Nac: Chapter 695D - Organizations For Dental Care

Link to law: http://www.leg.state.nv.us/nac/NAC-695D.html
Published: 2015

[Rev. 11/22/2013 10:32:12

AM--2013]



[NAC-695D Revised Date: 2-12]

CHAPTER 695D - ORGANIZATIONS FOR DENTAL

CARE

GENERAL PROVISIONS

695D.010         Definitions.

695D.015         “Commissioner” defined.

695D.020         “Division” defined.

695D.025         “Member” defined.

695D.030         “Organization” defined.

695D.040         “Plan” defined.

695D.045         “Policy” defined.

695D.050         “Provider” defined.

695D.060         “Service” defined.

APPLICATION FOR CERTIFICATE OF AUTHORITY

695D.070         Submission; format.

695D.080         Contents.

695D.090         Applicant licensed in another state.

695D.100         Incomplete application.

695D.110         Request to review or obtain copy;

notification of pending application.

ADMINISTRATION AND RECORDS

695D.120         Name of organization.

695D.130         Maintenance of principal office and

place of business.

695D.140         Maintenance of records.

695D.150         Qualifications of person responsible

for operating organization.

695D.160         Powers of organization; approval by

Commissioner.

695D.170         Accessibility of services.

695D.180         Organization desiring to enlarge its

geographic area of service.

695D.190         Contract between organization and

provider.

695D.200         Notification of changes in list of

providers.

695D.220         Coordination of benefits.

695D.225         Summary of coverage: Filing,

contents and delivery of disclosure.

695D.230         Provision of copy of plan to

members; advertising; solicitation.

FINANCES

695D.240         Reserves maintained by organization.

695D.250         Investment of money.

695D.260         Filing of periodic reports and financial

statements.

695D.270         Determination of financial

condition: Assets considered.

695D.280         Determination of financial

condition: Assets not considered.

695D.290         Determination of financial

condition: Charges against assets.

695D.300         Maintenance of financial security.

ORGANIZATIONS LICENSED IN OTHER STATES

695D.310         Submission of copy of license to

Commissioner.

695D.320         Organization desiring to contract

with providers out of State for services for members in State.

695D.330         Notification of disciplinary action

taken in another state.

MISCELLANEOUS PROVISIONS

695D.340         Certification of information

concerning limitation on rates for coverage.

695D.350         Contract to perform marketing,

enrollment or administrative services.

695D.360         Administrative hearings and other

proceedings.

695D.370         Requirements for conducting

examinations.

SYSTEM FOR RESOLVING COMPLAINTS OF MEMBERS

695D.500         Establishment; scope; examination of

system.

695D.510         Requirements for approval.

695D.520         Notices: Right of member to file

complaint; denial of coverage; clear and comprehensible language.

695D.530         Annual report: Submission;

resolution of oral inquiry.

695D.540         Annual report: Content; maintenance

of records.

 

 

 

GENERAL PROVISIONS

      NAC 695D.010  Definitions. (NRS 679B.130, 695D.100)  As used

in this chapter, unless the context otherwise requires, the words and terms

defined in NAC 695D.015 to 695D.060,

inclusive, have the meanings ascribed to them in those sections.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88; A

by R132-98, 3-30-99)

      NAC 695D.015  “Commissioner” defined.  “Commissioner” means the

Commissioner of Insurance.

     (Supplied in codification)

      NAC 695D.020  “Division” defined. (NRS 679B.130, 695D.100)  “Division”

means the Division of Insurance of the Department of Business and Industry.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88; A 5-27-92)

      NAC 695D.025  “Member” defined. (NRS 679B.130, 695D.100)  “Member”

has the meaning ascribed to it in NRS

695D.050.

     (Added to NAC by Comm’r of Insurance by R132-98, eff. 3-30-99)

      NAC 695D.030  “Organization” defined. (NRS 679B.130, 695D.100)  “Organization”

means an organization for dental care as defined by NRS 695D.060.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88)

      NAC 695D.040  “Plan” defined. (NRS 679B.130, 695D.100)  “Plan”

means a plan for dental care as defined by NRS 695D.070.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88)

      NAC 695D.045  “Policy” defined. (NRS 679B.130, 695D.100)  “Policy”

has the meaning ascribed to it in NRS

695D.080.

