[Rev. 2/11/2015 11:52:43
AM--2014R2]
CHAPTER 689B - GROUP AND BLANKET HEALTH
INSURANCE
GENERAL PROVISIONS
NRS 689B.010 Short
title; scope.
NRS 689B.015 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;
schedule of fees.
GROUP POLICIES
General Provisions
NRS 689B.020 “Group
health insurance” defined; eligible groups and benefits.
NRS 689B.026 Delivery
of policy to group formed to purchase health insurance prohibited; exception.
NRS 689B.0265 Policy
to guaranteed association.
NRS 689B.027 Summary
of coverage: Contents of disclosure; approval by Commissioner; copy to be made
available to employer or producer acting on behalf of employer.
NRS 689B.028 Summary
of coverage: Copy to be provided before policy issued; policy may not be
offered unless summary approved by Commissioner.
NRS 689B.0283 Coverage
for prescription drugs: Provision of notice and information regarding use of
formulary.
NRS 689B.0285 System
for resolving complaints: Approval; requirements; examination.
NRS 689B.029 Annual
report regarding system for resolving complaints; insurer to maintain records
of complaints concerning something other than health care services.
NRS 689B.0295 Written
notice to insured explaining right to file complaint; notice to insured
required when insurer denies coverage of health care service.
Coverage
NRS 689B.030 Required
provisions.
NRS 689B.0303 Required
provision concerning coverage for continued medical treatment.
NRS 689B.0306 Required
provision concerning coverage for treatment received as part of clinical trial
or study.
NRS 689B.031 Required
provision concerning coverage of certain gynecological or obstetrical services
without authorization or referral from primary care physician.
NRS 689B.0313 Required
provision concerning coverage for human papillomavirus vaccine.
NRS 689B.0317 Required
provision concerning coverage for prostate cancer screening.
NRS 689B.033 Required
provision concerning coverage for newly born and adopted children and children
placed for adoption.
NRS 689B.0335 Required
provision concerning coverage for autism spectrum disorders.
NRS 689B.034 Required
provision concerning effect of benefits under other valid group coverage;
subrogation.
NRS 689B.0345 Required
provision concerning coverage for employee or member on leave without pay as
result of total disability.
NRS 689B.035 Required
provision concerning termination of coverage on dependent child.
NRS 689B.0353 Required
provision concerning coverage for treatment of certain inherited metabolic
diseases.
NRS 689B.0357 Required
provision concerning coverage for management and treatment of diabetes.
NRS 689B.0362 Required
provision concerning coverage for orally administered chemotherapy.
NRS 689B.0365 Required
provision concerning coverage for use of certain drugs for treatment of cancer.
NRS 689B.0367 Required
provision concerning coverage for screening for colorectal cancer.
NRS 689B.0368 Required
provision concerning coverage for prescription drug previously approved for
medical condition of insured.
NRS 689B.0374 Required
provision concerning coverage for cytologic screening tests and mammograms for
certain women.
NRS 689B.0375 Required
provision concerning coverage relating to mastectomy.
NRS 689B.0376 Policy
covering prescription drugs or devices to provide coverage for drug or device
for contraception and of hormone replacement therapy in certain circumstances;
prohibited actions by insurer; exceptions.
NRS 689B.0377 Policy
covering outpatient care to provide coverage for health care services related
to contraceptives and hormone replacement therapy; prohibited actions by
insurer; exceptions.
NRS 689B.0379 Required
provision concerning coverage for treatment of temporomandibular joint.
Reimbursement and Payment
NRS 689B.038 Reimbursement
for treatments by licensed psychologist.
NRS 689B.0383 Reimbursement
for treatments by licensed marriage and family therapist or licensed clinical
professional counselor.
NRS 689B.0385 Reimbursement
for treatments by licensed associate in social work, social worker, independent
social worker or clinical social worker.
NRS 689B.039 Reimbursement
for treatments by chiropractor.
NRS 689B.0393 Reimbursement
for treatments by podiatrist.
NRS 689B.0397 Reimbursement
for treatment by licensed clinical alcohol and drug abuse counselor.
NRS 689B.040 Direct
payment for hospital and medical services and home health care; payment to
assignee.
NRS 689B.045 Reimbursement
for services provided by certain nurses; prohibited limitations; exception.
NRS 689B.047 Reimbursement
to provider of medical transportation.
NRS 689B.049 Reimbursement
for acupuncture.
Miscellaneous Provisions
NRS 689B.050 Extended
disability benefit.
NRS 689B.060 Readjustment
of premiums; dividends.
NRS 689B.061 Limitations
on deductibles and copayments charged under policy which offers difference of payment
between preferred providers of health care and providers who are not preferred.
NRS 689B.063 Primary
and secondary policies: Determination of benefits.
NRS 689B.064 Primary
and secondary policies: Order of benefits.
NRS 689B.065 Policy
issued to replace discontinued policy or coverage: Requirements; notice of
reduction of benefits; statement of benefits; applicability of section.
NRS 689B.067 Provision
in policy requiring binding arbitration for disputes with insurer authorized;
procedure for arbitration; declaratory relief.
NRS 689B.068 Insurer
prohibited from denying coverage solely because person was victim of domestic
violence.
NRS 689B.069 Insurer
prohibited from requiring or using information concerning genetic testing;
exceptions.
BLANKET POLICIES
NRS 689B.070 “Blanket
accident and health insurance” defined.
NRS 689B.080 Authority
to issue; required provisions.
NRS 689B.090 Application
and certificates.
NRS 689B.100 Payment
of benefits.
NRS 689B.110 Legal
liability of policyholders for death of or injury to insured member unaffected.
NRS 689B.115 Access
by Commissioner to information concerning rates; confidentiality of
information.
CONVERSION OF GROUP POLICIES TO INDIVIDUAL POLICIES
NRS 689B.120 Policies
of group health insurance to contain provision for conversion; exceptions;
conditions. [Repealed.]
