health Insurance Coverage
NRS 689A.715 Requirements
for employee welfare benefit plan for providing benefits for employees of more
than one employer.
NRS 689A.720 Written
certification of coverage required for determining period of creditable coverage
accumulated by person; provision of certificate to insured.
Bona Fide Associations
NRS 689A.725 Requirements
for plan for coverage.
NRS 689A.730 Producer
may only sign up eligible persons if eligible persons are actively engaged in
or related to association. [Repealed.]
Miscellaneous Provisions
NRS 689A.740 Regulations.
SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS
NRS 689A.745 Approval;
requirements; examination.
NRS 689A.750 Annual
report; insurer to maintain records of complaints concerning something other
than health care services.
NRS 689A.755 Written
notice to insured explaining right to file complaint; notice to insured
required when insurer denies coverage of health care service.
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GENERAL PROVISIONS
NRS 689A.010 Short title. This
chapter may be cited as the Uniform Health Policy Provision Law.
(Added to NRS by 1971, 1751)
NRS 689A.020 Scope. Nothing in
this chapter applies to or affects:
1. Any policy of liability or workers’
compensation insurance with or without supplementary expense coverage therein.
2. Any group or blanket policy.
3. Life insurance, endowment or annuity
contracts, or contracts supplemental thereto which contain only such provisions
relating to health insurance as to:
(a) Provide additional benefits in case of death
or dismemberment or loss of sight by accident or accidental means; or
(b) Operate to safeguard such contracts against
lapse, or to give a special surrender value or special benefit or an annuity if
the insured or annuitant becomes totally and permanently disabled, as defined
by the contract or supplemental contract.
4. Reinsurance, except as otherwise
provided in NRS 689A.470 to 689A.740, inclusive, and 689C.610 to 689C.940, inclusive, relating to the
program of reinsurance.
(Added to NRS by 1971, 1751; A 1997, 2899; 2013, 3608)
NRS 689A.030 General requirements. A
policy of health insurance must not be delivered or issued for delivery to any
person in this State unless it otherwise complies with this Code, and complies
with the following:
1. The entire money and other
considerations for the policy must be expressed therein.
2. The time when the insurance takes
effect and terminates must be expressed therein.
3. It must purport to insure only one
person, except that a policy may insure, originally or by subsequent amendment,
upon the application of an adult member of a family, who shall be deemed the
policyholder, any two or more eligible members of that family, including the
husband, wife, domestic partner as defined in NRS 122A.030, dependent children, from
the time of birth, adoption or placement for the purpose of adoption as
provided in NRS 689A.043, or any child on or
before the last day of the month in which the child attains 26 years of age,
and any other person dependent upon the policyholder.
4. The style, arrangement and overall
appearance of the policy must not give undue prominence to any portion of the
text, and every printed portion of the text of the policy and of any
endorsements or attached papers must be plainly printed in light-faced type of
a style in general use, the size of which must be uniform and not less than 10
points with a lowercase unspaced alphabet length not less than 120 points.
“Text” includes all printed matter except the name and address of the insurer,
the name or the title of the policy, the brief description, if any, and
captions and subcaptions.
5. The exceptions and reductions of
indemnity must be set forth in the policy and, other than those contained in NRS 689A.050 to 689A.290,
inclusive, must be printed, at the insurer’s option, with the benefit provision
to which they apply or under an appropriate caption such as “Exceptions” or
“Exceptions and Reductions,” except that if an exception or reduction
specifically applies only to a particular benefit of the policy, a statement of
that exception or reduction must be included with the benefit provision to
which it applies.
6. Each such form, including riders and
endorsements, must be identified by a number in the lower left-hand corner of
the first page thereof.
7. The policy must not contain any
provision purporting to make any portion of the charter, rules, constitution or
bylaws of the insurer a part of the policy unless that portion is set forth in
full in the policy, except in the case of the incorporation of or reference to
a statement of rates or classification of risks, or short-rate table filed with
the Commissioner.
8. The policy must provide benefits for
expense arising from care at home or health supportive services if that care or
service was prescribed by a physician and would have been covered by the policy
if performed in a medical facility or facility for the dependent as defined in chapter 449 of NRS.
9. The policy must provide, at the option
of the applicant, benefits for expenses incurred for the treatment of abuse of
alcohol or drugs, unless the policy provides coverage only for a specified
disease or provides for the payment of a specific amount of money if the
insured is hospitalized or receiving health care in his or her home.
10. The policy must provide benefits for
expense arising from hospice care.
(Added to NRS by 1971, 1752; A 1973, 546; 1975, 446,
1108, 1848; 1979,
1176; 1983,
1933, 2035;
1985, 1568,
1772; 1989, 738, 1031; 2013, 3609)
NRS 689A.035 Contracts between insurer and provider of health care:
Prohibiting insurer from charging provider of health care fee for inclusion on
list of providers given to insureds; form to obtain information on provider of
health care; modification; providing schedule of fees.
1. An insurer 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 insurer to its insureds.
2. An insurer shall not contract with a
provider of health care to provide health care to an insured unless the insurer
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 an insurer 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 insurer upon giving to the provider 45 days’ written notice
of the modification of the insurer’s schedule of payments, including any
changes to the fee schedule applicable to the provider’s 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 an insurer contracts with a provider
of health care to provide health care to an insured, the insurer 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
provider’s 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.
(Added to NRS by 1999, 1647; A 2001, 2729; 2003, 3355; 2011, 2532)
REQUIRED PROVISIONS
NRS 689A.040 Contents of policy; substitution of provisions; captions;
omission or modification of provisions.
1. Except as otherwise provided in
subsections 2 and 3, each such policy delivered or issued for delivery to any
person in this State must contain the provisions specified in NRS 689A.050 to 689A.170,
inclusive, in the words in which the provisions appear, except that the insurer
may, at its option, substitute for one or more of the provisions corresponding
provisions of different wording approved by the Commissioner which are in each
instance not less favorable in any respect to the insured or the beneficiary.
Each such provision must be preceded individually by the applicable caption
shown or, at the option of the insurer, by such appropriate individual or group
captions or subcaptions as the Commissioner may approve.
2. If any such provision is in whole or in
part inapplicable to or inconsistent with the coverage provided by a particular
form of policy, the insurer, with the approval of the Commissioner, may omit
from the policy any inapplicable provision or part of a provision, and shall
modify any inconsistent provision or part of a provision in such a manner as to
make the provision as contained in the policy consistent with the coverage
provided by the policy.
(Added to NRS by 1971, 1753; A 1973, 547; 1985, 1059; 2007, 3237; 2013, 3610)
NRS 689A.0403 Procedure for arbitration of disputes concerning independent
medical evaluations.
1. Each policy of health insurance must
include a procedure for binding arbitration to resolve disputes concerning
independent medical evaluations pursuant to the rules of the American
Arbitration Association.
2. If an insurer, for any final
determination of benefits or care, requires an independent evaluation of the
medical or chiropractic care of any person for whom such care is covered under
the terms of the contract of insurance, only a physician or chiropractor who is
certified to practice in the same field of practice as the primary treating
physician or chiropractor or who is formally educated in that field may conduct
the independent evaluation.
3. The independent evaluation must include
a physical examination of the patient, unless the patient is deceased, and a
personal review of all X rays and reports prepared by the primary treating
physician or chiropractor. A certified copy of all reports of findings must be
sent to the primary treating physician or chiropractor and the insured person
within 10 working days after the evaluation. If the insured person disagrees
with the finding of the evaluation, the insured person must submit an appeal to
the insurer pursuant to the procedure for binding arbitration set forth in the
policy of insurance within 30 days after the insured person receives the
finding of the evaluation. Upon its receipt of an appeal, the insurer shall so
notify in writing the primary treating physician or chiropractor.
4. The insurer shall not limit or deny
coverage for care related to a disputed claim while the dispute is in
arbitration, except that, if the insurer prevails in the arbitration, the
primary treating physician or chiropractor may not recover any payment from
either the insurer, insured person or the patient for services that the primary
treating physician or chiropractor provided to the patient after receiving
written notice from the insurer pursuant to subsection 3 concerning the appeal
of the insured person.
(Added to NRS by 1989, 2114)
NRS 689A.04033 Coverage for treatment received as part of clinical trial or
study.
1. A policy of health insurance must
provide coverage for medical treatment which a policyholder or subscriber
receives as part of a clinical trial or study if:
(a) The medical treatment is provided in a Phase
I, Phase II, Phase III or Phase IV study or clinical trial for the treatment of
cancer or in a Phase II, Phase III or Phase IV study or clinical trial for the
treatment of chronic fatigue syndrome;
(b) The clinical trial or study is approved by:
(1) An agency of the National Institutes
of Health as set forth in 42 U.S.C. § 281(b);
(2) A cooperative group;
(3) The Food and Drug Administration as an
application for a new investigational drug;
(4) The United States Department of
Veterans Affairs; or
(5) The United States Department of
Defense;
(c) In the case of:
(1) A Phase I clinical trial or study for
the treatment of cancer, the medical treatment is provided at a facility
authorized to conduct Phase I clinical trials or studies for the treatment of
cancer; or
(2) A Phase II, Phase III or Phase IV
study or clinical trial for the treatment of cancer or chronic fatigue
syndrome, the medical treatment is provided by a provider of health care and
the facility and personnel for the clinical trial or study have the experience
and training to provide the treatment in a capable manner;
(d) There is no medical treatment available which
is considered a more appropriate alternative medical treatment than the medical
treatment provided in the clinical trial or study;
(e) There is a reasonable expectation based on
clinical data that the medical treatment provided in the clinical trial or
study will be at least as effective as any other medical treatment;
(f) The clinical trial or study is conducted in
this State; and
(g) The policyholder or subscriber has signed,
before participating in the clinical trial or study, a statement of consent
indicating that the policyholder or subscriber has been informed of, without limitation:
(1) The procedure to be undertaken;
(2) Alternative methods of treatment; and
(3) The risks associated with
participation in the clinical trial or study, including, without limitation,
the general nature and extent of such risks.
2. Except as otherwise provided in
subsection 3, the coverage for medical treatment required by this section is
limited to:
(a) Coverage for any drug or device that is
approved for sale by the Food and Drug Administration without regard to whether
the approved drug or device has been approved for use in the medical treatment
of the policyholder or subscriber.
(b) The cost of any reasonably necessary health
care services that are required as a result of the medical treatment provided
in a Phase II, Phase III or Phase IV clinical trial or study or as a result of
any complication arising out of the medical treatment provided in a Phase II,
Phase III or Phase IV clinical trial or study, to the extent that such health
care services would otherwise be covered under the policy of health insurance.
(c) The cost of any routine health care services
that would otherwise be covered under the policy of health insurance for a
policyholder or subscriber participating in a Phase I clinical trial or study.
(d) The initial consultation to determine whether
the policyholder or subscriber is eligible to participate in the clinical trial
or study.
(e) Health care services required for the
clinically appropriate monitoring of the policyholder or subscriber during a
Phase II, Phase III or Phase IV clinical trial or study.
(f) Health care services which are required for
the clinically appropriate monitoring of the policyholder or subscriber during
a Phase I clinical trial or study and which are not directly related to the
clinical trial or study.
Ê Except as
otherwise provided in NRS 689A.04036, the
services provided pursuant to paragraphs (b), (c), (e) and (f) must be covered
only if the services are provided by a provider with whom the insurer has contracted
for such services. If the insurer has not contracted for the provision of such
services, the insurer shall pay the provider the rate of reimbursement that is
paid to other providers with whom the insurer has contracted for similar
services and the provider shall accept that rate of reimbursement as payment in
full.
3. Particular medical treatment described
in subsection 2 and provided to a policyholder or subscriber is not required to
be covered pursuant to this section if that particular medical treatment is
provided by the sponsor of the clinical trial or study free of charge to the
policyholder or subscriber.
4. The coverage for medical treatment
required by this section does not include:
(a) Any portion of the clinical trial or study
that is customarily paid for by a government or a biotechnical, pharmaceutical
or medical industry.
(b) Coverage for a drug or device described in
paragraph (a) of subsection 2 which is paid for by the manufacturer,
distributor or provider of the drug or device.
(c) Health care services that are specifically
excluded from coverage under the policyholder’s or subscriber’s policy of
health insurance, regardless of whether such services are provided under the
clinical trial or study.
(d) Health care services that are customarily
provided by the sponsors of the clinical trial or study free of charge to the
participants in the trial or study.
(e) Extraneous expenses related to participation
in the clinical trial or study including, without limitation, travel, housing
and other expenses that a participant may incur.
(f) Any expenses incurred by a person who
accompanies the policyholder or subscriber during the clinical trial or study.
(g) Any item or service that is provided solely
to satisfy a need or desire for data collection or analysis that is not
directly related to the clinical management of the policyholder or subscriber.
(h) Any costs for the management of research
relating to the clinical trial or study.
5. An insurer who delivers or issues for
delivery a policy of health insurance specified in subsection 1 may require
copies of the approval or certification issued pursuant to paragraph (b) of
subsection 1, the statement of consent signed by the policyholder or
subscriber, protocols for the clinical trial or study and any other materials
related to the scope of the clinical trial or study relevant to the coverage of
medical treatment pursuant to this section.
6. An insurer who delivers or issues for
delivery a policy specified in subsection 1 shall:
(a) Include in the disclosure required pursuant
to NRS 689A.390 notice to each policyholder and subscriber
under the policy of the availability of the benefits required by this section.
(b) Provide the coverage required by this section
subject to the same deductible, copayment, coinsurance and other such
conditions for coverage that are required under the policy.
7. A policy of health insurance subject to
the provisions of this chapter that is delivered, issued for delivery or
renewed on or after January 1, 2006, has the legal effect of including the
coverage required by this section, and any provision of the policy that
conflicts with this section is void.
8. An insurer who delivers or issues for
delivery a policy specified in subsection 1 is immune from liability for:
(a) Any injury to a policyholder or subscriber
caused by:
(1) Any medical treatment provided to the
policyholder or subscriber in connection with his or her participation in a
clinical trial or study described in this section; or
(2) An act or omission by a provider of
health care who provides medical treatment or supervises the provision of
medical treatment to the policyholder or subscriber in connection with his or
her participation in a clinical trial or study described in this section.
(b) Any adverse or unanticipated outcome arising
out of a policyholder’s or subscriber’s participation in a clinical trial or
study described in this section.
9. As used in this section:
(a) “Cooperative group” means a network of
facilities that collaborate on research projects and has established a peer
review program approved by the National Institutes of Health. The term
includes:
(1) The Clinical Trials Cooperative Group
Program; and
(2) The Community Clinical Oncology
Program.
(b) “Facility authorized to conduct Phase I
clinical trials or studies for the treatment of cancer” means a facility or an
affiliate of a facility that:
(1) Has in place a Phase I program which
permits only selective participation in the program and which uses clear-cut
criteria to determine eligibility for participation in the program;
(2) Operates a protocol review and
monitoring system which conforms to the standards set forth in the Policies and
Guidelines Relating to the Cancer-Center Support Grant published by the Cancer
Centers Branch of the National Cancer Institute;
(3) Employs at least two researchers and
at least one of those researchers receives funding from a federal grant;
(4) Employs at least three clinical
investigators who have experience working in Phase I clinical trials or studies
conducted at a facility designated as a comprehensive cancer center by the
National Cancer Institute;
(5) Possesses specialized resources for
use in Phase I clinical trials or studies, including, without limitation,
equipment that facilitates research and analysis in proteomics, genomics and
pharmacokinetics;
(6) Is capable of gathering, maintaining
and reporting electronic data; and
(7) Is capable of responding to audits
instituted by federal and state agencies.
(c) “Provider of health care” means:
(1) A hospital; or
(2) A person licensed pursuant to chapter 630, 631
or 633 of NRS.
(Added to NRS by 2003, 3519; A 2005, 2009)
NRS 689A.04036 Coverage for continued medical treatment.