     (Added to NAC by Comm’r of Insurance by R132-98, eff. 3-30-99)

      NAC 695D.050  “Provider” defined. (NRS 679B.130, 695D.100)  “Provider”

means a person who provides dental care.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88)

      NAC 695D.060  “Service” defined. (NRS 679B.130, 695D.100)  “Service”

means the provision of dental care.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88)

APPLICATION FOR CERTIFICATE OF AUTHORITY

      NAC 695D.070  Submission; format. (NRS 679B.130, 695D.100, 695D.120)

     1.  An organization that applies for a

certificate of authority must submit to the Commissioner an original and two

copies of its application.

     2.  The original and each copy of the

application must be submitted in a binder having three rings. The original

application, the original of the completed forms supplied by the Division and

the originals or certified copies of any supporting documents must all be

contained in a single binder.

     3.  Each binder must contain a table of

contents and dividers that separate the various sections of the application and

indicate the subject of each section.

 

     4.  If an applicant submits any new pages to

supplement or amend its application, the date of submission must be noted on

the bottom of each page, and each page must be prepared so that it may be

placed in the binder with the other materials.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88; A 5-27-92)

      NAC 695D.080  Contents. (NRS 679B.130, 695D.100, 695D.120)

     1.  In addition to the information required

to be submitted pursuant to NRS

695D.120, an applicant for a certificate of authority shall include in its

application:

     (a) A list of its actual and prospective providers;

     (b) A clear description of the geographic area it

proposes to serve;

     (c) A statement of facts demonstrating, with

particular reference to the location of its providers and any provision made by

them for emergencies, that the services of providers will be reasonably

available to members;

     (d) A description of the measures to be taken to

increase the number of its providers as the number of members increases; and

     (e) If the applicant is affiliated with an insurer:

          (1) A description of its relationship with the

insurer; and

          (2) The information required by chapter 692C of NRS for filings by an

insurance holding company system.

     2.  Financial statements and projections

submitted as part of an application must be prepared in accordance with

statutory principles of insurance accounting.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88)

      NAC 695D.090  Applicant licensed in another state. (NRS 679B.130, 695D.100, 695D.120)  Any

applicant licensed as an organization in another state, or having an affiliate

or subsidiary that is so licensed, shall include in its application:

     1.  A copy of the license; and

     2.  If it is available, a certificate from

the agency of the state responsible for regulating the organization, stating

that the organization is licensed in good standing.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88)

      NAC 695D.100  Incomplete application. (NRS 679B.130, 695D.100)

     1.  Any incomplete application, with respect

to which there is no activity by the applicant for 60 days or more, shall be

deemed to have been withdrawn by the applicant.

     2.  If an application is deemed withdrawn,

the Division will give written notice to the applicant of the status of the

application. A new application, together with all applicable fees, including,

without limitation, all applicable fees required by NRS 695D.130, must be submitted

before the Division takes any further action.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88; A 5-27-92;

R103-09, 1-28-2010)

      NAC 695D.110  Request to review or obtain copy; notification of pending

application. (NRS

679B.130, 695D.100)

     1.  Any person who wishes to review or obtain

a copy of an application for a certificate of authority must submit a written

request to the offices of the Division at 1818 East College Parkway, Suite 103,

Carson City, Nevada 89706. If a copy is requested, a fee in an amount

sufficient to cover the cost of the copy and any cost of postage must be

submitted with the request.

     2.  Any person who wishes to be notified of a

pending application must file with the Division a written request to be placed

on a list maintained by the Division for that purpose.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88; A 5-27-92;

R249-03, 11-12-2004)

 

ADMINISTRATION AND RECORDS

      NAC 695D.120  Name of organization. (NRS 679B.130, 695D.100)  The name

of an organization must not include the words “health” or “medical” or in any

way imply coverage for other than dental care, unless the word “dental” is used

in the name.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88)

      NAC 695D.130  Maintenance of principal office and place of business. (NRS 679B.130, 695D.100)

     1.  Except as otherwise provided in

subsection 2, every domestic organization must maintain its principal office

and place of business in this State.

     2.  The Commissioner, for good cause shown,

may permit an organization to maintain its principal office or place of

business in another state if it is:

     (a) In the best interests of the organization and

its members; and

     (b) Reasonably convenient to the Commissioner in

supervising the insurer.

     3.  Permission granted pursuant to this

subsection is subject to such reasonable terms and conditions as the

Commissioner establishes in the order granting permission.