NRS 689B.130 Conversion
privilege available to spouse and children; conditions. [Repealed.]
NRS 689B.140 Denial
of converted policy because of overinsurance; notice concerning cancellation of
other coverage. [Repealed.]
NRS 689B.150 Choice
of plans for converted policy. [Repealed.]
NRS 689B.170 Benefits
payable under converted policy may be reduced by amount payable under group
policy. [Repealed.]
NRS 689B.180 Issuance
and effective date of converted policy; premiums; persons covered. [Repealed.]
NRS 689B.200 Notice
of conversion privilege. [Repealed.]
NRS 689B.210 Converted
policy delivered outside Nevada: Form. [Repealed.]
CONTINUATION OF COVERAGE UNDER CERTAIN GROUP POLICIES
NRS 689B.245 Required
provision concerning continuation of coverage. [Repealed.]
NRS 689B.246 Notice
of eligibility or election to continue coverage. [Repealed.]
NRS 689B.247 Payment
of premium for continued coverage. [Repealed.]
NRS 689B.248 New
insurer to provide continued coverage. [Repealed.]
NRS 689B.249 Termination
of continued coverage before end of period. [Repealed.]
MISCELLANEOUS PROVISIONS
NRS 689B.250 Acceptance
of uniform forms for billing and claims.
NRS 689B.255 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 689B.260 Required
provision concerning coverage relating to complications of pregnancy.
NRS 689B.270 Required
procedure for arbitration of disputes concerning independent medical
evaluations.
NRS 689B.275 Contents,
approval and provision of summary of coverage; provision of information about
guaranteed availability of certain plans for benefits.
NRS 689B.280 Disclosure
of information concerning medication of insured prohibited.
NRS 689B.283 Mandatory
renewal of coverage under conversion health benefit plan. [Repealed.]
NRS 689B.285 Offering
policy of health insurance for purposes of establishing health savings account.
NRS 689B.287 Insurer
prohibited from denying coverage solely because insured was intoxicated or
under influence of controlled substance; exceptions.
ELIGIBILITY FOR COVERAGE UNDER GROUP POLICY
NRS 689B.290 Definitions.
NRS 689B.300 Effect
of eligibility for medical assistance under Medicaid; assignment of rights to
state agency.
NRS 689B.310 Insurer
prohibited from asserting certain grounds to deny enrollment of child of
insured pursuant to order.
NRS 689B.320 Certain
accommodations to be made when child is covered under policy of noncustodial
parent.
NRS 689B.330 Insurer
to authorize enrollment of child of parent who is required by order to provide
medical coverage for child.
PORTABILITY AND ACCOUNTABILITY
NRS 689B.340 Definitions.
NRS 689B.350 “Affiliation
period” defined.
NRS 689B.355 “Blanket
accident and health insurance” defined.
NRS 689B.360 “Carrier”
defined.
NRS 689B.370 “Contribution”
defined.
NRS 689B.380 “Creditable
coverage” defined.
NRS 689B.390 “Group
health plan” defined.
NRS 689B.400 “Group
participation” defined.
NRS 689B.410 “Health
benefit plan” defined. [Repealed.]
NRS 689B.420 “Health
status-related factor” defined. [Repealed.]
NRS 689B.430 “Open
enrollment” defined.
NRS 689B.440 “Plan
sponsor” defined.
NRS 689B.450 “Preexisting
condition” defined.
NRS 689B.460 “Waiting
period” defined.
NRS 689B.470 Certain
plan, fund or program to be treated as employee welfare benefit plan which is
group health plan; partnership deemed employer of each partner. [Repealed.]
NRS 689B.480 Determination
of applicable creditable coverage of person; determination of period of
creditable coverage of person; required statement.
NRS 689B.490 Written
certification of coverage required for purpose of determining period of
creditable coverage accumulated by person.
NRS 689B.500 Coverage
of preexisting conditions.
NRS 689B.510 Carrier
authorized to modify coverage for insurance product under certain
circumstances.
NRS 689B.520 Group
plan or coverage that includes coverage for maternity care and pediatric care:
Required to allow minimum stay in hospital in connection with childbirth;
prohibited acts.
NRS 689B.530 Carrier
required to permit eligible employee or dependent of employee to enroll for
coverage under certain circumstances.
NRS 689B.540 Manner
and period for enrollment of dependent of covered employee; period of special
enrollment.
NRS 689B.550 Carrier
prohibited from imposing restriction on participation inconsistent with
chapter; restrictions on rules of eligibility that may be established; premiums
to be equitable.
NRS 689B.560 Carrier
required to renew coverage at option of plan sponsor; exceptions; discontinuation
of form of product of group health insurance; discontinuation of group health
insurance through bona fide association.
NRS 689B.570 Carrier
that offers coverage through network plan not required to offer coverage to
employer that does not employ enrollees who reside or work in geographic
service area for which carrier is authorized to transact insurance.
NRS 689B.575 Carrier
that offers coverage through network plan: Contracts with certain federally
qualified health centers. [Repealed.]
NRS 689B.580 Plan
sponsor of governmental plan authorized to elect to exclude governmental plan
from compliance with certain statutes; duties of plan sponsor.
NRS 689B.590 Converted
policies: Carrier may only offer choice of basic and standard plans; election
of basic or standard plan; premium; rates must be same for persons with similar
case characteristics; losses must be spread across book. [Repealed.]
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GENERAL PROVISIONS
NRS 689B.010 Short title; scope.
1. This chapter may be cited as the Group
or Blanket Health Insurance Law.
2. This chapter applies only to group
health insurance contracts and to blanket accident and health insurance
contracts as provided in this chapter.
(Added to NRS by 1971, 1767; A 2001, 2220)
NRS 689B.015 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; schedule of fees.
1. An insurer that issues a policy of
group health insurance 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 specified in subsection 1
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 specified
in subsection 1 and a provider of health care may be modified:
(a) At any time pursuant to a written agreement
executed by both parties.