1. The provisions of this section apply to
a policy of health insurance offered or issued by an insurer if an insured
covered by the policy receives health care through a defined set of providers
of health care who are under contract with the insurer.
2. Except as otherwise provided in this
section, if an insured who is covered by a policy described in subsection 1 is
receiving medical treatment for a medical condition from a provider of health
care whose contract with the insurer is terminated during the course of the
medical treatment, the policy must provide that:
(a) The insured may continue to obtain medical
treatment for the medical condition from the provider of health care pursuant
to this section, if:
(1) The insured is actively undergoing a
medically necessary course of treatment; and
(2) The provider of health care and the
insured agree that the continuity of care is desirable.
(b) The provider of health care is entitled to
receive reimbursement from the insurer for the medical treatment the provider
of health care provides to the insured pursuant to this section, if the
provider of health care agrees:
(1) To provide medical treatment under the
terms of the contract between the provider of health care and the insurer with
regard to the insured, including, without limitation, the rates of payment for
providing medical service, as those terms existed before the termination of the
contract between the provider of health care and the insurer; and
(2) Not to seek payment from the insured
for any medical service provided by the provider of health care that the
provider of health care could not have received from the insured were the
provider of health care still under contract with the insurer.
3. The coverage required by subsection 2
must be provided until the later of:
(a) The 120th day after the date the contract is
terminated; or
(b) If the medical condition is pregnancy, the
45th day after:
(1) The date of delivery; or
(2) If the pregnancy does not end in
delivery, the date of the end of the pregnancy.
4. The requirements of this section do not
apply to a provider of health care if:
(a) The provider of health care was under
contract with the insurer and the insurer terminated that contract because of
the medical incompetence or professional misconduct of the provider of health
care; and
(b) The insurer did not enter into another
contract with the provider of health care after the contract was terminated
pursuant to paragraph (a).
5. A policy subject to the provisions of
this chapter that is delivered, issued for delivery or renewed on or after
October 1, 2003, has the legal effect of including the coverage required by
this section, and any provision of the policy or renewal thereof that is in
conflict with this section is void.
6. The Commissioner shall adopt
regulations to carry out the provisions of this section.
(Added to NRS by 2003, 3354)
NRS 689A.0404 Coverage for use of certain drugs for treatment of cancer. Except as otherwise provided in NRS 689A.04033:
1. No policy of health insurance that
provides coverage for a drug approved by the Food and Drug Administration for
use in the treatment of an illness, disease or other medical condition may be
delivered or issued for delivery in this state unless the policy includes
coverage for any other use of the drug for the treatment of cancer, if that use
is:
(a) Specified in the most recent edition of or
supplement to:
(1) The United States Pharmacopoeia
Drug Information; or
(2) The American Hospital Formulary
Service Drug Information; or
(b) Supported by at least two articles reporting
the results of scientific studies that are published in scientific or medical
journals, as defined in 21 C.F.R. § 99.3.
2. The coverage required pursuant to this
section:
(a) Includes coverage for any medical services
necessary to administer the drug to the insured.
(b) Does not include coverage for any:
(1) Experimental drug used for the
treatment of cancer if that drug has not been approved by the Food and Drug
Administration; or
(2) Use of a drug that is contraindicated
by the Food and Drug Administration.
3. A policy of health insurance subject to
the provisions of this chapter that is delivered, issued for delivery or
renewed on or after October 1, 1999, has the legal effect of including the
coverage required by this section, and any provision of the policy that conflicts
with the provisions of this section is void.
(Added to NRS by 1999, 759; A 2003, 3522)
NRS 689A.04042 Coverage for screening for colorectal cancer.
1. A policy of health insurance that
provides coverage for the treatment of colorectal cancer must provide coverage
for colorectal cancer screening in accordance with:
(a) The guidelines concerning colorectal cancer
screening which are published by the American Cancer Society; or
(b) Other guidelines or reports concerning
colorectal cancer screening which are published by nationally recognized
professional organizations and which include current or prevailing supporting
scientific data.
2. A policy of health insurance subject to
the provisions of this chapter that is delivered, issued for delivery or
renewed on or after October 1, 2003, has the legal effect of including the
coverage required by this section, and any provision of the policy that
conflicts with the provisions of this section is void.
(Added to NRS by 2003, 1334)
NRS 689A.04045 Coverage for prescription drug previously approved for medical
condition of insured.
1. Except as otherwise provided in this
section, a policy of health insurance which provides coverage for prescription
drugs must not limit or exclude coverage for a drug if the drug:
(a) Had previously been approved for coverage by
the insurer for a medical condition of an insured and the insured’s provider of
health care determines, after conducting a reasonable investigation, that none
of the drugs which are otherwise currently approved for coverage are medically
appropriate for the insured; and
(b) Is appropriately prescribed and considered
safe and effective for treating the medical condition of the insured.
2. The provisions of subsection 1 do not:
(a) Apply to coverage for any drug that is
prescribed for a use that is different from the use for which that drug has
been approved for marketing by the Food and Drug Administration;
(b) Prohibit:
(1) The insurer from charging a
deductible, copayment or coinsurance for the provision of benefits for
prescription drugs to the insured or from establishing, by contract,
limitations on the maximum coverage for prescription drugs;
(2) A provider of health care from
prescribing another drug covered by the policy 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 policy.
3. Any provision of a policy subject to
the provisions of this chapter that is delivered, issued for delivery or
renewed on or after October 1, 2001, which is in conflict with this section is
void.
(Added to NRS by 2001, 857; A 2003, 2298)
NRS 689A.0405 Coverage for cytologic screening test and mammograms for certain
women.
1. A policy of health insurance must
provide coverage for benefits payable for expenses incurred for:
(a) An annual cytologic screening test for women
18 years of age or older;
(b) A baseline mammogram for women between the
ages of 35 and 40; and
(c) An annual mammogram for women 40 years of age
or older.
2. A policy of health insurance must not
require an insured to obtain prior authorization for any service provided
pursuant to subsection 1.
3. A policy subject to the provisions of
this chapter which is delivered, issued for delivery or renewed on or after
October 1, 1989, has the legal effect of including the coverage required by
subsection 1, and any provision of the policy or the renewal which is in
conflict with subsection 1 is void.
(Added to NRS by 1989, 1888; A 1997, 1729)
NRS 689A.041 Coverage relating to mastectomy.
1. A policy of health insurance which
provides coverage for the surgical procedure known as a mastectomy must also
provide commensurate coverage for:
(a) Reconstruction of the breast on which the
mastectomy has been performed;
(b) Surgery and reconstruction of the other
breast to produce a symmetrical structure; and
(c) Prostheses and physical complications for all
stages of mastectomy, including lymphedemas.
2. The provision of services must be
determined by the attending physician and the patient.
3. The plan or issuer may require
deductibles and coinsurance payments if they are consistent with those
established for other benefits.
4. Written notice of the availability of
the coverage must be given upon enrollment and annually thereafter. The notice
must be sent to all participants:
(a) In the next mailing made by the plan or
issuer to the participant or beneficiary; or
(b) As part of any annual information packet sent
to the participant or beneficiary,
Ê whichever is
earlier.
5. A plan or issuer may not:
(a) Deny eligibility, or continued eligibility,
to enroll or renew coverage, in order to avoid the requirements of subsections
1 to 4, inclusive; or
(b) Penalize, or limit reimbursement to, a provider
of care, or provide incentives to a provider of care, in order to induce the
provider not to provide the care listed in subsections 1 to 4, inclusive.
6. A plan or issuer may negotiate rates of
reimbursement with providers of care.
7. If reconstructive surgery is begun
within 3 years after a mastectomy, the amount of the benefits for that surgery
must equal the amounts provided for in the policy at the time of the
mastectomy. If the surgery is begun more than 3 years after the mastectomy, the
benefits provided are subject to all of the terms, conditions and exclusions
contained in the policy at the time of the reconstructive surgery.
8. A policy subject to the provisions of
this chapter which is delivered, issued for delivery or renewed on or after
October 1, 2001, has the legal effect of including the coverage required by
this section, and any provision of the policy or the renewal which is in
conflict with this section is void.
9. For the purposes of this section,
“reconstructive surgery” means a surgical procedure performed following a
mastectomy on one breast or both breasts to re-establish symmetry between the
two breasts. The term includes augmentation mammoplasty, reduction mammoplasty
and mastopexy.
(Added to NRS by 1983, 614; A 1989, 1889; 2001, 2218)
NRS 689A.0413 Coverage for certain gynecological or obstetrical services
without authorization or referral from primary care physician.
1. A policy of health insurance must
include a provision authorizing a woman covered by the policy to obtain covered
gynecological or obstetrical services without first receiving authorization or
a referral from her primary care physician.
2. The provisions of this section do not
authorize a woman covered by a policy of health insurance to designate an
obstetrician or gynecologist as her primary care physician.
3. A policy subject to the provisions of
this chapter that is delivered, issued for delivery or renewed on or after
October 1, 1999, has the legal effect of including the coverage required by
this section, and any provision of the policy or the renewal which is in
conflict with this section is void.
4. As used in this section, “primary care
physician” has the meaning ascribed to it in NRS 695G.060.
(Added to NRS by 1999, 1943)
NRS 689A.0415 Coverage for drug or device for contraception and for hormone
replacement therapy in certain circumstances; prohibited actions by insurer;
exceptions.
1. Except as otherwise provided in
subsection 5, an insurer that offers or issues a policy of health insurance
which provides coverage for prescription drugs or devices shall include in the
policy coverage for:
(a) Any type of drug or device for contraception;
and
(b) Any type of hormone replacement therapy,
Ê which is
lawfully prescribed or ordered and which has been approved by the Food and Drug
Administration.
2. An insurer that offers or issues a
policy of health insurance that provides coverage for prescription drugs shall
not:
(a) Require an insured to pay a higher
deductible, copayment or coinsurance or require a longer waiting period or
other condition for coverage for a prescription for a contraceptive or hormone
replacement therapy than is required for other prescription drugs covered by
the policy;
(b) Refuse to issue a policy of health insurance
or cancel a policy of health insurance solely because the person applying for
or covered by the policy uses or may use in the future any of the services
listed in subsection 1;
(c) Offer or pay any type of material inducement
or financial incentive to an insured to discourage the insured from accessing
any of the services listed in subsection 1;
(d) Penalize a provider of health care who
provides any of the services listed in subsection 1 to an insured, including,
without limitation, reducing the reimbursement of the provider of health care;
or
(e) Offer or pay any type of material inducement,
bonus or other financial incentive to a provider of health care to deny,
reduce, withhold, limit or delay any of the services listed in subsection 1 to
an insured.
3. Except as otherwise provided in
subsection 5, a policy subject to the provisions of this chapter that is
delivered, issued for delivery or renewed on or after October 1, 1999, has the
legal effect of including the coverage required by subsection 1, and any
provision of the policy or the renewal which is in conflict with this section
is void.
4. The provisions of this section do not:
(a) Require an insurer to provide coverage for
fertility drugs.
(b) Prohibit an insurer from requiring an insured
to pay a deductible, copayment or coinsurance for the coverage required by
paragraphs (a) and (b) of subsection 1 that is the same as the insured is
required to pay for other prescription drugs covered by the policy.
5. An insurer which offers or issues a
policy of health insurance and which is affiliated with a religious
organization is not required to provide the coverage required by paragraph (a)
of subsection 1 if the insurer objects on religious grounds. Such an insurer
shall, before the issuance of a policy of health insurance and before the
renewal of such a policy, provide to the prospective insured, written notice of
the coverage that the insurer refuses to provide pursuant to this subsection.
6. As used in this section, “provider of
health care” has the meaning ascribed to it in NRS 629.031.
(Added to NRS by 1999, 1995)
NRS 689A.0417 Coverage for health care services related to contraceptives and
hormone replacement therapy in certain circumstances; prohibited actions by
insurer; exceptions.
1. Except as otherwise provided in
subsection 5, an insurer that offers or issues a policy of health insurance
which provides coverage for outpatient care shall include in the policy
coverage for any health care service related to contraceptives or hormone replacement
therapy.
2. An insurer that offers or issues a
policy of health insurance that provides coverage for outpatient care shall
not:
(a) Require an insured to pay a higher
deductible, copayment or coinsurance or require a longer waiting period or other
condition for coverage for outpatient care related to contraceptives or hormone
replacement therapy than is required for other outpatient care covered by the
policy;
(b) Refuse to issue a policy of health insurance
or cancel a policy of health insurance solely because the person applying for
or covered by the policy uses or may use in the future any of the services
listed in subsection 1;
(c) Offer or pay any type of material inducement
or financial incentive to an insured to discourage the insured from accessing
any of the services listed in subsection 1;
(d) Penalize a provider of health care who
provides any of the services listed in subsection 1 to an insured, including,
without limitation, reducing the reimbursement of the provider of health care;
or
(e) Offer or pay any type of material inducement,
bonus or other financial incentive to a provider of health care to deny,
reduce, withhold, limit or delay any of the services listed in subsection 1 to
an insured.
3. Except as otherwise provided in
subsection 5, a policy subject to the provisions of this chapter that is
delivered, issued for delivery or renewed on or after October 1, 1999, has the
legal effect of including the coverage required by subsection 1, and any
provision of the policy or the renewal which is in conflict with this section
is void.
4. The provisions of this section do not
prohibit an insurer from requiring an insured to pay a deductible, copayment or
coinsurance for the coverage required by subsection 1 that is the same as the
insured is required to pay for other outpatient care covered by the policy.
5. An insurer which offers or issues such
a policy of health insurance and which is affiliated with a religious
organization is not required to provide the coverage for health care service
related to contraceptives required by this section if the insurer objects on
religious grounds. Such an insurer shall, before the issuance of a policy of
health insurance and before the renewal of such a policy, provide to the
prospective insured written notice of the coverage that the insurer refuses to
provide pursuant to this subsection.
6. As used in this section, “provider of
health care” has the meaning ascribed to it in NRS 629.031.
(Added to NRS by 1999, 1996)
NRS 689A.042 Coverage relating to complications of pregnancy.
1. No health insurance policy may be
delivered or issued for delivery in this state if it contains any exclusion, reduction
or other limitation of coverage relating to complications of pregnancy, unless
the provision applies generally to all benefits payable under the policy.
2. As used in this section, the term
“complications of pregnancy” includes any condition which requires hospital
confinement for medical treatment and:
(a) If the pregnancy is not terminated, is caused
by an injury or sickness not directly related to the pregnancy or by acute
nephritis, nephrosis, cardiac decompensation, missed abortion or similar
medically diagnosed conditions; or
(b) If the pregnancy is terminated, results in
nonelective cesarean section, ectopic pregnancy or spontaneous termination.
3. A policy subject to the provisions of
this chapter which is delivered or issued for delivery on or after July 1,
1977, has the legal effect of including the coverage required by this section,
and any provision of the policy which is in conflict with this section is void.
(Added to NRS by 1977, 415)
NRS 689A.0423 Coverage for treatment of certain inherited metabolic diseases.
1. A policy of health insurance must
provide coverage for:
(a) Enteral formulas for use at home that are
prescribed or ordered by a physician as medically necessary for the treatment
of inherited metabolic diseases characterized by deficient metabolism, or
malabsorption originating from congenital defects or defects arising shortly
after birth, of amino acid, organic acid, carbohydrate or fat; and
(b) At least $2,500 per year for special food
products which are prescribed or ordered by a physician as medically necessary
for the treatment of a person described in paragraph (a).
2. The coverage required by subsection 1
must be provided whether or not the condition existed when the policy was
purchased.
3. A policy subject to the provisions of
this chapter that is delivered, issued for delivery or renewed on or after
January 1, 1998, has the legal effect of including the coverage required by
this section, and any provision of the policy or the renewal which is in
conflict with this section is void.
4. As used in this section:
(a) “Inherited metabolic disease” means a disease
caused by an inherited abnormality of the body chemistry of a person.
(b) “Special food product” means a food product
that is specially formulated to have less than one gram of protein per serving
and is intended to be consumed under the direction of a physician for the
dietary treatment of an inherited metabolic disease. The term does not include
a food that is naturally low in protein.