     4.  For the purposes of this section,

“domestic organization” means an organization formed under the laws of this

State.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88)

      NAC 695D.140  Maintenance of records. (NRS 679B.130, 695D.100)

     1.  An organization shall retain permanently,

on microfilm or by other suitable means, the minutes of each meeting of its

governing body and any advisory panel on members’ satisfaction.

     2.  An organization shall retain for 3 years,

or until an examination of the organization has been completed by the Division,

a copy of all published material used to market the organization and scripts

used for advertising on radio or television.

     3.  The records of an organization must be

segregated from the records of any subsidiary or related corporation and must

be treated as separate corporate documents.

     4.  All records of the organization must be

kept in this State and retained for examination by the Division for 3 years or

until the next examination is completed by the Division. Each organization

shall comply with the provisions of NRS

693A.050, 693A.060 and 693A.070.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88; A 5-27-92)

      NAC 695D.150  Qualifications of person responsible for operating organization. (NRS 679B.130, 695D.100)  Each

person responsible for operating an organization must possess adequate

knowledge concerning the operation of such an organization and insurance laws

and procedures that apply to the organization.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88)

      NAC 695D.160  Powers of organization; approval by Commissioner. (NRS 679B.130, 695D.100)

     1.  Subject to the approval of the

Commissioner as provided in subsections 2 and 3, the powers of an organization

include the power to:

     (a) Purchase, lease, construct, renovate, operate

or maintain any dental facility, ancillary equipment or other property

reasonably required for its principal office or any other purpose related to

the business of the organization.

     (b) Make any loan in furtherance of its program to

provide services to its members:

          (1) To a dental group under contract with the

organization; or

          (2) To a corporation under its control.

     (c) Furnish services through providers under

contract with the organization or employed by it.

     (d) Contract with any person for the performance of

services related to marketing, enrollment and administration.

     (e) Contract with any insurance company that is

licensed in this State or is authorized to do business in this State for the

provision of insurance for, indemnity against, or reimbursement of the cost of

services provided by the organization.

     2.  The exercise of any power specified in

subsection 1 must be approved in advance by the Commissioner. A written request

to exercise any such power must be submitted to the Commissioner, accompanied

by such supporting information as the Commissioner deems necessary to review

the request. The Commissioner may deny the request if he or she determines that

the exercise of the power would:

     (a) Have a substantial adverse effect upon the

financial soundness of the organization; and

     (b) Impair the ability of the organization to meet

its obligations.

     3.  If the Commissioner does not deny a

request within 60 days after it is submitted, it shall be deemed approved.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88)

      NAC 695D.170  Accessibility of services. (NRS 679B.130, 695D.100)  If the

geographic area served or proposed to be served by an organization:

     1.  Includes a county having a population of

30,000 or more, the distance between the place of business of any provider and

that of any subscriber must not exceed 25 miles. As used in this subsection,

“subscriber” means a person who purchases a plan for himself or herself or

another person pursuant to a written contract with the organization.

     2.  Does not include a county having a

population of 30,000 or more, the organization must submit:

     (a) With its application; and

     (b) At any time thereafter, upon request of the

Commissioner,

Ê a statement

demonstrating, with reference to the standards of the area for accessibility,

that the services of providers are or will be reasonably available to members.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88)

      NAC 695D.180  Organization desiring to enlarge its geographic area of service. (NRS 679B.130, 695D.100, 695D.140)  If an

organization wishes to enlarge its geographic area of service beyond that

stated in its application, it must submit to the Division:

     1.  A written description of the area it

proposes to serve;

     2.  A list of the providers who will offer

services to members in the new area;

     3.  A copy of the contract between the

organization and each such provider;

     4.  A statement:

     (a) Describing the effect of the expansion on the

operation and financial position of the organization; and

     (b) Certifying that the expansion is financially

feasible for the organization;

     5.  A statement describing the method of

marketing and the projected number of members in the new area; and

     6.  Evidence that the organization has given

notice of the proposed expansion to the insurers for its contracts of surety,

fidelity and stop loss insurance.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88; A 5-27-92)

      NAC 695D.190  Contract between organization and provider. (NRS 679B.130, 695D.100)

     1.  Each contract between an organization and

a provider must:

     (a) Contain a complete description of the duties of

each party under the agreement.

     (b) Require the provider to release each member of

the organization from all liability for the cost of services rendered under the

plan, except for uncovered expenditures and any copayments or deductibles made

by a member.

     (c) Be effective for not less than 1 year, subject

to any mutual right of termination provided by the agreement.