(b) Except as otherwise provided in this
paragraph, by the 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 specified in subsection 1
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, 1648; A 2001, 2730; 2003, 3357; 2011, 2533)
GROUP POLICIES
General Provisions
NRS 689B.020 “Group health insurance” defined; eligible groups and benefits.
1. “Group health insurance” is hereby
declared to be that form of health insurance covering groups of two or more
persons, formed for a purpose other than obtaining insurance.
2. Any group health policy which contains
provisions for the payment by the insurer of benefits for expenses incurred on
account of hospital, nursing, medical, dental or surgical services, home health
care or health supportive services for members of the family or dependents of a
person in the insured group may provide for the continuation of such benefit
provisions, or any part or parts thereof, after the death of the person in the
insured group.
3. The Commissioner may, in the discretion
of the Commissioner, require the form of each certificate proposed to be
delivered in this state under a group health policy not made under the laws of
this state to be filed with the Commissioner by the insurer for informational
purposes only.
(Added to NRS by 1971, 1767; A 1971, 1954; 1975, 447)
NRS 689B.026 Delivery of policy to group formed to purchase health insurance
prohibited; exception.
1. Except as otherwise provided in this
section, no policy of group health insurance may be delivered or issued for
delivery in this state to a group which was formed for the purpose of
purchasing one or more policies of group health insurance.
2. A policy of group health insurance may
be delivered to a group described in subsection 1 if the Commissioner approves
the issuance. The Commissioner shall not grant approval unless the Commissioner
finds that:
(a) The benefits of the policy are reasonable in
relation to the premiums charged;
(b) The group to which the policy is issued is
organized and operated in a fiscally sound manner; and
(c) All policy rates and forms are filed with and
approved by the Division before marketing to a resident or employer in this
State.
3. The Commissioner shall use the
provisions of this chapter and chapter 689C
of NRS to review insurance products marketed to employers in this State. The
Commissioner shall use the provisions of chapter
689A of NRS to review insurance products marketed to natural persons in
this State.
4. The provisions of this section apply to
the offering in this state of a policy issued in another state.
(Added to NRS by 1985, 1060; A 1995, 1628; 2011, 3381)
NRS 689B.0265 Policy to guaranteed association.
1. An insurer may offer a policy of group
health insurance to a guaranteed association if the policy provides coverage
for 200 or more members, employees of members or employees of the guaranteed
association or their dependents.
2. When an insurer offers coverage to a
guaranteed association pursuant to subsection 1, the insurer shall offer
coverage to all members, employees of members and employees of the guaranteed
association and all dependents thereof without regard to the actual or expected
health status of any such member or employee or dependent thereof. The
provisions of this subsection apply only for the purpose of requiring coverage
to be offered to all such members, employees and dependents.
3. An insurer offering coverage to a
guaranteed association pursuant to subsection 1 shall establish rates for
premiums as follows:
(a) For the initial 12-month period of coverage,
the insurer shall submit to the Commissioner the opinion of a qualified actuary
that the rates charged by the guaranteed association for premiums are
actuarially sound. The opinion must certify the accuracy of the rating
methodology as established by the American Academy of Actuaries or a successor
organization approved by the Commissioner. The Commissioner by regulation may
further define or enlarge the scope of this opinion.
(b) For any subsequent 12-month period of
coverage, according to a rating methodology as established by the American
Academy of Actuaries or a successor organization approved by the Commissioner.
4. Except as otherwise provided in
subsection 5, a member, employee of a member or employee of a guaranteed
association may apply for coverage offered pursuant to subsection 1 only:
(a) If, as applicable, the person has been an
active member of the association or employed by a member or the guaranteed
association for not less than 30 days;
(b) During an annual open enrollment period
offered by the guaranteed association; and
(c) After meeting any additional eligibility
requirements agreed upon by the guaranteed association and the insurer.
5. If a member, employee of a member or
employee of a guaranteed association or a dependent thereof terminates coverage
offered pursuant to subsection 1, the member, employee or dependent must be
excluded from such coverage until the beginning of the next annual enrollment
period. During the next annual enrollment period or any annual enrollment
period thereafter, such a member or employee may enroll for coverage of the
member or employee or dependent thereof pursuant to subsection 4.
6. The provisions of this section do not
apply to or affect the status of a person, including, without limitation,
whether the person is an employee, self-employed or an independent contractor,
for the purposes of industrial insurance or any other law relating to labor or
employment.
7. As used in this section:
(a) “Guaranteed association” means an association
which:
(1) Has a constitution and bylaws;
(2) Is determined by the Commissioner to
be a bona fide association which was organized and is maintained in good faith
for purposes other than that of obtaining insurance; and
(3) Has been in existence for at least 5
years.
(b) “Qualified actuary” means a member in good
standing of the American Academy of Actuaries, or a successor organization
approved by the Commissioner.
(Added to NRS by 2007, 2457)
NRS 689B.027 Summary of coverage: Contents of disclosure; approval by
Commissioner; copy to be made available to employer or producer acting on
behalf of employer.
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 group health insurance offered by the insurer. The disclosure
must include:
(a) Any significant exception, reduction or
limitation that applies to the policy;
(b) Any restrictions on payments for emergency
care, including related definitions of an emergency and medical necessity;
(c) Any provisions concerning the insurer’s right
to change premium rates and the characteristics, other than claim experience,
that affect changes in premium rates;
(d) Any provisions relating to renewability;
(e) Any provisions relating to preexisting
conditions; and
(f) 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 include a statement that the disclosure
is a summary of the policy only, and that the policy 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.
4. The insurer shall make available to an
employer or a producer acting on behalf of an employer upon request a copy of
the disclosure approved by the Commissioner pursuant to this section for each
policy of health insurance coverage for which that employer may be eligible.