(Added to NRS by 1997, 1526)
NRS 689A.0425 Individual health benefit plan that includes coverage for
maternity care and pediatric care: Requirement to allow minimum stay in
hospital in connection with childbirth; prohibited acts.
1. Except as otherwise provided in this
subsection, an individual health benefit plan issued pursuant to this chapter
that includes coverage for maternity care and pediatric care for newborn
infants may not restrict benefits for any length of stay in a hospital in
connection with childbirth for a mother or newborn infant covered by the plan
to:
(a) Less than 48 hours after a normal vaginal
delivery; and
(b) Less than 96 hours after a cesarean section.
Ê If a
different length of stay is provided in the guidelines established by the
American College of Obstetricians and Gynecologists, or its successor
organization, and the American Academy of Pediatrics, or its successor
organization, the individual health benefit plan may follow such guidelines in
lieu of following the length of stay set forth above. The provisions of this
subsection do not apply to any individual health benefit plan in any case in
which the decision to discharge the mother or newborn infant before the
expiration of the minimum length of stay set forth in this subsection is made
by the attending physician of the mother or newborn infant.
2. Nothing in this section requires a
mother to:
(a) Deliver her baby in a hospital; or
(b) Stay in a hospital for a fixed period
following the birth of her child.
3. An individual health benefit plan that
offers coverage for maternity care and pediatric care of newborn infants may
not:
(a) Deny a mother or her newborn infant coverage
or continued coverage under the terms of the plan or coverage if the sole
purpose of the denial of coverage or continued coverage is to avoid the
requirements of this section;
(b) Provide monetary payments or rebates to a
mother to encourage her to accept less than the minimum protection available
pursuant to this section;
(c) Penalize, or otherwise reduce or limit, the
reimbursement of an attending provider of health care because the attending
provider of health care provided care to a mother or newborn infant in
accordance with the provisions of this section;
(d) Provide incentives of any kind to an
attending physician to induce the attending physician to provide care to a
mother or newborn infant in a manner that is inconsistent with the provisions
of this section; or
(e) Except as otherwise provided in subsection 4,
restrict benefits for any portion of a hospital stay required pursuant to the
provisions of this section in a manner that is less favorable than the benefits
provided for any preceding portion of that stay.
4. Nothing in this section:
(a) Prohibits an individual health benefit plan
from imposing a deductible, coinsurance or other mechanism for sharing costs
relating to benefits for hospital stays in connection with childbirth for a
mother or newborn child covered by the plan, except that such coinsurance or
other mechanism for sharing costs for any portion of a hospital stay required
by this section may not be greater than the coinsurance or other mechanism for
any preceding portion of that stay.
(b) Prohibits an arrangement for payment between
an individual health benefit plan and a provider of health care that uses
capitation or other financial incentives, if the arrangement is designed to
provide services efficiently and consistently in the best interest of the
mother and her newborn infant.
(c) Prevents an individual health benefit plan
from negotiating with a provider of health care concerning the level and type
of reimbursement to be provided in accordance with this section.
(Added to NRS by 1997, 2898)
NRS 689A.0427 Coverage for management and treatment of diabetes.
1. No policy of health insurance that provides
coverage for hospital, medical or surgical expenses may be delivered or issued
for delivery in this state unless the policy includes coverage for the
management and treatment of diabetes, including, without limitation, coverage
for the self-management of diabetes.
2. An insurer who delivers or issues for
delivery a policy specified in subsection 1:
(a) Shall include in the disclosure required
pursuant to NRS 689A.390 notice to each
policyholder and subscriber under the policy of the availability of the
benefits required by this section.
(b) Shall provide the coverage required by this
section subject to the same deductible, copayment, coinsurance and other such
conditions for coverage that are required under the policy.
3. A policy of health insurance subject to
the provisions of this chapter that is delivered, issued for delivery or
renewed on or after January 1, 1998, has the legal effect of including the
coverage required by this section, and any provision of the policy that
conflicts with this section is void.
4. As used in this section:
(a) “Coverage for the management and treatment of
diabetes” includes coverage for medication, equipment, supplies and appliances
that are medically necessary for the treatment of diabetes.
(b) “Coverage for the self-management of
diabetes” includes:
(1) The training and education provided to
an insured person after the insured person is initially diagnosed with diabetes
which is medically necessary for the care and management of diabetes,
including, without limitation, counseling in nutrition and the proper use of
equipment and supplies for the treatment of diabetes;
(2) Training and education which is
medically necessary as a result of a subsequent diagnosis that indicates a
significant change in the symptoms or condition of the insured person and which
requires modification of the insured person’s program of self-management of
diabetes; and
(3) Training and education which is
medically necessary because of the development of new techniques and treatment
for diabetes.
(c) “Diabetes” includes type I, type II and
gestational diabetes.
(Added to NRS by 1997, 742)
NRS 689A.043 Coverage of newly born and adopted children and children placed
for adoption.
1. All individual health insurance
policies providing family coverage on an expense-incurred basis must as to
family members’ coverage provide that the health benefits applicable for
children are payable with respect to:
(a) A newly born child of the insured from the
moment of birth;
(b) An adopted child from the date the adoption
becomes effective, if the child was not placed in the home before adoption; and
(c) A child placed with the insured for the
purpose of adoption from the moment of placement as certified by the public or
private agency making the placement. The coverage of such a child ceases if the
adoption proceedings are terminated as certified by the public or private
agency making the placement.
Ê The policies
must provide the coverage specified in subsection 3 and must not exclude
premature births.
2. The policy or contract may require that
notification of:
(a) The birth of a newly born child;
(b) The effective date of adoption of a child; or
(c) The date of placement of a child for
adoption,
Ê and payments
of the required premium or fees, if any, must be furnished to the insurer
within 31 days after the date of birth, adoption or placement for adoption in
order to have the coverage continue beyond the 31-day period.
3. The coverage for newly born and adopted
children and children placed for adoption consists of coverage of injury or
sickness, including the necessary care and treatment of medically diagnosed
congenital defects and birth abnormalities and, within the limits of the
policy, necessary transportation costs from place of birth to the nearest
specialized treatment center under major medical policies, and with respect to
basic policies to the extent such costs are charged by the treatment center.
(Added to NRS by 1975, 1109; A 1989, 739)
NRS 689A.0435 Coverage for autism spectrum disorders.
1. A health benefit plan must provide an
option of coverage for screening for and diagnosis of autism spectrum disorders
and for treatment of autism spectrum disorders for persons covered by the
policy under the age of 18 or, if enrolled in high school, until the person
reaches the age of 22.
2. Optional coverage provided pursuant to
this section must be subject to:
(a) A maximum benefit of not less than $36,000
per year for applied behavior analysis treatment; and
(b) Copayment, deductible and coinsurance
provisions and any other general exclusions or limitations of a policy of
health insurance to the same extent as other medical services or prescription
drugs covered by the policy.
3. A health benefit plan that offers or
issues a policy of health insurance which provides coverage for outpatient care
shall not:
(a) Require an insured to pay a higher
deductible, copayment or coinsurance or require a longer waiting period for
optional coverage for outpatient care related to autism spectrum disorders than
is required for other outpatient care covered by the policy; or
(b) Refuse to issue a policy of health insurance
or cancel a policy of health insurance solely because the person applying for
or covered by the policy uses or may use in the future any of the services
listed in subsection 1.
4. Except as provided in subsections 1 and
2, an insurer who offers optional coverage pursuant to subsection 1 shall not
limit the number of visits an insured may make to any person, entity or group
for treatment of autism spectrum disorders.
5. Treatment of autism spectrum disorders
must be identified in a treatment plan and may include medically necessary
habilitative or rehabilitative care, prescription care, psychiatric care,
psychological care, behavior therapy or therapeutic care that is:
(a) Prescribed for a person diagnosed with an
autism spectrum disorder by a licensed physician or licensed psychologist; and
(b) Provided for a person diagnosed with an
autism spectrum disorder by a licensed physician, licensed psychologist,
licensed behavior analyst or other provider that is supervised by the licensed
physician, psychologist or behavior analyst.
Ê An insurer
may request a copy of and review a treatment plan created pursuant to this
subsection.
6. Nothing in this section shall be
construed as requiring an insurer to provide reimbursement to an early
intervention agency or school for services delivered through early intervention
or school services.
7. As used in this section:
(a) “Applied behavior analysis” means the design,
implementation and evaluation of environmental modifications using behavioral
stimuli and consequences to produce socially significant improvement in human
behavior, including, without limitation, the use of direct observation,
measurement and functional analysis of the relations between environment and
behavior.
(b) “Autism spectrum disorders” means a
neurobiological medical condition including, without limitation, autistic
disorder, Asperger’s Disorder and Pervasive Developmental Disorder Not
Otherwise Specified.
(c) “Behavioral therapy” means any interactive
therapy derived from evidence-based research, including, without limitation,
discrete trial training, early intensive behavioral intervention, intensive
intervention programs, pivotal response training and verbal behavior provided
by a licensed psychologist, licensed behavior analyst, licensed assistant
behavior analyst or certified autism behavior interventionist.
(d) “Certified autism behavior interventionist”
means a person who is certified as an autism behavior interventionist by the
Board of Psychological Examiners and who provides behavior therapy under the
supervision of:
(1) A licensed psychologist;
(2) A licensed behavior analyst; or
(3) A licensed assistant behavior analyst.
(e) “Evidence-based research” means research that
applies rigorous, systematic and objective procedures to obtain valid knowledge
relevant to autism spectrum disorders.
(f) “Habilitative or rehabilitative care” means
counseling, guidance and professional services and treatment programs,
including, without limitation, applied behavior analysis, that are necessary to
develop, maintain and restore, to the maximum extent practicable, the
functioning of a person.
(g) “Licensed assistant behavior analyst” means a
person who holds current certification or meets the standards to be certified
as a board certified assistant behavior analyst issued by the Behavior Analyst
Certification Board, Inc., or any successor in interest to that organization,
who is licensed as an assistant behavior analyst by the Board of Psychological
Examiners and who provides behavioral therapy under the supervision of a
licensed behavior analyst or psychologist.
(h) “Licensed behavior analyst” means a person
who holds current certification or meets the standards to be certified as a
board certified behavior analyst or a board certified assistant behavior
analyst issued by the Behavior Analyst Certification Board, Inc., or any
successor in interest to that organization, and who is licensed as a behavior
analyst by the Board of Psychological Examiners.
(i) “Prescription care” means medications
prescribed by a licensed physician and any health-related services deemed
medically necessary to determine the need or effectiveness of the medications.
(j) “Psychiatric care” means direct or
consultative services provided by a psychiatrist licensed in the state in which
the psychiatrist practices.
(k) “Psychological care” means direct or
consultative services provided by a psychologist licensed in the state in which
the psychologist practices.
(l) “Screening for autism spectrum disorders”
means medically necessary assessments, evaluations or tests to screen and
diagnose whether a person has an autism spectrum disorder.
(m) “Therapeutic care” means services provided by
licensed or certified speech pathologists, occupational therapists and physical
therapists.
(n) “Treatment plan” means a plan to treat an
autism spectrum disorder that is prescribed by a licensed physician or licensed
psychologist and may be developed pursuant to a comprehensive evaluation in
coordination with a licensed behavior analyst.
(Added to NRS by 2009, 1465)
NRS 689A.044 Coverage for human papillomavirus vaccine.
1. A policy of health insurance must
provide coverage for benefits payable for expenses incurred for 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 policy of health insurance must not
require an insured to obtain prior authorization for any service provided
pursuant to subsection 1.
3. A policy subject to the provisions of
this chapter which is delivered, issued for delivery or renewed on or after
July 1, 2007, has the legal effect of including the coverage required by
subsection 1, and any provision of the policy or the renewal which is in
conflict with subsection 1 is void.
4. For the purposes of this section, “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.
(Added to NRS by 2007, 3236; A 2013, 3610)
NRS 689A.0445 Coverage for prostate
cancer screening.
1. A policy of health insurance that
provides coverage for the treatment of prostate cancer must provide coverage
for prostate cancer screening in accordance with:
(a) The guidelines concerning prostate cancer
screening which are published by the American Cancer Society; or
(b) Other guidelines or reports concerning
prostate cancer screening which are published by nationally recognized
professional organizations and which include current or prevailing supporting
scientific data.
2. A policy of health insurance that
provides coverage for the treatment of prostate cancer must not require an
insured to obtain prior authorization for any service provided pursuant to
subsection 1.
3. A policy of health insurance that
provides coverage for the treatment of prostate cancer which is delivered,
issued for delivery or renewed on or after July 1, 2007, has the legal effect
of including the coverage required by subsection 1, and any provision of the
policy or the renewal which is in conflict with subsection 1 is void.
(Added to NRS by 2007, 3236)
NRS 689A.0447 Coverage for orally administered chemotherapy.
1. An insurer that offers or issues a
policy of health insurance which provides coverage for the treatment of cancer
through the use of chemotherapy shall not:
(a) Require a copayment, deductible or
coinsurance amount for chemotherapy administered orally by means of a
prescription drug in a combined amount that is more than $100 per prescription.
The limitation on the amount of the deductible that may be required pursuant to
this paragraph does not apply to a health benefit plan, as defined in NRS 687B.470, if the health benefit plan
is a high deductible health plan, as defined in 26 U.S.C. § 223, and the amount
of the annual deductible has not been satisfied.
(b) Make the coverage subject to monetary limits
that are less favorable for chemotherapy administered orally by means of a
prescription drug than the monetary limits applicable to chemotherapy which is
administered by injection or intravenously.
(c) Decrease the monetary limits applicable to
chemotherapy administered orally by means of a prescription drug or to
chemotherapy which is administered by injection or intravenously to meet the
requirements of this section.
2. A policy subject to the provisions of
this chapter which provides coverage for the treatment of cancer through the
use of chemotherapy and that is delivered, issued for delivery or renewed on or
after January 1, 2015, has the legal effect of providing that coverage subject
to the requirements of this section, and any provision of the policy or renewal
which is in conflict with this section is void.
3. Nothing in this section shall be
construed as requiring an insurer to provide coverage for the treatment of
cancer through the use of chemotherapy administered by injection or
intravenously or administered orally by means of a prescription drug.
(Added to NRS by 2013, 1997;
A 2013,
3657)
NRS 689A.045 Termination of coverage on dependent child. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689A.0455 Coverage for treatment of conditions relating to severe mental
illness.
1. A policy of health insurance delivered
or issued for delivery in this state pursuant to this chapter must provide
coverage for the treatment of conditions relating to severe mental illness.
2. As used in this section, “severe mental
illness” means any of the following mental illnesses that are biologically
based and for which diagnostic criteria are prescribed in the most recent
edition of the Diagnostic and Statistical Manual of Mental Disorders,
published by the American Psychiatric Association:
(a) Schizophrenia.
(b) Schizoaffective disorder.
(c) Bipolar disorder.
(d) Major depressive disorders.
(e) Panic disorder.
(f) Obsessive-compulsive disorder.
(Added to NRS by 1999, 3100; A 2013, 3610)
NRS 689A.046 Benefits for treatment of abuse of alcohol or drugs.
1. The benefits provided by a policy for
health insurance for treatment of the abuse of alcohol or drugs must consist
of:
(a) Treatment for withdrawal from the
physiological effect of alcohol or drugs, with a minimum benefit of $1,500 per
calendar year.
(b) Treatment for a patient admitted to a
facility, with a minimum benefit of $9,000 per calendar year.
(c) Counseling for a person, group or family who
is not admitted to a facility, with a minimum benefit of $2,500 per calendar
year.
2. These benefits must be paid in the same
manner as benefits for any other illness covered by a similar policy are paid.
3. The insured person is entitled to these
benefits if treatment is received in any:
(a) Facility for the treatment of abuse of
alcohol or drugs which is certified by the Division of Public and Behavioral
Health of the Department of Health and Human Services.