     (d) Require the provider to comply with the

organization’s program to assure the quality of dental care provided to

members.

     (e) If the organization becomes insolvent, require

the provider to provide to each member all the services specified by the plan

and the agreement during the period for which a premium has been paid by or on

behalf of the member.

     (f) Require the provider to furnish the

organization with evidence of:

          (1) A contract of insurance against liability

to third persons for any injury caused by professional malpractice; or

          (2) A reasonable substitute for such

insurance, as determined by the organization.

     (g) Require a provider, if he or she leaves the

panel of dentists associated with the organization, to transfer or arrange for

the maintenance of the records of members who are his or her patients.

     2.  An organization may require a provider to

indemnify it against liability to third persons resulting from services

rendered by the provider.

     3.  As used in this section, “uncovered

expenditures” means the cost of any services, including services provided

during an emergency:

     (a) That are rendered by a provider and paid for by

the organization;

     (b) Concerning which there is no agreement between

the provider and organization to release the member from liability; and

     (c) For which the member may be liable if the

organization becomes insolvent.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88)

      NAC 695D.200  Notification of changes in list of providers. (NRS 679B.130, 695D.100)  An

organization shall notify:

     1.  The Division in writing at the end of

each quarter of each calendar year of any changes in its list of providers. If

there are no changes, a statement to that effect may be filed with the

organization’s annual statement.

     2.  A member in writing of the disassociation

of his or her dentist from the organization within 30 working days after the

disassociation occurs.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88; A 5-27-92)

      NAC 695D.220  Coordination of benefits. (NRS 679B.130, 695D.100)

     1.  A plan that is offered to a group and

that coordinates its benefits must determine its benefits and its order of

benefits as provided in NRS

689B.063 and 689B.064.

     2.  An organization may include in its

evidence of coverage provisions:

     (a) Prohibiting the duplication of benefits; and

     (b) Stating its intention to impose a lien, upon

any money recovered by a member from a third person for injuries inflicted by

that person, for the cost of any benefits provided to the member in connection

with those injuries. The amount of the lien must not exceed the reasonable

value of the services provided by the organization.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88)

      NAC 695D.225  Summary of coverage: Filing, contents and delivery of disclosure.

(NRS

679B.130, 695D.100, 695D.102)

     1.  Each organization for dental care shall

file with the Commissioner, for his or her approval, a disclosure summarizing

the coverage provided by a group plan for dental care offered by the organization

for dental care.

     2.  The disclosure must:

     (a) Be in at least 10-point type;

     (b) Include the name, address and telephone number

of the organization for dental care;

     (c) Include the name, address and telephone number

of the agent and broker, if applicable;

     (d) Include a statement describing the principal

benefits and the type of coverage being provided;

     (e) Include a description of any provision of the

plan for dental care which significantly excludes, eliminates, reduces or in

any other manner operates to limit the payment of the benefits;

     (f) Include a statement concerning the renewal

provisions of the plan; and

     (g) Define the term “usual and customary” or any

similar term used in the plan.

     3.  The agent for the organization for dental

care, the organization after a response to a direct-response solicitation or

the broker representing the member shall deliver the approved disclosure

summary to the proposed group policyholder as provided in NRS 695D.104.

     (Added to NAC by Comm’r of Insurance, eff. 2-21-90)

      NAC 695D.230  Provision of copy of plan to members; advertising; solicitation. (NRS 679B.130, 695D.100)

     1.  Each organization shall, at the time a

member enrolls, provide the member with a copy of its plan which:

     (a) States clearly, in boldface type, any period of

waiting required before a member is eligible to receive benefits under the

plan; and

     (b) Refers to the plan by the number used in filing

it with the Division.

     2.  Each advertisement of an organization

must comply with the provisions of NAC

689A.010 to 689A.270, inclusive.

     3.  An organization may not solicit door to

door for new members.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88; A 5-27-92)

FINANCES

      NAC 695D.240  Reserves maintained by organization. (NRS 679B.130, 695D.100, 695D.250)  All

reserves maintained by an organization pursuant to NRS 695D.250:

     1.  Must be deposited in a trust account in a

federally insured financial institution located in this State. All income

earned by the account belongs to the organization and may be credited and paid

to the organization and used for its operations.

     2.  Are in addition to those reserves

established by the organization according to good business and accounting

practices to cover claims that have been incurred but not reported and other

similar claims.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88)

      NAC 695D.250  Investment of money. (NRS 679B.130, 695D.100)

     1.  An organization may invest its money only

in cash, cash equivalents or the securities described in NRS 682A.060 and 682A.190.