(Added to NRS by 1989, 1249; A 1991, 1846; 1997, 2913; 1999, 2806)
NRS 689B.028 Summary of coverage: Copy to be provided before policy issued;
policy may not be offered unless summary approved by Commissioner. An insurer shall provide to the group
policyholder to whom it offers a policy of group health insurance a copy of the
disclosure approved for that policy pursuant to NRS
689B.027 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 689B.0283 Coverage for prescription drugs: Provision of notice and
information regarding use of formulary.
1. An insurer that offers or issues a
policy of group 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 group 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, 857)
NRS 689B.0285 System for resolving complaints: Approval; requirements;
examination.
1. Except as otherwise provided in
subsection 4, each insurer that issues a policy of group 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
group 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
group 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
the health care services that complies with the provisions of NRS 695G.200 to 695G.310, inclusive.
(Added to NRS by 1997, 309; A 2003, 775; 2011, 3382)
NRS 689B.029 Annual report regarding system for resolving complaints; insurer
to maintain records of complaints concerning something other than health care
services.
1. Each
insurer that issues a policy of group 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 689B.0285 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, 309; A 2003, 775)
NRS 689B.0295 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 group 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
certificate of coverage or evidence of coverage;
(b) Any time that the insurer denies coverage of
a health care service or limits coverage of a health care service to an
insured; and
(c) Any other time deemed necessary by the
Commissioner.
2. Any time that an insurer denies
coverage of a health care service, including, without limitation, denying a
claim relating to a policy of group health insurance or blanket insurance
pursuant to NRS 689B.255, to an insured 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, 309; A 1999, 3084)
Coverage
NRS 689B.030 Required provisions. Each
group health insurance policy must contain in substance the following
provisions:
1. A provision that, in the absence of
fraud, all statements made by applicants or the policyholders or by an insured
person are representations and not warranties, and that no statement made for
the purpose of effecting insurance voids the insurance or reduces its benefits
unless the statement is contained in a written instrument signed by the
policyholder or the insured person, a copy of which has been furnished to the
policyholder or insured person or a beneficiary of the policyholder or insured
person.
2. A provision that the insurer will
furnish to the policyholder for delivery to each employee or member of the
insured group a statement in summary form of the essential features of the
insurance coverage of that employee or member and to whom benefits thereunder
are payable. If dependents are included in the coverage, only one statement
need be issued for each family.
3. A provision that to the group
originally insured may be added from time to time eligible new employees or
members or dependents, as the case may be, in accordance with the terms of the
policy.
4. A provision for benefits for expense
arising from care at home or health supportive services if the 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.
5. A provision for benefits for expenses
arising from hospice care.
(Added to NRS by 1971, 1767; A 1975, 448, 1850; 1979, 1178; 1983, 1934, 2037; 1985, 1774; 1989, 1032; 2009, 1810)
NRS 689B.0303 Required provision concerning coverage for continued medical
treatment.
1. The provisions of this section apply to
a policy of group 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, 3356)
NRS 689B.0306 Required provision concerning coverage for treatment received as
part of clinical trial or study.
1. A policy of group health insurance must
provide coverage for medical treatment which a person insured under the group
policy receives as part of a clinical trial or study if:
(a) The medical treatment is provided in a Phase
I, Phase II, Phase III or Phase IV study or clinical trial for the treatment of
cancer or in a Phase II, Phase III or Phase IV study or clinical trial for the
treatment of chronic fatigue syndrome;
(b) The clinical trial or study is approved by:
(1) An agency of the National Institutes
of Health as set forth in 42 U.S.C. § 281(b);
(2) A cooperative group;
(3) The Food and Drug Administration as an
application for a new investigational drug;
(4) The United States Department of
Veterans Affairs; or
(5) The United States Department of
Defense;
(c) In the case of:
(1) A Phase I clinical trial or study for
the treatment of cancer, the medical treatment is provided at a facility
authorized to conduct Phase I clinical trials or studies for the treatment of
cancer; or
(2) A Phase II, Phase III or Phase IV
study or clinical trial for the treatment of cancer or chronic fatigue
syndrome, the medical treatment is provided by a provider of health care and
the facility and personnel for the clinical trial or study have the experience
and training to provide the treatment in a capable manner;
(d) There is no medical treatment available which
is considered a more appropriate alternative medical treatment than the medical
treatment provided in the clinical trial or study;
(e) There is a reasonable expectation based on
clinical data that the medical treatment provided in the clinical trial or
study will be at least as effective as any other medical treatment;
(f) The clinical trial or study is conducted in
this State; and
(g) The insured has signed, before participating
in the clinical trial or study, a statement of consent indicating that the
insured has been informed of, without limitation:
(1) The procedure to be undertaken;
(2) Alternative methods of treatment; and
(3) The risks associated with
participation in the clinical trial or study, including, without limitation,
the general nature and extent of such risks.
2. Except as otherwise provided in
subsection 3, the coverage for medical treatment required by this section is
limited to:
(a) Coverage for any drug or device that is
approved for sale by the Food and Drug Administration without regard to whether
the approved drug or device has been approved for use in the medical treatment
of the insured person.
(b) The cost of any reasonably necessary health
care services that are required as a result of the medical treatment provided
in a Phase II, Phase III or Phase IV clinical trial or study or as a result of
any complication arising out of the medical treatment provided in a Phase II,
Phase III or Phase IV clinical trial or study, to the extent that such health
care services would otherwise be covered under the policy of group health
insurance.
(c) The cost of any routine health care services
that would otherwise be covered under the policy of group health insurance for
an insured participating in a Phase I clinical trial or study.
(d) The initial consultation to determine whether
the insured is eligible to participate in the clinical trial or study.
(e) Health care services required for the
clinically appropriate monitoring of the insured during a Phase II, Phase III
or Phase IV clinical trial or study.
(f) Health care services which are required for
the clinically appropriate monitoring of the insured during a Phase I clinical
trial or study and which are not directly related to the clinical trial or
study.