(b) Hospital or other medical facility or
facility for the dependent which is licensed by the Division of Public and
Behavioral Health of the Department of Health and Human Services, accredited by
the Joint Commission on Accreditation of Healthcare Organizations and provides
a program for the treatment of abuse of alcohol or drugs as part of its
accredited activities.
(Added to NRS by 1979, 1176; A 1983, 2036; 1985, 1569, 1773; 1993, 1918; 1997, 1301; 1999, 1888; 2001, 438)
NRS 689A.0465 Coverage of treatment of temporomandibular joint.
1. Except as otherwise provided in this
section, no policy of health insurance may be delivered or issued for delivery
in this state if it contains an exclusion of coverage of treatment of the
temporomandibular joint whether by specific language in the policy or by a
claims settlement practice. A policy may exclude coverage of those methods of
treatment which are recognized as dental procedures, including, but not limited
to, the extraction of teeth and the application of orthodontic devices and
splints.
2. The insurer may limit its liability on
the treatment of the temporomandibular joint to:
(a) No more than 50 percent of the usual and
customary charges for such treatment actually received by an insured, but in no
case more than 50 percent of the maximum benefits provided by the policy for
such treatment; and
(b) Treatment which is medically necessary.
3. Any provision of a policy subject to
the provisions of this chapter and issued or delivered on or after January 1,
1990, which is in conflict with this section is void.
(Added to NRS by 1989, 2137)
REIMBURSEMENT FOR CERTAIN MEDICALLY RELATED TREATMENT AND
SERVICES
NRS 689A.0475 Acupuncture. If any
policy of health insurance provides coverage for acupuncture performed by a
physician, the insured is entitled to reimbursement for acupuncture performed
by a person who is licensed pursuant to chapter
634A of NRS.
(Added to NRS by 1991, 1133)
NRS 689A.048 Treatment by licensed psychologist. If
any policy of health insurance provides coverage for treatment of an illness
which is within the authorized scope of the practice of a qualified
psychologist, the insured is entitled to reimbursement for treatments by a
psychologist who is licensed pursuant to chapter
641 of NRS.
(Added to NRS by 1979, 367; A 1989, 1553)
NRS 689A.0483 Treatment by licensed marriage and family therapist or licensed
clinical professional counselor. If
any policy of health insurance provides coverage for treatment of an illness
which is within the authorized scope of practice of a licensed marriage and
family therapist or licensed clinical professional counselor, the insured is
entitled to reimbursement for treatment by a marriage and family therapist or
clinical professional counselor who is licensed pursuant to chapter 641A of NRS.
(Added to NRS by 1987, 2133; A 2007, 3093)
NRS 689A.0485 Treatment by licensed associate in social work, social worker,
independent social worker or clinical social worker. If
any policy of health insurance provides coverage for treatment of an illness
which is within the authorized scope of the practice of a licensed associate in
social work, social worker, independent social worker or clinical social
worker, the insured is entitled to reimbursement for treatment by an associate
in social work, social worker, independent social worker or clinical social
worker who is licensed pursuant to chapter 641B
of NRS.
(Added to NRS by 1987, 1123)
NRS 689A.0487 Treatment by licensed
podiatrist.
1. If any policy of health insurance
provides coverage for treatment of an illness which is within the authorized
scope of practice of a qualified podiatrist, the insured is entitled to
reimbursement for treatments by a podiatrist who is licensed pursuant to chapter 635 of NRS.
2. The terms of the policy must not limit:
(a) Coverage for treatments by a podiatrist to a
number less than for treatments by other physicians.
(b) Reimbursement for treatments by a podiatrist
to an amount less than that reimbursed for similar treatments by other
physicians.
(Added to NRS by 2007, 1046)
NRS 689A.049 Treatment by licensed chiropractor; restriction on policy
limitations.
1. If any policy of health insurance
provides coverage for treatment of an illness which is within the authorized
scope of practice of a qualified chiropractor, the insured is entitled to
reimbursement for treatments by a chiropractor who is licensed pursuant to chapter 634 of NRS.
2. The terms of the policy must not limit:
(a) Coverage for treatments by a chiropractor to
a number less than for treatments by other physicians.
(b) Reimbursement for treatments by a
chiropractor to an amount less than that reimbursed for similar treatments by
other physicians.
(Added to NRS by 1981, 930; A 1983, 327)
NRS 689A.0493 Treatment by
licensed clinical alcohol and drug abuse counselor. If
any policy of health insurance provides coverage for treatment of an illness
which is within the authorized scope of practice of a licensed clinical alcohol
and drug abuse counselor, the insured is entitled to reimbursement for treatment
by a clinical alcohol and drug abuse counselor who is licensed pursuant to chapter 641C of NRS.
(Added to NRS by 2007, 3093)
NRS 689A.0495 Services provided by certain registered nurses; restriction on
policy limitations; exception.
1. If any policy of health insurance
provides coverage for services which are within the authorized scope of
practice of a registered nurse who is authorized pursuant to chapter 632 of NRS to perform additional acts in
an emergency or under other special conditions as prescribed by the State Board
of Nursing, and which are reimbursed when provided by another provider of
health care, the insured is entitled to reimbursement for services provided by
such a registered nurse.
2. The terms of the policy must not limit:
(a) Coverage for services provided by such a
registered nurse to a number of occasions less than for services provided by
another provider of health care.
(b) Reimbursement for services provided by such a
registered nurse to an amount less than that reimbursed for similar services
provided by another provider of health care.
3. An insurer is not required to pay for
services provided by such a registered nurse which duplicate services provided
by another provider of health care.
(Added to NRS by 1985, 1446)
NRS 689A.0497 Provider of medical transportation.
1. Except as otherwise provided in
subsection 3, every policy of health insurance amended, delivered or issued for
delivery in this State after October 1, 1989, that provides coverage for
medical transportation, must contain a provision for the direct reimbursement
of a provider of medical transportation for covered services if that provider
does not receive reimbursement from any other source.
2. The insured or the provider may submit
the claim for reimbursement. The provider shall not demand payment from the
insured until after that reimbursement has been granted or denied.
3. Subsection 1 does not apply to any
agreement between an insurer and a provider of medical transportation for the
direct payment by the insurer for the provider’s services.
(Added to NRS by 1989, 1273)
MISCELLANEOUS PROVISIONS
NRS 689A.050 Entire contract; changes. There
shall be a provision as follows:
Entire Contract; Changes:
This policy, including the endorsements and the attached papers, if any,
constitutes the entire contract of insurance. No change in this policy shall be
valid until approved by an executive officer of the insurer and unless such
approval is endorsed hereon or attached hereto. No agent has authority to
change this policy or to waive any of its provisions.
(Added to NRS by 1971, 1753)
NRS 689A.060 Time limit on certain defenses. There
shall be a provision as follows:
Time Limit on Certain Defenses:
1. After 3 years
from the date of issue of this policy no misstatements, except fraudulent
misstatements, made by the applicant in the application for such policy shall
be used to void the policy or to deny a claim for loss incurred or disability
(as defined in the policy) commencing after the expiration of such 3-year
period.
The foregoing policy provision shall not be so construed as
to affect any legal requirement for avoidance of a policy or denial of a claim
during such initial 3-year period, nor to limit the application of NRS 689A.200 to 689A.230,
inclusive, in the event of misstatement with respect to age or occupation or
other insurance. A policy which the insured has the right to continue in force
subject to its terms by the timely payment of the premium until at least age 50
or, in the case of a policy issued after age 44, for at least 5 years from its
date of issue, may contain in lieu of the foregoing the following provision
(from which the clause in parentheses may be omitted at the insurer’s option):
“Incontestable: After this policy has been in force for a period of three years
during the lifetime of the insured (excluding any period during which the
insured is disabled), it shall become incontestable as to the statements
contained in the application.”
2. No claim for
loss incurred or disability (as defined in the policy) commencing after 3 years
from the date of issue of this policy shall be reduced or denied on the ground
that a disease or physical condition not excluded from coverage by name or
specific description effective on the date of loss had existed prior to the
effective date of coverage of this policy.
(Added to NRS by 1971, 1753)
NRS 689A.070 Grace period. There
shall be a provision as follows:
Grace Period: A grace period
of ..... (insert a number not less than “7” for weekly premium policies, “10”
for monthly premium policies and “31” for all other policies) days will be
granted for the payment of each premium falling due after the first premium,
during which grace period the policy shall continue in force.
A policy in which the insurer reserves the right to refuse
any renewal shall have, at the beginning of the above provision:
Unless not less than 30 days
prior to the premium due date the company has delivered to the insured or has
mailed to the last address of the insured as shown by the records of the
insurer written notice of its intention not to renew this policy beyond the
period for which the premium has been accepted.
(Added to NRS by 1971, 1754)
NRS 689A.080 Reinstatement.
1. There shall be a provision as follows:
Reinstatement: If any renewal
premium be not paid within the time granted the insured for payment, a
subsequent acceptance of premium by the insurer or by any agent duly authorized
by the insurer to accept such premium, without requiring in connection
therewith an application for reinstatement, shall reinstate the policy;
provided, however, that if the insurer or such agent requires an application
for reinstatement and issues a conditional receipt for the premium tendered,
the policy will be reinstated upon approval of such application by the insurer
or, lacking such approval, upon the 45th day following the date of such
conditional receipt unless the insurer has previously notified the insured in
writing of its disapproval of such application. The reinstated policy shall
cover only loss resulting from such accidental injury as may be sustained after
the date of reinstatement and loss due to such sickness as may begin more than
10 days after such date. In all other respects the insured and insurer shall
have the same rights thereunder as they had under the policy immediately before
the due date of the defaulted premium, subject to any provisions endorsed
herein or attached hereto in connection with the reinstatement. Any premium
accepted in connection with a reinstatement shall be applied to a period for
which premium has not been previously paid, but not to any period more than 60
days prior to the date of reinstatement.
2. The last sentence of subsection 1 may
be omitted from any policy which the insured has the right to continue in force
subject to its terms by the timely payment of premiums:
(a) Until at least age 50; or
(b) In the case of a policy issued after age 44,
for at least 5 years from its date of issue.
3. Pursuant to the last sentence in
subsection 1, the insurer shall apply the premium accepted in such manner as to
place the policy currently in force, exclusive of any applicable grace period,
but not in any event to any period more than 60 days prior to the date of
reinstatement.
(Added to NRS by 1971, 1754)
NRS 689A.090 Notice of claim.
1. There shall be a provision as follows:
Notice of Claim: Written
notice of claim must be given to the insurer within 20 days after the
occurrence or commencement of any loss covered by the policy, or as soon
thereafter as is reasonably possible. Notice given by or on behalf of the
insured or the beneficiary to the insurer at ................ (insert the
location of such office as the insurer may designate for the purpose), or to
any authorized agent of the insurer, with information sufficient to identify
the insured, shall be deemed notice to the insurer.
2. In a policy providing a loss-of-time
benefit which may be payable for at least 2 years, an insurer may at its option
insert the following between the first and second sentence of subsection 1:
Subject to the qualifications
set forth below, if the insured suffers loss of time on account of disability
for which indemnity may be payable for at least 2 years, the insured shall, at
least once in every 6 months after having given notice of the claim, give to
the insurer notice of continuance of said disability, except in the event of
legal incapacity. The period of 6 months following any filing of proof by the
insured or any payment by the insurer on account of such claim or any denial of
liability in whole or in part by the insurer shall be excluded in applying this
provision. Delay in the giving of such notice shall not impair the insured’s
right to any indemnity which would otherwise have accrued during the period of
6 months preceding the date on which such notice is actually given.
(Added to NRS by 1971, 1755)
NRS 689A.100 Claim forms: Required provision. There
shall be a provision as follows:
Claim Forms: The insurer,
upon receipt of a notice of claim, will furnish to the claimant such forms as
are usually furnished by it for filing proofs of loss. If such forms are not
furnished within 15 days after the giving of such notice the claimant shall be
deemed to have complied with the requirements of this policy as to proof of
loss upon submitting, within the time fixed in the policy for filing proofs of
loss, written proof covering the occurrence, the character and the extent of
the loss for which claim is made.
(Added to NRS by 1971, 1756)
NRS 689A.105 Claim forms: Uniform billing, claims forms. Every insurer under a health insurance
contract and every state agency for its records shall accept from:
1. A hospital the Uniform Billing and
Claims Forms established by the American Hospital Association in lieu of its
individual billing and claims forms.
2. An individual who is licensed to
practice one of the health professions regulated by Title 54 of NRS such
uniform health insurance claims forms as the Commissioner shall prescribe,
except in those cases where the Commissioner has excused uniform reporting.
(Added to NRS by 1975, 897)
NRS 689A.110 Claim forms: Acceptance of uniform forms. There shall be a provision as follows:
Proofs of Loss: Written proof
of loss must be furnished to the insurer at its office in case of claim for
loss for which this policy provides any periodic payment contingent upon
continuing loss within 90 days after the termination of the period for which
the insurer is liable and in case of claim for any other loss within 90 days
after the date of such loss. Failure to furnish such proof within the time
required shall not invalidate nor reduce any claim if it was not reasonably
possible to give proof within such time, provided such proof is furnished as
soon as reasonably possible and in no event, except in the absence of legal
capacity, later than 1 year from the time proof is otherwise required.
(Added to NRS by 1971, 1756)
NRS 689A.120 Time of payment of claims. There
shall be a provision as follows:
Time of Payment of Claims:
Indemnities payable under this policy for any loss, other than loss for which
this policy provides any periodic payment, will be paid immediately upon
receipt of due written proof of such loss. Subject to due written proof of
loss, all accrued indemnities for loss for which this policy provides periodic
payment will be paid ................ (insert period for payment which must not
be less frequently than monthly) and any balance remaining unpaid upon the
termination of liability will be paid immediately upon receipt of due written
proof.
(Added to NRS by 1971, 1756)
NRS 689A.130 Payment of claims.
1. There shall be a provision as follows:
Payment of Claims: Indemnity
for loss of life will be payable in accordance with the beneficiary designation
and the provisions respecting such payment which may be prescribed herein and
effective at the time of payment. If no such designation or provision is then
effective, such indemnity shall be payable to the estate of the insured. Any
other accrued indemnities unpaid at the insured’s death may, at the option of
the insurer, be paid either to such beneficiary or to such estate. All other
indemnities will be payable to the insured.
2. The following provisions, or either of
them, may be included with the provision in subsection 1 at the option of the
insurer:
If any indemnity of this
policy shall be payable to the estate of the insured, or to an insured or
beneficiary who is a minor or otherwise not competent to give a valid release,
the insurer may pay such indemnity, up to an amount not exceeding $.....
(insert an amount which shall not exceed $1,000), to any relative by blood or
connection by marriage of the insured or beneficiary who is deemed by the
insurer to be equitably entitled thereto. Any payment made by the insurer in
good faith pursuant to this provision shall fully discharge the insurer to the
extent of such payment.
Subject to any written
direction of the insured in the application or otherwise all or a portion of
any indemnities provided by this policy on account of hospital, nursing,
medical or surgical services may, at the insurer’s option and unless the
insured requests otherwise in writing not later than the time of filing proofs
of such loss, be paid directly to the hospital or person rendering such
services; but it is not required that the service be rendered by a particular
hospital or person.
(Added to NRS by 1971, 1756)
NRS 689A.135 Assignment of benefits to provider of health care.
1. A person insured under a policy of
health insurance may assign his or her right to benefits to the provider of
health care who provided the services covered by the policy. The insurer shall
pay all or the part of the benefits assigned by the insured to the person
designated by the insured. A payment made pursuant to this subsection
discharges the insurer’s obligation to pay those benefits.
2. If the insured makes an assignment
under this section, but the insurer after receiving a copy of the assignment
pays the benefits to the insured, the insurer shall also pay those benefits to
the provider of health care who received the assignment as soon as the insurer
receives notice of the incorrect payment.
3. For the purpose of this section,
“provider of health care” has the meaning ascribed to it in NRS 629.031.