     2.  Any investment made by an organization:

     (a) Must be authorized or ratified by its board of

directors or by a committee charged with the supervision of such investments;

     (b) Must be interest-bearing, interest-accruing,

entitled to dividends or otherwise produce income;

     (c) Must not be in default in any respect;

     (d) Must not be purchased at a price above its fair

or market value; and

     (e) Must comply with the provisions of NRS 682A.050, to the extent those

provisions are applicable.

     3.  An organization may receive for its use

and benefit the interest or other income accruing on its investments.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88)

 

      NAC 695D.260  Filing of periodic reports and financial statements. (NRS 679B.130, 695D.100, 695D.260)

     1.  As a condition of doing business in this

State, each organization must submit to the Commissioner an annual report

required by NRS 695D.260 that:

     (a) Conforms to the format prescribed by the

National Association of Insurance Commissioners in the Annual Statement

Instructions for Health and the Accounting Practices and Procedures

Manual, which have been adopted by reference in NAC 679B.033;

     (b) Contains exhibits and schedules that follow the

specifications developed by the National Association of Insurance

Commissioners; and

     (c) Contains any other information relating to the

organization required by the Commissioner.

     2.  Information from the annual report of the

organization must be filed:

     (a) Pursuant to the specifications adopted by the

National Association of Insurance Commissioners for filing information in an

electronic format;

     (b) At the central office of the National

Association of Insurance Commissioners, 2301 McGee Street, Suite 800, Kansas

City, Missouri 64108-2662; and

     (c) On or before March 1 of each year.

     3.  If a foreign or alien organization files

a report in an electronic format with the National Association of Insurance

Commissioners, that report will be deemed to have been filed with the

Commissioner if:

     (a) The foreign or alien organization submits an

affidavit, a jurat page or a copy of the jurat page to the Commissioner

indicating that the report has been so filed. If the organization submits a

jurat page, the jurat page must:

          (1) Conform to the format prescribed by the

National Association of Insurance Commissioners in the Annual Statement

Instructions for Health, which has been adopted by reference in NAC 679B.033; and

          (2) Be executed by a notarial officer pursuant

to NRS 240.1655 and 240.167.

     (b) The affidavit, jurat page or copy of the jurat

page, is accompanied by the applicable fees set forth in NRS 680B.010.

     4.  An annual report required by NRS 695D.260 to be filed with the

Commissioner by an organization must be on the current version of the Annual

Statement Blanks for Health adopted by the National Association of

Insurance Commissioners, which has been adopted by reference in NAC 679B.033. Each organization shall,

in preparing the report, follow the Annual Statement Instructions for Health

adopted by the National Association of Insurance Commissioners, which

accompanies the Annual Statement Blanks for Health.

     5.  If necessary to determine the financial

condition of a foreign or alien organization or the fulfillment of contractual

obligations or compliance with law by a foreign or alien organization, the

Commissioner may require the foreign or alien organization to file a financial

report more frequently than annually. Such a report must be:

     (a) Filed on the current form adopted by the

National Association of Insurance Commissioners for the type of organization

filing;

     (b) Completed in accordance with the instructions

accompanying that form; and

     (c) Filed with the National Association of

Insurance Commissioners in an electronic format.

     6.  Each domestic organization shall file a

quarterly report with the Commissioner. A quarterly report must be:

     (a) Filed on the current form adopted by the

National Association of Insurance Commissioners for the type of organization

reporting;

     (b) Completed in accordance with the instructions

accompanying that form; and

     (c) Filed with the National Association of

Insurance Commissioners in an electronic format.

     7.  The audited financial statement of the

organization filed pursuant to subsection 3 of NRS 695D.260 is a separate

document from the annual statement required to be filed pursuant to paragraph

(a) of subsection 2 of NRS

695D.260. Each organization filing the audited financial statement shall

follow the Annual Statement Instructions for Health adopted by the

National Association of Insurance Commissioners. Consolidated statements for

organizations that are members of an insurance holding company are not

acceptable.

     8.  The Commissioner will, if appropriate,

take disciplinary action pursuant to NRS 695D.300 against an

organization which fails to file its annual financial reports or statements on

the prescribed forms, in the prescribed format or by the prescribed date.

     9.  The Commissioner may grant a reasonable

extension of time for filing the annual report or the audited financial

statement required by NRS 695D.260

if the request for an extension is submitted in writing and in advance and

shows good cause.