Ê Except as
otherwise provided in NRS 689B.0303, 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 person insured under the group policy is not
required to be covered pursuant to this section if that particular medical
treatment is provided by the sponsor of the clinical trial or study free of
charge to the person insured under the group policy.
4. The coverage for medical treatment
required by this section does not include:
(a) Any portion of the clinical trial or study
that is customarily paid for by a government or a biotechnical, pharmaceutical
or medical industry.
(b) Coverage for a drug or device described in
paragraph (a) of subsection 2 which is paid for by the manufacturer,
distributor or provider of the drug or device.
(c) Health care services that are specifically excluded
from coverage under the insured’s policy of group health insurance, regardless
of whether such services are provided under the clinical trial or study.
(d) Health care services that are customarily
provided by the sponsors of the clinical trial or study free of charge to the
participants in the trial or study.
(e) Extraneous expenses related to participation
in the clinical trial or study including, without limitation, travel, housing
and other expenses that a participant may incur.
(f) Any expenses incurred by a person who
accompanies the insured during the 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 insured.
(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 group health insurance specified in subsection 1 may
require copies of the approval or certification issued pursuant to paragraph
(b) of subsection 1, the statement of consent signed by the insured, protocols
for the clinical trial or study and any other materials related to the scope of
the clinical trial or study relevant to the coverage of medical treatment
pursuant to this section.
6. An insurer who delivers or issues for
delivery a policy of group health insurance specified in subsection 1 shall:
(a) Include in the disclosure required pursuant
to NRS 689B.027 notice to each group policyholder
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 group 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 of group health insurance specified in subsection 1 is immune
from liability for:
(a) Any injury to the insured caused by:
(1) Any medical treatment provided to the
insured in connection with his or her participation in a clinical trial or
study described in this section; or
(2) An act or omission by a provider of
health care who provides medical treatment or supervises the provision of
medical treatment to the insured in connection with his or her participation in
a clinical trial or study described in this section.
(b) Any adverse or unanticipated outcome arising
out of an insured’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, 3522; A 2005, 2012)
NRS 689B.031 Required provision concerning coverage of certain gynecological
or obstetrical services without authorization or referral from primary care
physician.
1. A policy of group 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 group 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, 1944)
NRS 689B.0313 Required provision
concerning coverage for human papillomavirus vaccine.
1. A policy of group 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 group 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, 3237; A 2013, 3618)
NRS 689B.0317 Required provision
concerning coverage for prostate cancer screening.
1. A policy of group 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 group 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 group 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, 3238)
NRS 689B.033 Required provision concerning coverage for newly born and
adopted children and children placed for adoption.
1. All group health insurance policies
providing coverage on an expense-incurred basis and all employee welfare plans
providing medical, surgical or hospital care or benefits established or
maintained for employees or their families or dependents, or for both, must as
to the 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 or
welfare plan 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, 740; 1995, 2430; 1997, 2914; 2013, 3618)
NRS 689B.0335 Required provision concerning coverage for autism spectrum
disorders.
1. A health benefit plan must provide
coverage for screening for and diagnosis of autism spectrum disorders and for
treatment of autism spectrum disorders to persons covered by the policy of
group health insurance under the age of 18 or, if enrolled in high school,
until the person reaches the age of 22.
2. Coverage provided under this section is
subject to:
(a) A maximum benefit of $36,000 per year for
applied behavior analysis treatment; and
(b) Copayment, deductible and coinsurance
provisions and any other general exclusion or limitation of a policy of group
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 group 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
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 group health
insurance or cancel a policy of group 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 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. A policy subject to the provisions of
this chapter that is delivered, issued for delivery or renewed on or after
January 1, 2011, 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 or 2 is void.
7. 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.
8. 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, 1467)
NRS 689B.034 Required provision concerning effect of benefits under other
valid group coverage; subrogation.
1. Every policy of group health insurance
must contain a provision which reduces the insurer’s liability because of
benefits under other valid group coverage. To the extent authorized by the Commissioner,
such a provision may include subrogation.
2. A provision for subrogation may include
a lien upon any recovery by an insured from a third person for the cost of
medical benefits paid by the insurer for injuries incurred as a result of the
actions of the third person. The lien may not exceed the amount paid by the
insurer.
3. An insurer may not deny payment for
services because of the inclusion of a provision required by this section.
(Added to NRS by 1985, 1060; A 1995, 1628)
NRS 689B.0345 Required provision concerning coverage for employee or member on
leave without pay as result of total disability.
1. As used in this section, “total
disability” and “totally disabled” mean the continuing inability of the
employee or member, because of an injury or illness, to perform substantially
the duties related to his or her employment for which the employee or member is
otherwise qualified.
2. No group policy of health insurance may
be delivered or issued for delivery in this state unless it provides continuing
coverage for an employee or member of the insured group, and the dependents of
the employee or member who are otherwise covered by the policy, while the
employee or member is on leave without pay as a result of a total disability.
The coverage must be for any injury or illness suffered by the employee or
member which is not related to the total disability or for any injury or
illness suffered by the dependent of the employee or member. The coverage for
such injury or illness must be equal to or greater than the coverage otherwise
provided by the policy.
3. The coverage required pursuant to
subsection 2 must continue until:
(a) The date on which the employment of the
employee or member is terminated;
(b) The date on which the employee or member
obtains another policy of health insurance;
(c) The date on which the group policy of health
insurance is terminated; or
(d) After a period of 12 months in which benefits
under such coverage are provided to the employee or member,
Ê whichever
occurs first.
(Added to NRS by 1989, 1249)
NRS 689B.035 Required provision concerning termination of coverage on
dependent child.
1. A group health insurance policy
delivered or issued for delivery after November 1, 1973, which provides for the
termination of coverage on a dependent child of a member of the insured group,
when such child attains a contractually specified limiting age, shall also
provide that such coverage shall not terminate when the dependent child reaches
such age if such child is and continues to be:
(a) Incapable of self-sustaining employment due
to a physical handicap or an intellectual disability; and
(b) Dependent on the member of the insured group
for support and maintenance.