(Added to NRS by 1983, 879)
NRS 689A.140 Physical examination and autopsy. There
shall be a provision as follows:
Physical Examinations and
Autopsy: The insurer at its own expense shall have the right and opportunity to
examine the person of the insured when and as often as it may reasonably
require during the pendency of a claim hereunder and to make an autopsy in case
of death where it is not forbidden by law.
(Added to NRS by 1971, 1757)
NRS 689A.150 Legal actions. There
shall be a provision as follows:
Legal Actions: No action at
law or in equity shall be brought to recover on this policy prior to the
expiration of 60 days after written proof of loss has been furnished in
accordance with the requirements of this policy. No such action shall be
brought after the expiration of 3 years after the time written proof of loss is
required to be furnished.
(Added to NRS by 1971, 1757)
NRS 689A.160 Change of beneficiary.
1. There shall be a provision as follows:
Change of Beneficiary: Unless
the insured makes an irrevocable designation of beneficiary, the right to
change of beneficiary is reserved to the insured and the consent of the
beneficiary or beneficiaries shall not be requisite to surrender or assignment
of this policy or to any change of beneficiary or beneficiaries, or to any
other changes in this policy.
2. The first clause of the provision set
forth in subsection 1, relating to the irrevocable designation of beneficiary,
may be omitted at the insurer’s option.
(Added to NRS by 1971, 1757)
NRS 689A.170 Right to examine and return policy.
1. Except as to nonrenewable accident
policies and individual credit health insurance policies, every individual
health insurance policy shall contain a provision therein or in a separate
rider attached thereto when delivered, stating in substance that the person to
whom the policy is issued shall be permitted to return the policy within 10
days of its delivery to such person and to have a refund of the premium paid if
after examination of the policy the purchaser is not satisfied with it for any
reason. The provision shall be set forth in the policy under an appropriate
caption, and if not so printed on the face page of the policy adequate notice
of the provision shall be printed or stamped conspicuously on the face page.
2. The policy may be so returned to the
insurer at its home or branch office or to the agent through whom it was
applied for, and thereupon shall be void as from the beginning and as if the
policy had not been issued.
(Added to NRS by 1971, 1758)
NRS 689A.180 Optional provisions. Except
as otherwise provided in NRS 689A.040, no such
policy delivered or issued for delivery to any person in this State may contain
provisions respecting the matters set forth in NRS
689A.190 to 689A.270, inclusive, unless the
provisions are in the words in which the provisions appear in the applicable
section, except that the insurer may, at its option, use in lieu of any such
provision a corresponding provision of different wording approved by the
Commissioner which is not less favorable in any respect to the insured or the
beneficiary. Any such provision contained in the policy must be preceded
individually by the appropriate caption or, at the option of the insurer, by
such appropriate individual or group captions or subcaptions as the
Commissioner may approve.
(Added to NRS by 1971, 1758; A 1985, 1060; 2005, 2343)
An insurer refused to pay a beneficiary death benefits
under a policy of insurance when the insured died from an accidental overdose
of medication prescribed by her physician on the ground that the policy
contained a provision denying coverage for any loss resulting from the
influence of drugs unless “taken as prescribed by a physician.” However, former
NRS 689A.280 authorizes
an insurer to deny coverage on that ground unless the narcotic is “administered
on the advice of a physician.” Additionally, NRS
689A.180 allows the use of language that is different from that contained
in former NRS 689A.280
if it is not less favorable to the insured or the beneficiary. The court
concluded that “taken as prescribed by a physician” was a stricter standard
than “administered on the advice of a physician” and was, therefore, less
advantageous to the insured and the beneficiary. As a result of that finding,
the court amended the language contained in former NRS 689A.280 into the
policy pursuant to NRS 689A.340, which provides
that, if the language in a policy conflicts with any provision of NRS ch. 689A, the provisions of the chapter apply, and
determined that under the statutory language, the plaintiff was entitled to
recover the benefits provided under the policy. Hummel v. Continental Cas. Ins.
Co., 254 F.Supp.2d 1183 (D. Nev. 2003)
NRS 689A.190 Extended disability benefit. Any
health insurance policy may contain a provision for payment not exceeding $500
as an extended disability benefit upon the insured’s death from any cause,
which benefit shall not be construed as life insurance.
(Added to NRS by 1971, 1758)
NRS 689A.200 Change of occupation. There
may be a provision as follows:
Change of Occupation: If the
insured be injured or contracts sickness after having changed his or her
occupation to one classified by the insurer as more hazardous than that stated
in this policy or while doing for compensation anything pertaining to an
occupation so classified, the insurer will pay only such portion of the
indemnities provided in this policy as the premium paid would have purchased at
the rates and within the limits fixed by the insurer for such more hazardous
occupation. If the insured changes his or her occupation to one classified by
the insurer as less hazardous than that stated in this policy, the insurer,
upon receipt of proof of such change of occupation, will reduce the premium
rate accordingly, and will return the excess pro rata unearned premium from the
date of change of occupation or from the policy anniversary date immediately
preceding receipt of such proof, whichever is the more recent. In applying this
provision, the classification of occupational risk and the premium rates shall
be such as have been last filed by the insurer prior to the occurrence of the
loss for which the insurer is liable or prior to date of proof of change in
occupation with the state official having supervision of insurance in the state
where the insured resided at the time this policy was issued; but if such
filing was not required, then the classification of occupational risk and the
premium rates shall be those last made effective by the insurer in such state
prior to the occurrence of the loss or prior to the date of proof of change in
occupation.
(Added to NRS by 1971, 1758)
NRS 689A.210 Misstatement of age. There
may be a provision as follows:
Misstatement of Age: If the
age of the insured has been misstated, all amounts payable under this policy
shall be such as the premium paid would have purchased at the correct age.
(Added to NRS by 1971, 1759)
NRS 689A.220 Coordination of benefits: Same insurer. There
may be a provision as follows:
If an accident or sickness or
accident and sickness policy or policies previously issued by the insurer to
the insured be in force concurrently herewith, making the aggregate indemnity
for ................ (insert type of coverage or coverages) in excess of $.....
(insert maximum limit of indemnity or indemnities), the excess shall be void
and all premiums paid for such excess shall be returned to the insured or to
the estate of the insured.
Or, in lieu thereof:
Insurance effective at any
one time on the insured under this policy and like policy or policies in this
insurer is limited to the one policy elected by the insured or the beneficiary
or estate of the insured, as the case may be, and the insurer will return all
premiums paid for all other such policies.
(Added to NRS by 1971, 1759)
NRS 689A.230 Coordination of benefits: All coverages.
1. There may be a provision as follows:
Coordination of Benefits: If,
with respect to a person covered under this policy, benefits for allowable
expense incurred during a claim determination period under this policy,
together with benefits for allowable expense during such period under all other
valid coverage (without giving effect to this provision or to any “coordination
of benefits provision” applying to such other valid coverage), exceed the total
of such person’s allowable expense during such period, this insurer shall be
liable only for such proportionate amount of the benefits for allowable expense
under this policy during such period as (a) the total allowable expense during
such period bears to (b) the total amount of benefits payable during such
period for such expense under this policy and all other valid coverage (without
giving effect to this provision or to any “coordination of benefits provision”
applying to such other valid coverage) less in both (a) and (b) any amount of
benefits for allowable expense payable under other valid coverage which does
not contain a “coordination of benefits provision.” In no event shall this
provision operate to increase the amount of benefits for allowable expense
payable under this policy with respect to a person covered under this policy
above the amount which would have been paid in the absence of this provision.
This insurer may pay benefits to any insurer providing other valid coverage in
the event of overpayment by such insurer. Any such payment shall discharge the
liability of this insurer as fully as if the payment had been made directly to
the insured or the assignee or beneficiary of the insured. If this insurer pays
benefits to the insured or the assignee or beneficiary of the insured, in
excess of the amount which would have been payable if the existence of other
valid coverage had been disclosed, this insurer shall have a right of action
against the insured or the assignee or beneficiary of the insured to recover
the amount which would not have been paid had there been a disclosure of the
existence of the other valid coverage. The amount of other valid coverage which
is on a provision of service basis shall be computed as the amount the services
rendered would have cost in the absence of such coverage.
For the purposes of this
provision:
(1) “Allowable expense”
means 100 percent of any necessary, reasonable and customary item of expense
which is covered, in whole or in part, as a hospital, surgical, medical or
major medical expense under this policy or under any other valid coverage.
(2) “Claim
determination period” with respect to any covered person means the initial
period of ..... (insert period of not less than 30 days) and each successive
period of a like number of days, during which allowable expense covered under
this policy is incurred on account of such person. The first such period begins
on the date when the first such expense is incurred, and successive periods
shall begin when such expense is incurred after expiration of a prior period.
or, in lieu thereof:
(2) “Claim
determination period” with respect to any covered person means each .....
(insert calendar or policy period of not less than a month) during which
allowable expense covered under this policy is incurred on account of such
person.
(3) “Coordination of
benefits provision” means this provision and any other provision which may reduce
an insurer’s liability because of the existence of benefits under other valid
coverage.
2. The foregoing policy provisions may be
inserted in all policies providing hospital, surgical, medical or major medical
benefits for which the application includes a question as to other coverages
subject to this provision. If the policy provision stated in subsection 1 is
included in a policy which also contains the policy provision stated in NRS 689A.240, there shall be added to the caption of
the provision stated in subsection 1 of the phrase “expense-incurred benefits.”
The insurer may make this provision applicable to either or both:
(a) Other valid coverage with other insurers; and
(b) Other valid coverage with the same insurer.
Ê The insurer
shall include in this provision a definition of “other valid coverage” approved
as to form by the Commissioner. Such term may include hospital, surgical,
medical or major medical benefits provided by individual or family-type
coverage, government programs or workers’ compensation. Such term shall not
include any automobile medical payments or third-party liability coverage. The
insurer shall not include a subrogation clause in the policy. The insurer may
require, as part of the proof of claim, the information necessary to administer
this provision.
3. If by application of any of the
foregoing provisions the insurer effects a material reduction of benefits
otherwise payable under the policy, the insurer shall refund to the insured any
premium unearned on the policy by reason of such reduction of coverage during
the policy year current and that next preceding at the time the loss commenced,
subject to the insurer’s right to provide in the policy that no such reduction
of benefits or refund will be made unless the unearned premium to be so
refunded amounts to $5 or such larger sum as the insurer may so specify.
(Added to NRS by 1971, 1760; A 2013, 3612)
NRS 689A.240 Relation of earnings to insurance.
1. There may be a provision as follows:
Relation of Earnings to
Insurance: After the loss-of-time benefit of this policy has been payable for
90 days, such benefit will be adjusted, as provided below, if the total amount
of unadjusted loss-of-time benefits provided in all valid loss-of-time coverage
upon the insured should exceed ..... percent of the insured’s earned income;
provided, however, that if the information contained in the application
discloses that the total amount of loss-of-time benefits under this policy and
under all other valid loss-of-time coverage expected to be effective upon the
insured in accordance with the application for this policy exceeded .....
percent of the insured’s earned income at the time of such application, such
higher percentage will be used in place of ..... percent. Such adjusted
loss-of-time benefit under this policy for any month shall be only such
proportion of the loss-of-time benefit otherwise payable under this policy as
(a) the product of the insured’s earned income and ..... percent (or, if higher
the alternative percentage described at the end of the first sentence of this provision)
bears to (b) the total amount of loss-of-time benefits payable for such
month under this policy and all other valid loss-of-time coverage on the
insured (without giving effect to the “overinsurance provision” in this or any
other coverage) less in both (a) and (b) any amount of loss-of-time benefits
payable under other valid loss-of-time coverage which does not contain an
“overinsurance provision.” In making such computation, all benefits and
earnings shall be converted to a consistent (insert “weekly” if the
loss-of-time benefit of this policy is payable weekly, “monthly” if such
benefit is payable monthly, etc.) basis. If the numerator of the foregoing
ratio is zero or is negative, no benefit shall be payable under this policy. In
no event shall this provision (1) operate to reduce the total combined amount
of loss-of-time benefits for such month payable under this policy and all other
valid loss-of-time coverage below the lesser of $300 and the total combined
amount of loss-of-time benefits determined without giving effect to any
“coordination of benefits provision,” nor (2) operate to increase the
amount of benefits payable under this policy above the amount which would have
been paid in the absence of this provision, nor (3) take into account or
operate to reduce any benefit other than the loss-of-time benefit.
For purposes of this
provision:
(A) “Earned income,”
except where otherwise specified, means the greater of the monthly earnings of
the insured at the time disability commences and the average monthly earnings
of the insured for a period of 2 years immediately preceding the commencement
of such disability, and shall not include any investment income or any other
income not derived from the insured’s vocational activities.
(B) “Coordination of
benefits provision” includes this provision and any other provision with
respect to any loss-of-time coverage which may have the effect of reducing an
insurer’s liability if the total amount of loss-of-time benefits under all
coverage exceeds a stated relationship to the insured’s earnings.
2. If the policy provision stated in
subsection 1 is included in a policy which also contains the policy provision
stated in NRS 689A.230, there shall be added to
the caption of the provision stated in subsection 1 the phrase “loss-of-time
benefits.”
3. The foregoing provision may be included
only in a policy which provides a loss-of-time benefit which may be payable for
at least 52 weeks, which is issued on the basis of selective underwriting of
each individual application, and for which the application includes a question
designed to elicit information necessary either to determine the ratio of the
total loss-of-time benefits of the insured to the insured’s earned income or to
determine that such ratio does not exceed the percentage of earnings, not less
than 60 percent selected by the insurer and inserted in lieu of the blank
factor above. The insurer may require, as part of the proof of claim, the
information necessary to administer this provision. If the application
indicates that other loss-of-time coverage is to be discontinued, the amount of
such other coverage shall be excluded in computing the alternative percentage
in the first sentence of the overinsurance provision. The policy shall include
a definition of “valid loss-of-time coverage,” approved as to form by the
Commissioner, which definition shall not include group insurance, benefits
provided by union welfare plans, employer or employee benefit plans, workers’
compensation or employer’s liability statute or third-party liability. The
insurer shall not include a subrogation clause in the policy.
4. If by application of any of the
foregoing provisions the insurer effects a material reduction of benefits
otherwise payable under the policy, the insurer shall refund to the insured any
premium unearned on the policy by reason of such reduction of coverage during
the policy year current and that next preceding at the time the loss commenced,
subject to the insurer’s right to provide in the policy that no such reduction
of benefits or refund will be made unless the unearned premium to be so
refunded amounts to $5 or such larger sum as the insurer may so specify.
(Added to NRS by 1971, 1761)
NRS 689A.250 Unpaid premiums. There
may be a provision as follows:
Unpaid Premium: Upon the
payment of a claim under this policy, any premium then due and unpaid or
covered by any note or written order may be deducted therefrom.
(Added to NRS by 1971, 1763)
NRS 689A.260 Conformity with state statutes. There
may be a provision as follows:
Conformity with State
Statutes: Any provision of this policy which, on its effective date is in
conflict with the statutes of the state in which the insured resides on such
date is hereby amended to conform to the minimum requirements of such statutes.
(Added to NRS by 1971, 1763)
NRS 689A.270 Illegal occupation. There
may be a provision as follows:
Illegal Occupation: The
insurer shall not be liable for any loss to which a contributing cause was the
insured’s commission of or attempt to commit a felony or to which a
contributing cause was the insured’s being engaged in an illegal occupation.
(Added to NRS by 1971, 1763)
NRS 689A.290 Renewability. Health
insurance policies, other than accident insurance only policies, in which the
insurer reserves the right to refuse renewal on an individual basis, shall
provide in substance in a provision thereof or in an endorsement thereon or
rider attached thereto that subject to the right to terminate the policy upon
nonpayment of premium when due, such right to refuse renewal may not be
exercised so as to take effect before the renewal date occurring on, or after
and nearest, each policy anniversary (or in the case of lapse and
reinstatement, at the renewal date occurring on, or after and nearest, each
anniversary of the last reinstatement), and that any refusal of renewal shall
be without prejudice to any claim originating while the policy is in force.