     10.  As used in this section, “jurat page”

means a written declaration by a notarial officer that the signer of a document

signed the document in the presence of the notarial officer and swore to or

affirmed that the statements in the document are true.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88; A

12-9-91; R249-03, 11-12-2004)

      NAC 695D.270  Determination of financial condition: Assets considered. (NRS 679B.130, 695D.100)  The

Division will consider the following assets owned by an organization in

determining its financial condition:

     1.  Cash in the possession of the

organization or in transit under its control, including the true balance of any

deposit in a solvent bank, trust company or savings and loan association.

     2.  Any investment or security acquired or

held as provided in NAC 695D.250.

     3.  Any asset acquired through the exercise

of its powers contained in paragraphs (a) and (b) of subsection 1 of NAC 695D.160 and approved pursuant to subsections 2

and 3 of that section.

     4.  Any interest due or accrued on:

     (a) Any bond that is not in default and is not

valued on a basis that includes accrued interest.

     (b) Cash deposited in a solvent bank, trust company

or savings and loan association.

     5.  The unaccrued portion of any tax paid

before the date it is due.

     6.  Any premium in collection, less any

commission payable on the premium. Except for a premium payable directly or

indirectly by the Federal Government or by any of its instrumentalities, a

premium in collection will not be considered for the purposes of this section

if it is more than 60 days past due.

     7.  The full amount of reinsurance

recoverable by an organization from a solvent reinsurer.

     8.  The cost of any machine and related

equipment used for a data processing, recordkeeping or accounting system, if:

     (a) That cost is not less than $5,000 per system;

     (b) The cost is amortized in full over a period of

not more than 5 years; and

     (c) The aggregate amount invested in all such

systems does not exceed 5 percent of the assets of the organization.

     9.  Any property acquired through the

exercise of its powers contained in NAC 695D.160.

     10.  To the extent consistent with the

provisions of this chapter and at such value as the Commissioner may determine,

any other asset deemed by the Commissioner to be available for the payment of

claims.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88; A 5-27-92)

      NAC 695D.280  Determination of financial condition: Assets not considered. (NRS 679B.130, 695D.100)  The

Division will not consider the following assets owned by an organization in

determining its financial condition:

     1.  Any goodwill, trade name or similar

intangible.

     2.  Any advance to an officer of the

organization, whether secured or unsecured, and any advance made on personal

security only.

     3.  Stock of the organization, owned by the

organization, or any equity therein or loans secured thereby, or any

proportionate interest in stock acquired or held through the ownership by the

organization in another firm, corporation or business.

     4.  Except as otherwise provided in NAC 695D.270, any furniture, fixture, furnishing,

safe, vehicle, library, stationery, literature or supplies.

     5.  The amount, if any, by which the

aggregate book value of investments carried in the ledger assets of the

organization exceeds the aggregate value thereof.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88; A 5-27-92)

      NAC 695D.290  Determination of financial condition: Charges against assets. (NRS 679B.130, 695D.100)  In

determining the financial condition of an organization, the Division will

charge against its assets:

     1.  The amount of its outstanding capital

stock.

     2.  The amount necessary to pay any unpaid

claims against the organization that are incurred on or before the date of its

financial statement, whether the claims are reported or unreported, plus the

expenses of adjusting those claims.

     3.  Unless a larger amount is required by NRS 695D.250, the amount of the

unearned premium reserves of the organization, computed as provided in NRS 681B.080.

     4.  All taxes, expenses and other obligations

of the organization that are due or accrued as of the date of its financial

statement.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88; A 5-27-92)

      NAC 695D.300  Maintenance of financial security. (NRS 679B.130, 695D.100, 695D.250)

     1.  An organization shall maintain:

     (a) A capital account with a net worth in an amount

which is the greater of:

          (1) The amount of risk-based capital

determined in the manner set forth in NRS 681B.290 and the regulations

adopted pursuant thereto; or

          (2) The amount, according to the number of

members in the organization, that is not less than the following amounts:

 

             Number of Members                     Net

Worth

 

                 Less than 2,500                            $50,000

                 2,500 to 5,000                              $75,000

                 5,000 or more                             $125,000

 

     (b) Except as otherwise provided in this paragraph,

a surety bond or deposit of cash or securities for the protection of members of

not less than the amount required by NRS 695D.170. The Commissioner

will allow the bond or deposit to be reduced to $125,000 until the organization

has 5,000 members.