2. Proof of such child’s incapacity and
dependency shall be furnished to the insurer by the member of the insured group
within 31 days after such child attains the specified limiting age and as often
as the insurer may thereafter require, but no more than once a year beginning 2
years after such child attains the specified limiting age.
(Added to NRS by 1973, 548; A 2013, 699)
NRS 689B.0353 Required provision concerning coverage for treatment of certain
inherited metabolic diseases.
1. A policy of group 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 689B.0357 Required provision concerning coverage for management and
treatment of diabetes.
1. No group 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 689B.027 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 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
the employee or member of the insured group after the employee or member 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 employee or member of
the insured group and which requires modification of his or her 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, 743)
NRS 689B.0362 Required provision concerning coverage for orally administered
chemotherapy.
1. An insurer that offers or issues a
policy of group 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, 1998;
A 2013,
3658)
NRS 689B.0365 Required provision concerning coverage for use of certain drugs
for treatment of cancer. Except as
otherwise provided in NRS 689B.0306:
1. No group 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 employee or member of the insured
group.
(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 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, 760; A 2003, 3525)
NRS 689B.0367 Required provision concerning coverage for screening for
colorectal cancer.
1. A policy of group 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 group 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, 1335)
NRS 689B.0368 Required provision concerning coverage for prescription drug
previously approved for medical condition of insured.
1. Except as otherwise provided in this
section, a policy of group 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, 858; A 2003, 2298)
NRS 689B.0374 Required provision concerning coverage for cytologic screening
tests and mammograms for certain women.
1. A policy of group 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 group 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, 1889; A 1997, 1730)
NRS 689B.0375 Required provision concerning coverage relating to mastectomy.
1. A policy of group 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 those amounts provided for in the policy at the time of the
mastectomy. If the surgery is begun more than 3 years after the mastectomy, the
benefits provided are subject to all of the terms, conditions and exclusions
contained in the policy at the time of the reconstructive surgery.
8. A policy subject to the provisions of
this chapter which is delivered, issued for delivery or renewed on or after
October 1, 2001, has the legal effect of including the coverage required by
this section, and any provision of the policy or the renewal which is in
conflict with this section is void.
9. For the purposes of this section,
“reconstructive surgery” means a surgical procedure performed following a
mastectomy on one breast or both breasts to re-establish symmetry between the
two breasts. The term includes augmentation mammoplasty, reduction mammoplasty
and mastopexy.
(Added to NRS by 1983, 615; A 1989, 1889; 2001, 2220)
NRS 689B.0376 Policy covering prescription drugs or devices to provide
coverage for drug or device for contraception and of 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 group 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 group 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 group health
insurance or cancel a policy of group 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 group 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 group health insurance and before the
renewal of such a policy, provide to the group policyholder or prospective
insured, as applicable, written notice of the coverage that the insurer refuses
to provide pursuant to this subsection. The insurer shall provide notice to
each insured, at the time the insured receives his or her certificate of
coverage or evidence of coverage, that the insurer refused to provide coverage
pursuant to this subsection.
6. If an insurer refuses, pursuant to
subsection 5, to provide the coverage required by paragraph (a) of subsection
1, an employer may otherwise provide for the coverage for the employees of the
employer.
7. As used in this section, “provider of
health care” has the meaning ascribed to it in NRS 629.031.
(Added to NRS by 1999, 1997)
NRS 689B.0377 Policy covering outpatient care to provide coverage for health
care services related to contraceptives and hormone replacement therapy;
prohibited actions by insurer; exceptions.
1. Except as otherwise provided in
subsection 5, an insurer that offers or issues a policy of group 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 group 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 group health
insurance or cancel a policy of group 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 a
policy of group 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
group health insurance and before the renewal of such a policy, provide to the
group policyholder or prospective insured, as applicable, written notice of the
coverage that the insurer refuses to provide pursuant to this subsection. The
insurer shall provide notice to each insured, at the time the insured receives
his or her certificate of coverage or evidence of coverage, that the insurer
refused to provide coverage pursuant to this subsection.
6. If an insurer refuses, pursuant to
subsection 5, to provide the coverage required by paragraph (a) of subsection
1, an employer may otherwise provide for the coverage for the employees of the
employer.
7. As used in this section, “provider of
health care” has the meaning ascribed to it in NRS 629.031.
(Added to NRS by 1999, 1998)
NRS 689B.0379 Required provision concerning coverage for treatment of
temporomandibular joint.
1. Except as otherwise provided in this
section, no policy of group health insurance may be delivered or issued for
delivery in this state if it contains an exclusion of coverage of the treatment
of the temporomandibular joint whether by specific language in the 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, 2138)
Reimbursement and Payment
NRS 689B.038 Reimbursement for treatments by licensed psychologist. If any policy of group 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 treatment by a psychologist who is licensed pursuant to chapter 641 of NRS.
(Added to NRS by 1981, 575; A 1989, 1553)
NRS 689B.0383 Reimbursement for treatments by licensed marriage and family
therapist or licensed clinical professional counselor. If
any policy of group 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 689B.0385 Reimbursement for treatments by licensed associate in social
work, social worker, independent social worker or clinical social worker. If any policy of group 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 689B.039 Reimbursement for treatments by chiropractor.
1. If any group 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 charged for similar treatments by
other physicians.
(Added to NRS by 1981, 930; A 1983, 327)
NRS 689B.0393 Reimbursement for
treatments by podiatrist.
1. If any group 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 689B.0397 Reimbursement
for treatment by licensed clinical alcohol and drug abuse counselor. If
any policy of group 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 689B.040 Direct payment for hospital and medical services and home health
care; payment to assignee.