(The parenthetic reference to lapse and reinstatement may be omitted at the
insurer’s option.)
(Added to NRS by 1971, 1764)
NRS 689A.300 Order of certain provisions. The
provisions which are the subject of NRS 689A.050
to 689A.290, inclusive, or any corresponding
provisions which are used in lieu thereof in accordance with such sections
shall be printed in the consecutive order of the provisions in such sections
or, at the option of the insurer, any such provision may appear as a unit in
any part of the policy, with other provisions to which it may be logically
related, provided that the resulting policy shall not be in whole or in part
unintelligible, uncertain, ambiguous, abstruse or likely to mislead a person to
whom the policy is offered, delivered or issued.
(Added to NRS by 1971, 1764)
NRS 689A.310 Ownership of policy by person other than insured. The word “insured,” as used in this chapter,
shall not be construed as preventing a person other than the insured with a
proper insurable interest from making application for and owning a policy
covering the insured or from being entitled under such a policy to any
indemnities, benefits and rights provided therein.
(Added to NRS by 1971, 1764)
NRS 689A.320 Requirements of other jurisdictions.
1. Any policy of a foreign or alien
insurer, when delivered or issued for delivery to any person in this state, may
contain any provision which is not less favorable to the insured or the
beneficiary than the provisions of this chapter and which is prescribed or
required by the law of the state or country under which the insurer is
organized.
2. Any policy of a domestic insurer may,
when issued for delivery in any other state or country, contain any provision
permitted or required by the laws of such other state or country.
(Added to NRS by 1971, 1764)
NRS 689A.330 Policies issued for delivery in another state. If any policy is issued by a domestic insurer
for delivery to a person residing in another state, and if the insurance
commissioner or corresponding public officer of that other state has informed
the Commissioner that the policy is not subject to approval or disapproval by
that officer, the Commissioner may by ruling require that the policy meet the
standards set forth in NRS 689A.030 to 689A.320, inclusive.
(Added to NRS by 1971, 1765; A 1985, 1447; 1989, 1273; 1997, 743; 1999, 760, 1997; 2003, 1334, 3355, 3522; 2007, 3237; 2009, 1467;
2013, 1998)
NRS 689A.340 Limitation on provisions not subject to chapter; effect of
violation.
1. No policy provision which is not
subject to this chapter shall make a policy, or any portion thereof, less
favorable in any respect to the insured or the beneficiary than the provisions
thereof which are subject to this chapter.
2. A policy delivered or issued for
delivery to any person in this state in violation of this chapter shall be held
valid but shall be construed as provided in this chapter. When any provision in
a policy subject to this chapter is in conflict with any provision of this
chapter, the rights, duties and obligations of the insurer, the insured and the
beneficiary shall be governed by the provisions of this chapter.
(Added to NRS by 1971, 1765)
NRS 689A.350 Age limit. If any
such policy contains a provision establishing, as an age limit or otherwise, a
date after which the coverage provided by the policy will not be effective, and
if such date falls within a period for which a premium is accepted by the
insurer or if the insurer accepts a premium after such date, the coverage
provided by the policy will continue in force subject to any right of
termination until the end of the period for which the premium has been
accepted. If the age of the insured has been misstated and if, according to the
correct age of the insured, the coverage provided by the policy would not have
become effective, or would have ceased prior to the acceptance of such premium
or premiums, then the liability of the insurer shall be limited to the refund
of all premiums paid for the period not covered by the policy.
(Added to NRS by 1971, 1765)
NRS 689A.370 Health insurance on franchise plan. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689A.380 Definitions of terms used in policies. As
used in any policy of health insurance delivered, issued for delivery or used
in this state, unless otherwise provided in the policy or in an endorsement
thereon or in a rider attached thereto:
1. “Accidental death” means death by
accident exclusively and independently of all other causes.
2. “Confinement to house” or “house
confinement” includes the activities of a convalescent not able to be gainfully
employed.
3. “Medical or surgical services” includes
also services within the scope of his or her license rendered by any person
while duly licensed by the State of Nevada under any of the following chapters
of NRS: 631 (dentistry); 633 (osteopathic medicine); 634 (chiropractic); 634A
(Oriental medicine); 635 (podiatry); or 636 (optometry). No policy of health
insurance may provide that the insured does not have the option of selecting
any licensee provided for in this subsection to perform any medical or surgical
services covered by a policy of insurance if the service is within the scope of
his or her license.
4. “Total disability” means inability to
perform the duties of any gainful occupation for which the insured is
reasonably fitted by training, experience and accomplishment.
(Added to NRS by 1971, 1766; A 1971, 1953; 1975, 240;
1977, 966)
NRS 689A.390 Summary of coverage: Contents of disclosure; approval by
Commissioner.
1. The Commissioner shall adopt
regulations which require an insurer to file with the Commissioner, for
approval by the Commissioner, a disclosure summarizing the coverage provided by
each policy of health insurance offered by the insurer. The disclosure must
include:
(a) Any significant exception, reduction or
limitation that applies to the policy; and
(b) Any other information,
Ê that the
Commissioner finds necessary to provide for full and fair disclosure of the
provisions of the policy.
2. The disclosure must be written in
language which is easily understood and must include a statement that the
disclosure is a summary of the policy only, and that the policy itself should
be read to determine the governing contractual provisions.
3. The Commissioner shall not approve any
proposed disclosure submitted to the Commissioner pursuant to this section
which does not comply with the requirements of this section and the applicable
regulations.
(Added to NRS by 1989, 1248)
NRS 689A.400 Summary of coverage: Copy to be provided before policy issued;
policy may not be offered unless summary approved by Commissioner. An insurer shall provide each person to whom
it offers a policy of health insurance with a copy of the disclosure approved
for that policy pursuant to NRS 689A.390 before
the policy is issued. An insurer shall not offer a policy of health insurance
unless the disclosure for that policy has been approved by the Commissioner.
(Added to NRS by 1989, 1249)
NRS 689A.405 Coverage for prescription drugs: Provision of notice and
information regarding use of formulary.
1. An insurer that offers or issues a
policy of health insurance which provides coverage for prescription drugs shall
include with any summary, certificate or evidence of that coverage provided to
an insured, notice of whether a formulary is used and, if so, of the
opportunity to secure information regarding the formulary from the insurer
pursuant to subsection 2. The notice required by this subsection must:
(a) Be in a language that is easily understood
and in a format that is easy to understand;
(b) Include an explanation of what a formulary
is; and
(c) If a formulary is used, include:
(1) An explanation of:
(I) How often the contents of the
formulary are reviewed; and
(II) The procedure and criteria for
determining which prescription drugs are included in and excluded from the
formulary; and
(2) The telephone number of the insurer
for making a request for information regarding the formulary pursuant to
subsection 2.
2. If an insurer offers or issues a policy
of health insurance which provides coverage for prescription drugs and a
formulary is used, the insurer shall:
(a) Provide to any insured or participating
provider of health care, upon request:
(1) Information regarding whether a
specific drug is included in the formulary.
(2) Access to the most current list of
prescription drugs in the formulary, organized by major therapeutic category,
with an indication of whether any listed drugs are preferred over other listed
drugs. If more than one formulary is maintained, the insurer shall notify the
requester that a choice of formulary lists is available.
(b) Notify each person who requests information
regarding the formulary, that the inclusion of a drug in the formulary does not
guarantee that a provider of health care will prescribe that drug for a
particular medical condition.
(Added to NRS by 2001, 856)
NRS 689A.410 Approval or denial of claims; payment of claims and interest;
requests for additional information; award of costs and attorney’s fees;
compliance with requirements.
1. Except as otherwise provided in
subsection 2, an insurer shall approve or deny a claim relating to a policy of
health insurance within 30 days after the insurer receives the claim. If the
claim is approved, the insurer shall pay the claim within 30 days after it is
approved. Except as otherwise provided in this section, if the approved claim
is not paid within that period, the insurer shall pay interest on the claim at
a rate of interest equal to the prime rate at the largest bank in Nevada, as
ascertained by the Commissioner of Financial Institutions, on January 1 or July
1, as the case may be, immediately preceding the date on which the payment was
due, plus 6 percent. The interest must be calculated from 30 days after the
date on which the claim is approved until the date on which the claim is paid.
2. If the insurer requires additional
information to determine whether to approve or deny the claim, it shall notify
the claimant of its request for the additional information within 20 days after
it receives the claim. The insurer shall notify the provider of health care of
all the specific reasons for the delay in approving or denying the claim. The
insurer shall approve or deny the claim within 30 days after receiving the
additional information. If the claim is approved, the insurer shall pay the
claim within 30 days after it receives the additional information. If the
approved claim is not paid within that period, the insurer shall pay interest
on the claim in the manner prescribed in subsection 1.
3. An insurer shall not request a claimant
to resubmit information that the claimant has already provided to the insurer,
unless the insurer provides a legitimate reason for the request and the purpose
of the request is not to delay the payment of the claim, harass the claimant or
discourage the filing of claims.
4. An insurer shall not pay only part of a
claim that has been approved and is fully payable.
5. A court shall award costs and
reasonable attorney’s fees to the prevailing party in an action brought
pursuant to this section.
6. The payment of interest provided for in
this section for the late payment of an approved claim may be waived only if
the payment was delayed because of an act of God or another cause beyond the
control of the insurer.
7. The Commissioner may require an insurer
to provide evidence which demonstrates that the insurer has substantially
complied with the requirements set forth in this section, including, without
limitation, payment within 30 days of at least 95 percent of approved claims or
at least 90 percent of the total dollar amount for approved claims.
8. If the Commissioner determines that an
insurer is not in substantial compliance with the requirements set forth in
this section, the Commissioner may require the insurer to pay an administrative
fine in an amount to be determined by the Commissioner. Upon a second or subsequent
determination that an insurer is not in substantial compliance with the
requirements set forth in this section, the Commissioner may suspend or revoke
the certificate of authority of the insurer.
(Added to NRS by 1991, 1328; A 1999, 1647; 2001, 2729; 2003, 3355)
NRS 689A.413 Insurer prohibited from denying coverage solely because person
was victim of domestic violence. An
insurer shall not deny a claim, refuse to issue a policy of health insurance or
cancel a policy of health insurance 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 health insurance policy was the victim of such an act of
domestic violence, regardless of whether the insured or applicant contributed
to any loss or injury.
(Added to NRS by 1997, 1095)
NRS 689A.415 Insurer prohibited from denying coverage solely because insured
was intoxicated or under influence of controlled substance; exceptions.
1. Except as otherwise provided in
subsection 2, an insurer shall not:
(a) Deny a claim under a policy of health
insurance 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 policy of health insurance 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 policy of health insurance
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 an insurer from enforcing a provision included in a policy of health
insurance pursuant to NRS 689A.270 to:
(a) Deny a claim which involves an injury to
which a contributing cause was the insured’s commission of or attempt to commit
a felony;
(b) Cancel a policy of health insurance solely
because of such a claim; or
(c) Refuse to issue a policy of health insurance
to an eligible applicant solely because of such a claim.
3. The provisions of this section do not
apply to an insurer under a policy of health insurance that provides coverage
for long-term care or disability income.
(Added to NRS by 2005, 2343; A 2007, 84)
NRS 689A.417 Insurer prohibited from requiring or using information
concerning genetic testing; exceptions.
1. Except as otherwise provided in
subsection 2, an insurer who provides health insurance shall not:
(a) Require an insured person or any member of
the family of the insured person to take a genetic test;
(b) Require an insured person to disclose whether
the insured person or any member of the family of the insured person has taken
a genetic test or any genetic information of the insured person or a member of
the family of the insured person; or
(c) Determine the rates or any other aspect of
the coverage or benefits for health care provided to an insured person based
on:
(1) Whether the insured person or any
member of the family of the insured person has taken a genetic test; or
(2) Any genetic information of the insured
person or any member of the family of the insured person.
2. The provisions of this section do not
apply to an insurer who issues a policy of health insurance that provides
coverage for long-term care or disability income.
3. As used in this section:
(a) “Genetic information” means any information
that is obtained from a genetic test.
(b) “Genetic test” means a test, including a
laboratory test that uses deoxyribonucleic acid extracted from the cells of a
person or a diagnostic test, to determine the presence of abnormalities or
deficiencies, including carrier status, that:
(1) Are linked to physical or mental
disorders or impairments; or
(2) Indicate a susceptibility to illness,
disease, impairment or any other disorder, whether physical or mental.
(Added to NRS by 1997, 1459)
NRS 689A.419 Offering policy of health insurance for purposes of establishing
health savings account. An insurer
may, subject to regulation by the Commissioner, offer a policy of health
insurance that has a high deductible and is in compliance with 26 U.S.C. § 223
for the purposes of establishing a health savings account.
(Added to NRS by 2005, 2136)
ELIGIBILITY FOR COVERAGE
NRS 689A.420 Definitions. As
used in NRS 689A.420 to 689A.460,
inclusive, unless the context otherwise requires:
1. “Medicaid” means a program established
in any state pursuant to Title XIX of the Social Security Act (42 U.S.C. §§
1396 et seq.) to provide assistance for part or all of the cost of medical care
rendered on behalf of indigent persons.
2. “Order for medical coverage” means an
order of a court or administrative tribunal to provide coverage under a policy
of health insurance to a child pursuant to the provisions of 42 U.S.C. §
1396g-1.
(Added to NRS by 1995, 2427)
NRS 689A.430 Effect of eligibility for medical assistance under Medicaid;
assignment of rights to state agency.
1. An insurer shall not, when considering
eligibility for coverage or making payments under a policy of health insurance,
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, an insurer, self-insured plan, group health
plan as defined in section 607(1) of the Employee Retirement Income Security
Act of 1974, 29 U.S.C.A. § 1167(1), service benefit plan or other organization
that has issued a policy of health insurance:
(a) Shall treat Medicaid as having a valid and
enforceable assignment of an insured’s benefits regardless of any exclusion of
Medicaid or the absence of a written assignment; and
(b) May, as otherwise allowed by the policy,
evidence of coverage or contract and applicable law or regulation concerning
subrogation, seek to enforce any right of a recipient of Medicaid to
reimbursement against any other liable party if:
(1) It is so authorized pursuant to a
contract with Medicaid for managed care; or
(2) It has reimbursed Medicaid in full for
the health care provided by Medicaid to its 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 policy of health insurance,
Ê the insurer
that issued the 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 policy.
4. If a state agency is assigned any
rights of an insured who is eligible for medical assistance under Medicaid, an
insurer 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 or
the insured’s spouse or dependent may be or may have been covered by the
insurer; and
(2) The nature of the coverage that is or
was provided by the insurer, including, without limitation, the name and
address of the insured and the identifying number of the policy, evidence of
coverage or contract;
(b) Respond to any inquiry by the state agency
regarding a claim for payment for the provision of any medical item or service
not later than 3 years after the date of the provision of the medical item or
service; and
(c) Agree not to deny a claim submitted by the
state agency solely on the basis of 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:
(1) 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
(2) 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.
(Added to NRS by 1995, 2427; A 2007, 2402)
NRS 689A.440 Insurer prohibited from asserting certain grounds to deny
enrollment of child of insured pursuant to order. An
insurer shall not deny the enrollment of a child pursuant to an order for
medical coverage, under a policy of health insurance pursuant to which a parent
of the child is insured, on the ground that the child:
1. Was born out of wedlock;
2. Has not been claimed as a dependent on
the parent’s federal income tax return; or
3. Does not reside with the parent or
within the insurer’s geographic area of service.
(Added to NRS by 1995, 2427)
NRS 689A.450 Certain accommodations to be made when child is covered under
policy of noncustodial parent. If
a child has coverage under a policy of health insurance pursuant to which a
noncustodial parent of the child is insured, the insurer issuing that policy
shall:
1. Provide to the custodial parent such
information as necessary for the child to obtain any benefits under that
coverage.