     (c) Blanket fidelity coverage issued by an

authorized insurer in an amount of not less than $1,000,000.

     (d) A contract of insurance providing that, in the

event the organization is declared insolvent by the Division or a court of

competent jurisdiction, the insurer will pay all claims made by a member from

the first dollar of eligible expenses for a period of not less than 60 days. If

this coverage is cancelled, written notice of the cancellation must be given to

the Division by the organization and its insurer not less than 90 days before

the cancellation becomes effective. The insurer may require the organization to

include in its agreements with its providers, a requirement that the provider

accept any assignment made by the organization to the insurer for the

continuation of benefits upon the insolvency of the organization.

     (e) A contract of insurance to stop the losses of

the organization, in an amount acceptable to the Commissioner.

     2.  The reserves required by NRS 695D.250 must be segregated

in a trust fund located in a federally insured financial institution in this

State. Any interest earned on the fund may be credited to the organization.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88; A 5-27-92;

R005-03, 2-12-2004; R249-03, 11-12-2004)

ORGANIZATIONS LICENSED IN OTHER STATES

      NAC 695D.310  Submission of copy of license to Commissioner. (NRS 679B.130, 695D.100)  An

organization that:

     1.  Receives a license as an organization in

another state; or

     2.  Whose affiliate or subsidiary receives

such a license,

Ê shall furnish

a copy of the license to the Commissioner within 30 days after it is received.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88)

      NAC 695D.320  Organization desiring to contract with providers out of State for

services for members in State. (NRS 679B.130, 695D.100)

     1.  If an organization authorized to operate

in this State is also licensed in a contiguous state and wishes to contract

with providers in that state for services for members in this State, the

organization shall submit to the Division, for its review and approval:

     (a) Two copies of the plan of the organization for

operation in the contiguous state;

     (b) A copy of the evidence of coverage to be

issued, if it has not previously been filed with the Division;

     (c) Its list of providers in the contiguous state

and a copy of its agreement with each provider; and

     (d) Such other material concerning the

administration of the plan as the Division deems necessary for its review.

     2.  The Division will consider such a plan to

be a material modification of the operations of the organization in this State.

     3.  The Division, before it approves the

plan, will consider whether the contiguous state will approve the plan.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88; A 5-27-92)

      NAC 695D.330  Notification of disciplinary action taken in another state. (NRS 679B.130, 695D.100)  An

organization authorized to operate in this State that is licensed in another

state shall:

     1.  Notify the Division of any disciplinary

action taken against it by the other state; and

     2.  File with the Division copies of all

documents relating to that action within 10 days after it receives those

documents.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88; A 5-27-92)

MISCELLANEOUS PROVISIONS

      NAC 695D.340  Certification of information concerning limitation on rates for

coverage. (NRS

679B.130, 695D.100)  Any

information provided by an organization to demonstrate its compliance with the

provisions of NRS 686B.125,

limiting rates for coverage for dental care, must be certified by an actuary.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88)

      NAC 695D.350  Contract to perform marketing, enrollment or administrative

services. (NRS

679B.130, 695D.100)

     1.  If an organization enters into a contract

for the performance of marketing, enrollment or administrative services, it

shall submit a copy of the contract to the Division for its review and

approval.

     2.  A person who enters into such a contract

with an organization shall be deemed to have:

     (a) Submitted himself or herself to the

jurisdiction of the Division for the purposes of the review; and

     (b) Authorized the Division to examine him or her

concerning:

 

          (1) His or her duties under the contract; and

          (2) The payment and handling of money pursuant

to the contract.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88; A 5-27-92)

      NAC 695D.360  Administrative hearings and other proceedings. (NRS 679B.130, 695D.100)

     1.  Any person who is not otherwise entitled

to a hearing pursuant to NRS

695D.310 and who is aggrieved by an action of the Commissioner relating to

the approval, denial, suspension or revocation of a certificate of authority

may request a hearing on the matter as provided in NRS 679B.310.

     2.  Any person who wishes to:

     (a) Be notified of a pending hearing must file with

the Division a written request to be placed on a list maintained by the

Division for that purpose.

     (b) Intervene in any proceeding held pursuant to NRS 695D.310 may request leave to

intervene as provided in NAC 679B.460,

679B.470 and 679B.480.

     3.  Except as otherwise provided in this

chapter and chapter 695D of NRS, any

administrative proceeding relating to an organization must be held as provided

in NAC 679B.161 to 679B.480, inclusive.