1. Any group health policy may provide
that all or any portion of any indemnities provided by any such policy on
account of hospital, nursing, medical or surgical services, home health care or
supportive services:
(a) May, at the insurer’s option; or
(b) Must, upon the written request of the
insured,
Ê be paid
directly to the hospital or person rendering the services. Payments made in
this manner discharge the insurer’s obligation.
2. If the insured assigns his or her
benefits pursuant to this section but the insurer after receiving a copy of the
assignment pays the benefits to the insured, the insurer shall also pay the
benefits to the assignee as soon as the insurer receives the notice of the
incorrect payment.
(Added to NRS by 1971, 1767; A 1975, 448; 1983, 880)
NRS 689B.045 Reimbursement for services provided by certain nurses;
prohibited limitations; exception.
1. If any group 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, 1447)
NRS 689B.047 Reimbursement to provider of medical transportation.
1. Except as otherwise provided in
subsection 3, every policy of group 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)
NRS 689B.049 Reimbursement for acupuncture. If
any policy of group 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, 1134)
Miscellaneous Provisions
NRS 689B.050 Extended disability benefit. Any
group health policy may provide for payment not exceeding three times the
amount of the monthly benefit under the policy as an extended disability
benefit upon the insured’s death from any cause. The extended disability
benefit must not be construed as life insurance.
(Added to NRS by 1971, 1768; A 1993, 1982)
NRS 689B.060 Readjustment of premiums; dividends.
1. Any contract of group health insurance
may provide for the readjustment of the rate of premium based upon the
experience thereunder. If a policy dividend is declared after January 1, 1972,
or a reduction in rate is made after January 1, 1972, or continued for the
first or any subsequent year of insurance under any policy of group health
insurance issued before, on or after January 1, 1972, to any policyholder, the
excess, if any, of the aggregate dividends or rate reductions under such a
policy and all other group insurance policies of the policyholder over the
aggregate expenditure for insurance under such policies made from money
contributed by the policyholder, or by an employer of insured persons, or by a
union or association to which the insured persons belong, including
expenditures made in connection with administration of such policies, must be
applied by the policyholder for the sole benefit of insured employees or
members.
2. This section does not apply as to
debtor groups.
(Added to NRS by 1971, 1768; A 1997, 1627)
NRS 689B.061 Limitations on deductibles and copayments charged under policy
which offers difference of payment between preferred providers of health care
and providers who are not preferred. A
policy of group health insurance which offers a difference of payment between
preferred providers of health care and providers of health care who are not
preferred:
1. May not require an insured, another
insurer who issues policies of group health insurance, a nonprofit medical
service corporation or a health maintenance organization to pay any amount in
excess of the deductible or coinsurance due from the insured based on the rates
agreed upon with a provider.
2. Must require that the deductible and
payment for coinsurance paid by the insured to a preferred provider of health
care be applied to the negotiated reduced rates of that provider.
3. Must include for providers of health
care who are not preferred a provision establishing the point at which an
insured’s payment for coinsurance is no longer required to be paid if such a
provision is included for preferred providers of health care. Such provisions
must be based on a calendar year. The point at which an insured’s payment for
coinsurance is no longer required to be paid for providers of health care who
are not preferred must not be greater than twice the amount for preferred
providers of health care, regardless of the method of payment.
4. Must provide that if there is a
particular service which a preferred provider of health care does not provide
and the provider of health care who is treating the insured requests the
service and the insurer determines that the use of the service is necessary for
the health of the insured, the service shall be deemed to be provided by the
preferred provider of health care.
5. Must require the insurer to process a
claim of a provider of health care who is not preferred not later than 30
working days after the date on which proof of the claim is received.
(Added to NRS by 1987, 1781; A 1991, 1329; 1995, 1629; 2013, 3619)
NRS 689B.063 Primary and secondary policies: Determination of benefits.
1. When a policy of group insurance is
primary, its benefits are determined before those of another policy and the
benefits of another policy are not considered. When a policy of group insurance
is secondary, its benefits are determined after those of another policy.
Secondary benefits may not be reduced because of benefits under the primary
policy. When there are more than two policies, a policy may be primary as to
one and may be secondary as to another.
2. The benefits payable under a policy of
group health insurance may not be reduced because of any benefits payable under
health insurance on a franchise plan or first-party coverage under an
automobile insurance policy.
3. As used in this section, “a policy of
group insurance” includes Medicare.
(Added to NRS by 1987, 848; A 1989, 1250; 1995, 1629; 2013, 3620)
NRS 689B.064 Primary and secondary policies: Order of benefits. A policy of group insurance determines its
order of benefits using the first of the following which applies:
1. A policy that does not coordinate with
other policies is always the primary policy.
2. The benefits of the policy which covers
a person as an employee, member or subscriber, other than a dependent, is the
primary policy. The policy which covers the person as a dependent is the
secondary policy.
3. When more than one policy covers the
same child as a dependent of different parents who are not divorced or
separated, the primary policy is the policy of the parent whose birthday falls
earlier in the year. The secondary policy is the policy of the parent whose
birthday falls later in the year. If both parents have the same birthday, the
benefits of the policy which covered the parent the longer is the primary
policy. The policy which covered the parent the shorter time is the secondary
policy.
4. If more than one policy covers a person
as a dependent child of divorced or separated parents, benefits for the child
are determined in the following order:
(a) First, the policy of the parent with custody
of the child;
(b) Second, the policy of the spouse of the
parent with custody; and
(c) Third, the policy of the parent without
custody of the child,
Ê unless the
specific terms of a court decree state that one parent is responsible for the
health care expenses of the child, in which case, the policy of that parent is
the primary policy. A parent responsible for the health care pursuant to a
court decree must notify the insurer of the terms of the decree.
5. The primary policy is the policy which
covers a person as an employee who is neither laid off or retired, or that
employee’s dependent. The secondary policy is the policy which covers that
person as a laid off or retired employee, or that employee’s dependent.