2. Allow the custodial parent or, with the
approval of the custodial parent, a provider of health care to submit claims
for covered services without the approval of the noncustodial parent.
3. Make payments on claims submitted
pursuant to subsection 2 directly to the custodial parent, the provider of
health care or an agency of this or another state responsible for the
administration of Medicaid.
(Added to NRS by 1995, 2428)
NRS 689A.460 Insurer 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 policy of health insurance for a child and the parent is eligible for
coverage of members of the family of the parent under a policy of health
insurance, the insurer that issued the policy:
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 insurer has written proof that:
(a) The order for medical coverage is no longer
in effect; or
(b) The child is or will be enrolled in
comparable coverage through another insurer on or before the effective date of
the termination of enrollment or elimination of coverage.
(Added to NRS by 1995, 2428)
PORTABILITY AND ACCOUNTABILITY
General Provisions
NRS 689A.470 Definitions. As
used in NRS 689A.470 to 689A.740,
inclusive, unless the context otherwise requires, the words and terms defined
in NRS 689A.475 to 689A.600,
inclusive, have the meanings ascribed to them in those sections.
(Added to NRS by 1997, 2883; A 2001, 1922; 2005, 2136; 2013, 3613)
NRS 689A.475 “Affiliated” defined. “Affiliated”
means any entity or person who directly, or indirectly through one or more
intermediaries, controls or is controlled by or is under common control with a
specified entity or person.
(Added to NRS by 1997, 2883)
NRS 689A.480 “Basic health benefit plan” defined. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689A.485 “Bona fide association” defined. “Bona
fide association” means, with respect to health insurance coverage offered in
this state, an association that:
1. Has been actively in existence for at
least 5 years;
2. Has been formed and maintained in good
faith for purposes other than obtaining insurance;
3. Does not condition membership in the
association on any health status-related factor relating to an individual,
including an employee of an employer or a dependent of an employee;
4. Makes health insurance coverage offered
through the association available to all of its members regardless of any
health status-related factors of the members or other individuals who are
eligible for such health insurance coverage through a member of the
association;
5. Does not make health insurance coverage
offered through the association available other than in connection with a
member of the association; and
6. Meets such additional requirements as
may be imposed by specific statute.
(Added to NRS by 1997, 2883)
NRS 689A.490 “Church plan” defined. “Church
plan” has the meaning ascribed to it in section 3(33) of the Employee
Retirement Income Security Act of 1974, as that section existed on July 16,
1997.
(Added to NRS by 1997, 2884)
NRS 689A.495 “Control” defined. “Control”
has the meaning ascribed to it in NRS
692C.050.
(Added to NRS by 1997, 2884)
NRS 689A.500 “Converted policy” defined. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689A.505 “Creditable coverage” defined. “Creditable
coverage” means, with respect to a person, health benefits or coverage provided
pursuant to:
1. A group health plan;
2. A health benefit plan;
3. Part A or Part B of Title XVIII of the
Social Security Act, 42 U.S.C. §§ 1395c et seq., also known as Medicare;
4. Title XIX of the Social Security Act,
42 U.S.C. §§ 1396 et seq., also known as Medicaid, other than coverage
consisting solely of benefits under section 1928 of that Title, 42 U.S.C. §
1396s;
5. The Civilian Health and Medical Program
of Uniformed Services, CHAMPUS, 10 U.S.C. §§ 1071 et seq.;
6. A medical care program of the Indian
Health Service or of a tribal organization;
7. A state health benefit risk pool;
8. A health plan offered pursuant to the
Federal Employees Health Benefits Program, FEHBP, 5 U.S.C. §§ 8901 et seq.;
9. A public health plan as defined in 45
C.F.R. § 146.113, authorized by the Public Health Service Act, 42 U.S.C. §
300gg(c)(1)(I);
10. A health benefit plan under section
5(e) of the Peace Corps Act, 22 U.S.C. § 2504(e);
11. The Children’s Health Insurance
Program established pursuant to 42 U.S.C. §§ 1397aa to 1397jj, inclusive;
12. A short-term health insurance policy;
or
13. A blanket student accident and health
insurance policy.
(Added to NRS by 1997, 2884; A 1999, 2239, 2802)
NRS 689A.510 “Dependent” defined. “Dependent”
has the meaning ascribed to it in NRS
689C.055.
(Added to NRS by 1997, 2884)
NRS 689A.515 “Eligible person” defined. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689A.520 “Established geographic service area” defined. [Replaced in revision by NRS 689A.527.]
NRS 689A.523 “Exclusion for a preexisting condition” defined. “Exclusion for a preexisting condition” means:
1. Any limitation or exclusion of benefits
relating to a condition that was present before the date coverage was first
provided, regardless of whether any medical advice, diagnosis, care or
treatment was recommended or received before that date; or
2. Any exclusion applicable to an
individual based on any information relating to the status of an individual’s
health that was obtained before the date coverage was first provided,
including, without limitation, any identification of a condition resulting
from:
(a) A preenrollment questionnaire or physical
examination provided to the individual; or
(b) A review of any medical records relating to
the period of preenrollment.
(Added to NRS by 2005, 2136)
NRS 689A.525 “Geographic rating area” defined. “Geographic
rating area” means an area established by the Commissioner for use in adjusting
the rates for a health benefit plan.
(Added to NRS by 1997, 2885; A 2013, 3613)
NRS 689A.527 “Geographic service area” defined. “Geographic
service area” means a geographic area, as approved by the Commissioner, within
which the carrier is authorized to provide coverage.
(Added to NRS by 1997, 2885; A 2013, 3613)—(Substituted
in revision for NRS 689A.520)
NRS 689A.530 “Governmental plan” defined. “Governmental
plan” has the meaning ascribed to it in section 3(32) of the Employee
Retirement Income Security Act of 1974, as that section existed on July 16,
1997, and any health plan of the Federal Government.
(Added to NRS by 1997, 2885)
NRS 689A.535 “Group health plan” defined.
1. “Group health plan” means an employee
welfare benefit plan, as defined in section 3(1) of the Employee Retirement
Income Security Act of 1974, as that section existed on July 16, 1997, to the
extent that the plan provides medical care to employees or their dependents as
defined under the terms of the plan directly, or through insurance, reimbursement
or otherwise.
2. The term does not include:
(a) Coverage that is only for accident or
disability income insurance, or any combination thereof;
(b) Coverage issued as a supplement to liability
insurance;
(c) Liability insurance, including general liability
insurance and automobile liability insurance;
(d) Workers’ compensation or similar insurance;
(e) Coverage for medical payments under a policy
of automobile insurance;
(f) Credit insurance;
(g) Coverage for on-site medical clinics; and
(h) Other similar insurance coverage specified in
federal regulations adopted pursuant to Public Law 104-191 under which benefits
for medical care are secondary or incidental to other insurance benefits.
3. The term does not include the following
benefits if the benefits are provided under a separate policy, certificate or
contract of insurance or are otherwise not an integral part of a health benefit
plan:
(a) Limited-scope dental or vision benefits;
(b) Benefits for long-term care, nursing home
care, home health care or community-based care, or any combination thereof; and
(c) Such other similar benefits as are specified
in federal regulations adopted pursuant to Public Law 104-191.
4. The term does not include the following
benefits if the benefits are provided under a separate policy, certificate or
contract of insurance, there is no coordination between the provision of the
benefits and any exclusion of benefits under any group health plan maintained
by the same plan sponsor, and such benefits are paid for a claim without regard
to whether benefits are provided for such a claim under any group health plan
maintained by the same plan sponsor:
(a) Coverage that is only for a specified disease
or illness; and
(b) Hospital indemnity or other fixed indemnity
insurance.
5. The term does not include any of the
following, if offered as a separate policy, certificate or contract of
insurance:
(a) Medicare supplemental health insurance as
defined in section 1882(g)(1) of the Social Security Act, as that section
existed on July 16, 1997;
(b) Coverage supplemental to the coverage
provided pursuant to chapter 55 of Title 10, United States Code (Civilian
Health and Medical Program of Uniformed Services (CHAMPUS)); and
(c) Similar supplemental coverage provided under
a group health plan.
(Added to NRS by 1997, 2885)
NRS 689A.540 “Health benefit plan” defined.
1. “Health benefit plan” means a policy,
contract, certificate or agreement offered by a carrier to provide for, deliver
payment for, arrange for the payment of, pay for or reimburse any of the costs
of health care services. Except as otherwise provided in this section, the term
includes catastrophic health insurance policies and a policy that pays on a
cost-incurred basis.
2. The term does not include:
(a) Coverage that is only for accident or
disability income insurance, or any combination thereof;
(b) Coverage issued as a supplement to liability
insurance;
(c) Liability insurance, including general
liability insurance and automobile liability insurance;
(d) Workers’ compensation or similar insurance;
(e) Coverage for medical payments under a policy
of automobile insurance;
(f) Credit insurance;
(g) Coverage for on-site medical clinics;
(h) Other similar insurance coverage specified in
federal regulations issued pursuant to Public Law 104-191 under which benefits
for medical care are secondary or incidental to other insurance benefits;
(i) Coverage under a short-term health insurance
policy; and
(j) Coverage under a blanket student accident and
health insurance policy.
3. The term does not include the following
benefits if the benefits are provided under a separate policy, certificate or
contract of insurance or are otherwise not an integral part of a health benefit
plan:
(a) Limited-scope dental or vision benefits;
(b) Benefits for long-term care, nursing home
care, home health care or community-based care, or any combination thereof; and
(c) Such other similar benefits as are specified
in any federal regulations adopted pursuant to the Health Insurance Portability
and Accountability Act of 1996, Public Law 104-191.
4. The term does not include the following
benefits if the benefits are provided under a separate policy, certificate or
contract of insurance, there is no coordination between the provision of the
benefits and any exclusion of benefits under any group health plan maintained
by the same plan sponsor, and the benefits are paid for a claim without regard
to whether benefits are provided for such a claim under any group health plan
maintained by the same plan sponsor:
(a) Coverage that is only for a specified disease
or illness; and
(b) Hospital indemnity or other fixed indemnity
insurance.
5. The term does not include any of the
following, if offered as a separate policy, certificate or contract of
insurance:
(a) Medicare supplemental health insurance as
defined in section 1882(g)(1) of the Social Security Act, 42 U.S.C. § 1395ss,
as that section existed on July 16, 1997;
(b) Coverage supplemental to the coverage
provided pursuant to the Civilian Health and Medical Program of Uniformed
Services, CHAMPUS, 10 U.S.C. §§ 1071 et seq.; and
(c) Similar supplemental coverage provided under
a group health plan.
(Added to NRS by 1997, 2886; A 1999, 2803)
NRS 689A.545 “Health status-related factor” defined. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689A.550 “Individual carrier” defined. “Individual
carrier” means any entity subject to the provisions of this title and the
regulations adopted pursuant thereto, that contracts or offers to contract to
provide for, deliver payment for, arrange for payment of, pay for, or reimburse
any cost of health care services, including a sickness and accident health
service corporation, and any other entity providing a plan of health insurance,
health benefits or health services to individuals and their dependents in this
state.
(Added to NRS by 1997, 2887)
NRS 689A.555 “Individual health benefit plan” defined. “Individual health benefit plan” means:
1. A health benefit plan for individuals
and their dependents, other than a converted policy or a plan for coverage of a
bona fide association; and
2. A certificate issued to an individual
that evidences coverage under a policy or contract issued to a trust or an
association or to any other similar group of persons, other than a plan for
coverage of a bona fide association, regardless of the situs of delivery of the
policy or contract, if the individual pays the premium and is not being covered
under the policy or contract pursuant to any provision for the continuation of
benefits applicable under federal or state law.
(Added to NRS by 1997, 2887)
NRS 689A.560 “Individual reinsuring carrier” defined. Repealed. (See chapter 541, Statutes of Nevada
2013, at page 3661.)
NRS 689A.565 “Individual risk-assuming carrier” defined. Repealed. (See chapter 541, Statutes of Nevada
2013, at page 3661.)
NRS 689A.570 “Plan for coverage of a bona fide association” defined. “Plan for coverage of a bona fide association”
means a health benefit plan for the members, and their dependents, of a bona
fide association in this state regardless of the situs of delivery of the
policy or contract, if the health benefit plan conforms with NRS 689A.725.
(Added to NRS by 1997, 2888)
NRS 689A.575 “Plan of operation” defined. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689A.580 “Plan sponsor” defined. “Plan
sponsor” has the meaning ascribed to it in section 3(16)(B) of the Employee
Retirement Security Act of 1974, as that section existed on July 16, 1997.
(Added to NRS by 1997, 2888)
NRS 689A.585 “Preexisting condition” defined. “Preexisting
condition” means a condition, regardless of the cause of the condition, for
which medical advice, diagnosis, care or treatment was recommended or received
during the 6 months preceding the effective date of the new coverage. The term
does not include genetic information in the absence of a diagnosis of the
condition related to such information.
(Added to NRS by 1997, 2888)
NRS 689A.590 “Producer” defined. “Producer”
means an agent or broker licensed pursuant to this Title.
(Added to NRS by 1997, 2888)
NRS 689A.595 “Program of Reinsurance” defined. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689A.600 “Provision for a restricted network” defined. “Provision for a restricted network” means any
provision of a health benefit plan that conditions the payment of benefits, in
whole or in part, on the use of a provider of health care that has entered into
a contractual arrangement with an individual carrier to provide health care
services to individuals covered by the plan.
(Added to NRS by 1997, 2888)
NRS 689A.605 “Standard health benefit plan” defined. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689A.610 Applicability; ceding arrangement prohibited in certain
circumstances. Repealed. (See
chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689A.615 Certain plan, fund or program to be treated as employee welfare
benefit plan which is group health plan; partnership deemed employer of each
partner. For the purposes of NRS 689A.470 to 689A.740,
inclusive:
1. Any plan, fund or program which would
not be, but for section 2721(e) of the Public Health Service Act, as amended by
Public Law 104-191, as that section existed on July 16, 1997, an employee
welfare benefit plan and which is established or maintained by a partnership to
the extent that the plan, fund or program provides medical care to current or
former partners in the partnership or to their dependents, as defined under the
terms of the plan, fund or program, directly or through insurance,
reimbursement or otherwise, must be treated, subject to subsection 2, as an
employee welfare benefit plan which is a group health plan.
2. In the case of a group health plan, a
partnership shall be deemed to be the employer of each partner.
(Added to NRS by 1997, 2889)
NRS 689A.620 Certain person with break in coverage deemed eligible person. Repealed. (See chapter 541, Statutes of Nevada
2013, at page 3661.)
Individual Carriers
NRS 689A.630 Requirement to renew coverage at option of individual;
exceptions; discontinuation of form of product of health benefit plan;
discontinuation of health benefit plan available through bona fide association.
1. Except as otherwise provided in this
section, coverage under an individual health benefit plan must be renewed by
the individual carrier that issued the plan, at the option of the individual,
unless:
(a) The individual has failed to pay premiums or
contributions in accordance with the terms of the health benefit plan or the
individual carrier has not received timely premium payments.
(b) The individual has performed an act or a
practice that constitutes fraud or has made an intentional misrepresentation of
material fact under the terms of the coverage.
(c) The individual carrier decides to discontinue
offering and renewing all health benefit plans delivered or issued for delivery
in this state. If the individual carrier decides to discontinue offering and
renewing such plans, the individual carrier shall:
(1) Provide notice of its intention to the
Commissioner and the chief regulatory officer for insurance in each state in
which the individual carrier is licensed to transact insurance at least 60 days
before the date on which notice of cancellation or nonrenewal is delivered or
mailed to the persons covered by the insurance to be discontinued pursuant to
subparagraph (2).
(2) Provide notice of its intention to all
persons covered by the discontinued insurance and to the Commissioner and the
chief regulatory officer for insurance in each state in which such a person is
known to reside. The notice must be made at least 180 days before the
nonrenewal of any health benefit plan by the individual carrier.
(3) Discontinue all health insurance
issued or delivered for issuance for individuals in this state and not renew
coverage under any health benefit plan issued to such individuals.