     (Added to NAC by Comm’r of Insurance, eff. 12-2-88; A 5-27-92;

12-15-94)

      NAC 695D.370  Requirements for conducting examinations. (NRS 679B.130, 695D.100, 695D.270)  Each

examination of an organization, including one made pursuant to NRS 695D.270, must be conducted

pursuant to the requirements found in the handbooks and manuals adopted by

reference in NAC 679B.033 and the

provisions of NRS 679B.250 to 679B.300, inclusive.

     (Added to NAC by Comm’r of Insurance, eff. 12-9-91)

SYSTEM FOR RESOLVING COMPLAINTS OF MEMBERS

      NAC 695D.500  Establishment; scope; examination of system. (NRS 679B.130, 695D.100)

     1.  Each organization that issues a policy in

this State shall establish with the approval of the Commissioner a system for

resolving any complaints of a member concerning services covered under the

policy. In determining whether to approve a system for resolving complaints,

the Commissioner will consult with the State Board of Health.

     2.  A system for resolving complaints

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 persons on a review board must be

members who receive services pursuant to a policy issued by the organization.

     3.  Each organization shall allow the

Commissioner or the State Board of Health to examine the system for resolving

complaints established pursuant to this section at such times as either deems

necessary or appropriate.

     (Added to NAC by Comm’r of Insurance by R132-98, eff. 3-30-99)

      NAC 695D.510  Requirements for approval. (NRS 679B.130, 695D.100)  To

obtain approval of a system for resolving complaints of members concerning

services covered by an organization from the Commissioner as required pursuant

to NAC 695D.500, an organization must:

     1.  Demonstrate that the system will resolve

oral and written complaints concerning:

     (a) Payment or reimbursement for covered services;

     (b) The availability, delivery or quality of

covered services, including, without limitation, adverse determinations made

pursuant to utilization review; and

     (c) The terms and conditions of the policies of a

member.

     2.  Submit to the Division:

     (a) The name and title of the employee responsible

for the system;

     (b) A description of the procedure used to notify a

member of the decision regarding his or her complaint; and

     (c) A copy of the explanation of rights and

procedures which is to be provided to members pursuant to NAC 695D.520.

     (Added to NAC by Comm’r of Insurance by R132-98, eff. 3-30-99)

      NAC 695D.520  Notices: Right of member to file complaint; denial of coverage;

clear and comprehensible language. (NRS 679B.130, 695D.100)

     1.  Following approval by the Commissioner,

each organization that issues a policy in this State shall provide written

notice to a member, in clear and comprehensible language that is understandable

to an ordinary layperson, explaining the right of the member to file a written

complaint. Such notice must be provided to a member:

     (a) At the time he or she receives the policy;

     (b) Any time that the organization denies coverage

of a service or limits coverage of a service to a member; and

     (c) Any other time deemed necessary by the

Commissioner.

     2.  Any time that an organization denies

coverage of a service to a member, it shall notify the member in writing of:

     (a) The reasons for denying the coverage of the

service;

     (b) The criteria by which the organization

determines whether to authorize or deny coverage of the service; and

     (c) The right to file a written 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 NAC by Comm’r of Insurance by R132-98, eff. 3-30-99)

      NAC 695D.530  Annual report: Submission; resolution of oral inquiry. (NRS 679B.130, 695D.100)

     1.  An organization shall submit its annual

report regarding its system for resolving complaints as required pursuant to NAC 695D.540 on or before June 1 of each year. The

organization shall retain a copy of the annual report for at least 3 years or

until the next examination conducted by the Division, whichever is longer.

     2.  The organization is not required to

include in the annual report information concerning an oral inquiry by a member

relating to a misunderstanding or miscommunication if the misunderstanding or

miscommunication was resolved within 1 working day after the inquiry was made.

If the misunderstanding or miscommunication was not resolved within 1 working

day, the organization shall report it as a complaint in the annual report.

     (Added to NAC by Comm’r of Insurance by R132-98, eff. 3-30-99;

A by R008-02, 5-23-2002)

      NAC 695D.540  Annual report: Content; maintenance of records. (NRS 679B.130, 695D.100)

     1.  Each organization that issues a policy 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 NAC 695D.500 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 a member;

     (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 organization shall maintain records

of complaints filed with it which concern something other than 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 NAC by Comm’r of Insurance by R132-98, eff. 3-30-99)
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