(d) The Commissioner finds that the continuation
of the coverage in this state by the individual carrier would not be in the
best interests of the policyholders or certificate holders of the individual
carrier or would impair the ability of the individual carrier to meet its
contractual obligations. If the Commissioner makes such a finding, the
Commissioner shall assist the persons covered by the discontinued insurance in
this state in finding replacement coverage.
2. An individual carrier may discontinue
the issuance and renewal of a form of a product of a health benefit plan if the
Commissioner finds that the form of the product offered by the individual
carrier is obsolete and is being replaced with comparable coverage. A form of a
product of a health benefit plan may be discontinued by the individual carrier
pursuant to this subsection only if:
(a) The individual carrier notifies the
Commissioner and the chief regulatory officer for insurance in each state in
which it is licensed of its decision pursuant to this subsection to discontinue
the issuance and renewal of the form of the product at least 60 days before the
individual carrier notifies the persons covered by the discontinued insurance
pursuant to paragraph (b).
(b) The individual carrier notifies each person
covered by the discontinued insurance, the Commissioner and the chief
regulatory officer for insurance in each state in which a person covered by the
discontinued insurance is known to reside of the decision of the individual
carrier to discontinue offering the form of the product. The notice must be
made to persons covered by the discontinued insurance at least 180 days before
the date on which the individual carrier will discontinue offering the form of
the product.
(c) The individual carrier offers to each person
covered by the discontinued insurance the option to purchase any other health
benefit plan currently offered by the individual carrier to individuals in this
state.
(d) In exercising the option to discontinue the
form of the product and in offering the option to purchase other coverage
pursuant to paragraph (c), the individual carrier acts uniformly without regard
to the claim experience of the persons covered by the discontinued insurance or
any health status-related factor relating to those persons or beneficiaries
covered by the discontinued form of the product or any persons or beneficiaries
who may become eligible for such coverage.
3. An individual carrier may discontinue
the issuance and renewal of a health benefit plan that is made available to
individuals pursuant to this chapter only through a bona fide association if:
(a) The membership of the individual in the
association was the basis for the provision of coverage;
(b) The membership of the individual in the
association ceases; and
(c) The coverage is terminated pursuant to this
subsection uniformly without regard to any health status-related factor
relating to the covered individual.
4. An individual carrier that elects not
to renew a health benefit plan pursuant to paragraph (c) of subsection 1 shall
not write new business for individuals pursuant to this chapter for 5 years
after the date on which notice is provided to the Commissioner pursuant to
subparagraph (2) of paragraph (c) of subsection 1.
5. If an individual carrier does business
in only one geographic service area of this state, the provisions of this
section apply only to the operations of the individual carrier in that service
area.
(Added to NRS by 1997, 2890; A 2013, 3614)
NRS 689A.635 Coverage offered through network plan not required to be offered
to person who does not reside or work in geographic service area or geographic
rating area.
1. An individual carrier that offers
coverage through a network plan is not required pursuant to NRS 689A.630 to offer coverage to or accept an application
from a person if the person does not reside or work in the geographic service
area or in a geographic rating area, provided that the coverage is refused or
terminated uniformly without regard to any health status-related factor of any
eligible person.
2. As used in this section, “network plan”
means a health benefit plan offered by a health carrier 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 carrier. The term
does not include an arrangement for the financing of premiums.
(Added to NRS by 1997, 2892; A 2013, 3615)
NRS 689A.637 Coverage offered through plan that provides for restricted
network: Contracts with certain federally qualified health centers.
1. An individual carrier that offers a
health benefit plan that includes a provision for a restricted network shall
use its best efforts to contract with at least one health center in each
geographic service area to provide health care services to persons covered by
the plan if the health center:
(a) Meets all conditions imposed by the carrier
on similarly situated providers of health care with which the carrier
contracts, including, without limitation:
(1) Certification for participation in the
Medicaid or Medicare program; and
(2) Requirements relating to the
appropriate credentials for providers of health care; and
(b) Agrees to reasonable reimbursement rates that
are generally consistent with those offered by the carrier to similarly
situated providers of health care with which the carrier contracts.
2. As used in this section, “health
center” has the meaning ascribed to it in 42 U.S.C. § 254b.
(Added to NRS by 2001, 1922; A 2013, 3615)
NRS 689A.640 Each health benefit plan marketed in this State required to be
offered to eligible persons. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689A.645 Coverage to eligible person who does not reside in established
geographic service area not required; coverage within certain areas not
required. Repealed. (See chapter
541, Statutes of Nevada 2013, at page 3661.)
NRS 689A.650 Coverage to eligible persons not required under certain
circumstances; notice to Commissioner of and prohibition on writing new
business after election not to offer new coverage required. Repealed. (See chapter 541, Statutes of Nevada
2013, at page 3661.)
NRS 689A.655 Requirement to file basic and standard health benefit plans with
Commissioner; disapproval of plan. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689A.660 Prohibited acts concerning preexisting conditions and
modification of health benefit plan. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689A.665 Certain health carriers not required to offer health benefit
insurance coverage to individuals. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689A.670 Election to operate as individual risk-assuming carrier or individual
reinsuring carrier: Notice to Commissioner; effective date; change in status. Repealed. (See chapter 541, Statutes of Nevada
2013, at page 3661.)
NRS 689A.675 Election to act as individual risk-assuming carrier: Suspension
by Commissioner; applicable statutes. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689A.680 Rates for individual health benefit plans to be developed based
on rating characteristics: Prohibited characteristics; health status as rating
factor. Repealed. (See chapter
541, Statutes of Nevada 2013, at page 3661.)
NRS 689A.685 Amount of change in rate of single block of business; plan with
provision for restricted network; involuntary transfer of individual or
dependent prohibited; premiums adjusted for block of business. Repealed. (See chapter 541, Statutes of Nevada
2013, at page 3661.)
NRS 689A.690 Information required to be disclosed as part of solicitation and
sales materials; information required to be maintained at place of business.
1. As part of its solicitation and sales
materials for an individual health benefit plan, an individual carrier shall
disclose, to the extent reasonable:
(a) The extent to which premium rates for an
individual and the dependent of the individual are established or adjusted
based upon rating characteristics;
(b) The right of the individual carrier to change
premium rates and the factors, other than claims experience, that may affect
changes in premium rates; and
(c) Any provisions in the individual health benefit
plan relating to the renewability of the plan.
2. For the purposes of this section, an
individual carrier shall maintain at its principal place of business a complete
and detailed description of its rating practices and underwriting practices, including
information and documentation that demonstrate that its rating methods and
practices are based upon commonly accepted actuarial assumptions and are in
accordance with sound actuarial principles.
(Added to NRS by 1997, 2895; A 2013, 3616)
NRS 689A.695 Information and documents to be made available to Commissioner;
proprietary information. An
individual carrier shall make the information and documents described in NRS 689A.690, 689A.695
and 689A.700 available to the Commissioner upon
request. Except in cases of violations of the provisions of this chapter, the
information, other than the premium rates charged by the individual carrier, is
proprietary, constitutes a trade secret and is not subject to disclosure by the
Commissioner to persons outside of the Division except as agreed to by the
individual carrier or as ordered by a court of competent jurisdiction.
(Added to NRS by 1997, 2896; A 2013, 3616)
NRS 689A.700 Regulations regarding rates. The
Commissioner may adopt regulations to carry out the provisions of this section
and NRS 689A.690 and 689A.695
and to ensure that the practices used by individual carriers relating to the establishment
of rates are consistent with the purposes of NRS
689A.470 to 689A.740, inclusive.
(Added to NRS by 1997, 2895; A 2013, 3617)
NRS 689A.705 Regulations concerning reissuance of health benefit plan. The Commissioner may adopt regulations to
require an individual carrier, as a condition of transacting business with
individuals in this state after July 16, 1997, to reissue a health benefit plan
to any individual whose health benefit plan has been terminated or not renewed
by the individual carrier after July 1, 1997. The Commissioner may prescribe
such terms for the reissue of coverage as the Commissioner finds are reasonable
and necessary to provide continuity of coverage to individuals.
(Added to NRS by 1997, 2897)
NRS 689A.710 Prohibited acts; denial of application for coverage;
regulations; violation may constitute unfair trade practice; applicability of
section.
1. Except as otherwise provided in this
section, an individual carrier or a producer shall not, directly or indirectly:
(a) Encourage or direct an individual or family
to refrain from filing an application for coverage with an individual carrier
because of the health status, claims experience, industry, occupation or
geographic location of the individual or family.
(b) Encourage or direct an individual or family
to seek coverage from another carrier because of the health status, claims
experience, industry, occupation or geographic location of the individual or
family.
2. The provisions of subsection 1 do not
apply to information provided to an individual or family by an individual
carrier or a producer relating to the geographic service area or a provision
for a restricted network of the individual carrier.
3. An individual carrier shall not, directly
or indirectly, enter into any contract, agreement or arrangement with a
producer if the contract, agreement or arrangement provides for or results in a
variation to the compensation paid to a producer for the sale of a health
benefit plan because of the health status, claims experience, industry,
occupation or geographic location of the individual at the time that the health
benefit plan is issued to or renewed by the individual.
4. An individual carrier shall not
terminate, fail to renew, or limit its contract or agreement of representation
with a producer for any reason related to the health status, claims experience,
industry, occupation or geographic location of an individual at the time that
the health benefit plan is issued to or renewed by the individual placed by the
producer with the individual carrier.
5. A denial by an individual carrier of an
application for coverage from an individual or family must be in writing and
must state the reason for the denial.
6. The Commissioner may adopt regulations
that set forth additional standards to provide for the fair marketing and broad
availability of health benefit plans to individuals or families in this state.
7. A violation of any provision of this
section by an individual carrier may constitute an unfair trade practice for
the purposes of chapter 686A of NRS.
8. The provisions of this section apply to
a third-party administrator if the third-party administrator enters into a contract,
agreement or other arrangement with an individual carrier to provide
administrative, marketing or other services related to the offering of a health
benefit plan to individuals or families in this state.
9. Nothing in this section interferes with
the right and responsibility of a producer to advise and represent the best
interests of an individual or family who is seeking health insurance coverage
from an individual carrier.
(Added to NRS by 1997, 2896; A 2013, 3617)
Individual Health Insurance Coverage
NRS 689A.715 Requirements for employee welfare benefit plan for providing
benefits for employees of more than one employer.
1. An employee welfare benefit plan for
providing benefits for employees of more than one employer under which
individual health insurance coverage is provided must comply with the
provisions of NRS 679B.139 and 689A.470 to 689A.740,
inclusive, and the regulations adopted by the Commissioner pursuant thereto.
2. As used in this section, the term
“employee welfare benefit plan for providing benefits for employees of more
than one employer” is intended to be equivalent to the term “employee welfare
benefit plan which is a multiple employer welfare arrangement” as used in
federal statutes and regulations.
(Added to NRS by 1997, 2890)
NRS 689A.720 Written certification of coverage required for determining
period of creditable coverage accumulated by person; provision of certificate
to insured.
1. To determine the period of creditable
coverage of a person, a health insurance issuer offering individual health
insurance coverage shall provide written certification of coverage on a form
prescribed by the Commissioner to the person that certifies:
(a) The period of creditable coverage of the
person under the individual health insurance coverage; and
(b) The date that a substantially completed
application was received by the health insurance issuer from the person for
individual health insurance coverage.
2. The certification of coverage must be
provided to the insured:
(a) At the time that the insured ceases to be
covered under the individual health insurance coverage or otherwise becomes
covered under any provision of the Consolidated Omnibus Budget Reconciliation
Act of 1985, as that act existed on July 16, 1997, relating to the continuation
of coverage;
(b) If the insured becomes covered under such a
provision, at the time that the insured ceases to be covered by that provision;
and
(c) Upon the request of the insured, if the
request is made not later than 24 months after the date on which the insured
ceased to be covered as described in paragraphs (a) and (b).
(Added to NRS by 1997, 2897)
Bona Fide Associations
NRS 689A.725 Requirements for plan for coverage. For
the purposes of NRS 689A.470 to 689A.740, inclusive, a plan for coverage of a bona
fide association must:
1. Conform with NRS
689A.690, 689A.695 and 689A.700
concerning rates.
2. Provide for the renewability of
coverage for members of the bona fide association, and their dependents, if
such coverage meets the criteria set forth in NRS
689A.630.
(Added to NRS by 1997, 2889; A 2013, 3618)
NRS 689A.730 Producer may only sign up eligible persons if eligible persons
are actively engaged in or related to association. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
Miscellaneous Provisions
NRS 689A.740 Regulations. The
Commissioner shall adopt regulations as necessary to carry out the provisions
of NRS 689A.470 to 689A.740,
inclusive.
(Added to NRS by 1997, 2896)
SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS
NRS 689A.745 Approval; requirements; examination.
1. Except as otherwise provided in
subsection 4, each insurer that issues a policy of health insurance in this
State shall establish a system for resolving any complaints of an insured
concerning health care services covered under the policy. The system must be
approved by the Commissioner in consultation with the State Board of Health.
2. A system for resolving complaints
established pursuant to subsection 1 must include an initial investigation, a
review of the complaint by a review board and a procedure for appealing a determination
regarding the complaint. The majority of the members on a review board must be
insureds who receive health care services pursuant to a policy of health
insurance issued by the insurer.
3. The Commissioner or the State Board of
Health may examine the system for resolving complaints established pursuant to
subsection 1 at such times as either deems necessary or appropriate.
4. Each insurer that issues a policy of
health insurance in this State that provides, delivers, arranges for, pays for
or reimburses any cost of health care services through managed care shall
provide a system for resolving any complaints of an insured concerning those
health care services that complies with the provisions of NRS 695G.200 to 695G.310, inclusive.
(Added to NRS by 1997, 307; A 2003, 774; 2011, 3381)
NRS 689A.750 Annual report; insurer to maintain records of complaints
concerning something other than health care services.
1. Each insurer that issues a policy of
health insurance in this State shall submit to the Commissioner and the State
Board of Health an annual report regarding its system for resolving complaints
established pursuant to subsection 1 of NRS 689A.745
on a form prescribed by the Commissioner in consultation with the State Board
of Health which includes, without limitation:
(a) A description of the procedures used for
resolving any complaints of an insured;
(b) The total number of complaints and appeals
handled through the system for resolving complaints since the last report and a
compilation of the causes underlying the complaints filed;
(c) The current status of each complaint and
appeal filed; and
(d) The average amount of time that was needed to
resolve a complaint and an appeal, if any.
2. Each insurer shall maintain records of
complaints filed with it which concern something other than health care
services and shall submit to the Commissioner a report summarizing such
complaints at such times and in such format as the Commissioner may require.
(Added to NRS by 1997, 308; A 2003, 774)
NRS 689A.755 Written notice to insured explaining right to file complaint;
notice to insured required when insurer denies coverage of health care service.
1. Following approval by the Commissioner,
each insurer that issues a policy of health insurance in this State shall
provide written notice to an insured, in clear and comprehensible language that
is understandable to an ordinary layperson, explaining the right of the insured
to file a written complaint. Such notice must be provided to an insured:
(a) At the time the insured receives his or her
evidence of coverage;
(b) Any time that the insurer denies coverage of
a health care service or limits coverage of a health care service to an
insured; and
(c) Any other time deemed necessary by the
Commissioner.
2. Any time that an insurer denies
coverage of a health care service to an insured, including, without limitation,
denying a claim relating to a policy of health insurance pursuant to NRS 689A.410, it shall notify the insured in writing
within 10 working days after it denies coverage of the health care service of:
(a) The reason for denying coverage of the
service;
(b) The criteria by which the insurer determines
whether to authorize or deny coverage of the health care service; and
(c) The right of the insured to file a written
complaint and the procedure for filing such a complaint.
3. A written notice which is approved by
the Commissioner shall be deemed to be in clear and comprehensible language
that is understandable to an ordinary layperson.
(Added to NRS by 1997, 308; A 1999, 3082)