6. If none of the rules in subsections 1
to 5, inclusive, determines the order of benefits, the primary policy is the
policy which covered an employee, member or subscriber longer. The secondary
policy is the policy which covered that person the shorter time.
Ê When a
policy is determined to be a secondary policy it acts to provide benefits in
excess of those provided by the primary policy. The secondary policy may not
reduce benefits based upon payments by the primary policy, except that this
provision does not require duplication of benefits.
(Added to NRS by 1987, 848)
NRS 689B.065 Policy issued to replace discontinued policy or coverage:
Requirements; notice of reduction of benefits; statement of benefits;
applicability of section.
1. A policy of group health insurance
issued to replace any discontinued policy or coverage for group health
insurance must:
(a) Provide coverage for all persons who were
covered under the previous policy or coverage on the date it was discontinued;
and
(b) Except as otherwise provided in subsection 2,
provide benefits which are at least as extensive as the benefits provided by
the previous policy or coverage, except that benefits may be reduced or
excluded to the extent that such a reduction or exclusion was permissible under
the terms of the previous policy or coverage,
Ê if that
replacement policy is issued within 60 days after the date on which the
previous policy or coverage was discontinued.
2. If an employer obtains a replacement
policy pursuant to subsection 1 to cover the employees of the employer, any
benefits provided by the previous policy or coverage may be reduced if notice
of the reduction is given to the employees of the employer pursuant to NRS 608.1577.
3. Any insurer which issues a replacement
policy pursuant to subsection 1 may submit a written request to the insurer who
provided the previous policy or coverage for a statement of benefits which were
provided under that policy or coverage. Upon receiving such a request, the
insurer who provided the previous policy or coverage shall give a written
statement to the insurer providing the replacement policy which indicates what
benefits were provided and what exclusions or reductions were in effect under
the previous policy or coverage.
4. The provisions of this section:
(a) Apply to a self-insured employer who provides
health benefits to the employees of the employer and replaces those benefits
with a policy of group health insurance.
(b) Do not apply to the Public Employees’
Benefits Program established pursuant to NRS
287.0402 to 287.049, inclusive.
(Added to NRS by 1987, 849; A 1991, 251; 1999, 3042)
NRS 689B.067 Provision in policy requiring binding arbitration for disputes
with insurer authorized; procedure for arbitration; declaratory relief.
1. Except as otherwise provided in NRS 689B.270 and subject to the approval of the
Commissioner, a policy of group health insurance may include a provision which
requires a member or a dependent of a member of the insured group and the
insurer to submit for binding arbitration any dispute between the member or
dependent and the insurer concerning any matter directly or indirectly related
to, or associated with, the policy. If such a provision is included in the
policy:
(a) A member and any dependent of the member must
be given the opportunity to decline to participate in binding arbitration at
the time they elect to be covered by the policy.
(b) It must clearly state that the insurer and a
member or dependent of a member of the insured group who has not declined to
participate in binding arbitration agree to forego their right to resolve any
such dispute in a court of law or equity.
2. Except as otherwise provided in
subsection 3, the arbitration must be conducted pursuant to the rules for
commercial arbitration established by the American Arbitration Association. The
insurer is responsible for any administrative fees and expenses relating to the
arbitration, except that the insurer is not responsible for attorney’s fees and
fees for expert witnesses unless those fees are awarded by the arbitrator.
3. If a dispute required to be submitted
to binding arbitration requires an immediate resolution to protect the physical
health of a member or a dependent of a member, any party to the dispute may
waive arbitration and seek declaratory relief in a court of competent
jurisdiction.
4. If a provision described in subsection
1 is included in a policy of group health insurance, the provision shall not be
deemed unenforceable as an unreasonable contract of adhesion if the provision
is included in compliance with the provisions of subsection 1.
(Added to NRS by 1995, 2557)
NRS 689B.068 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 group health
insurance or cancel a policy of group 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 policy of group health insurance 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, 1096)
NRS 689B.069 Insurer prohibited from requiring or using information
concerning genetic testing; exceptions.
1. Except as otherwise provided in
subsection 2, an insurer who provides group 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 group 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, 1460)
BLANKET POLICIES
NRS 689B.070 “Blanket accident and health insurance” defined. “Blanket accident and health insurance” is
that form of accident insurance, health insurance, or both, covering groups of
persons as enumerated in one of the following subsections under a policy or
contract issued to:
1. Any common carrier or to any operator,
owner or lessee of a means of transportation, who or which shall be deemed the
policyholder, covering a group of persons who may become passengers defined by
reference to their travel status on the common carrier or means of
transportation.
2. An employer, who shall be deemed the
policyholder, covering any group of employees, dependents or guests, defined by
reference to specified hazards incident to an activity or activities or
operations of the policyholder.
3. A college, school or other institution
of learning, a school district or districts, or school jurisdictional unit, or
to the head, principal or governing board of any such educational unit, who or
which shall be deemed the policyholder, covering students, teachers or
employees.
4. A religious, charitable, recreational,
educational or civic organization, or branch thereof, which shall be deemed the
policyholder, covering any group of members or participants defined by
reference to specified hazards incident to an activity or activities or
operations sponsored or supervised by the policyholder.
5. A sports team, camp or sponsor thereof,
which shall be deemed the policyholder, covering members, campers, employees,
officials or supervisors.
6. A volunteer fire department,
organization providing first aid, organization for emergency management or
other such volunteer organization, which shall be deemed the policyholder,
covering any group of members or participants defined by reference to specified
hazards incident to an activity or activities or operations sponsored or
supervised by the policyholder.
7. A newspaper or other publisher, which
shall be deemed the policyholder, covering its carriers.
8. An association, including a labor
union, which has a constitution and bylaws and which has been organized and is
maintained in good faith for purposes other than that of obtaining insurance,
which shall be deemed the policyholder, covering any group of members or participants
defined by reference to specified hazards incident to an activity or activities
or operations sponsored or supervised by the policyholder.
9. Cover any other risk or class of risks
which, in the discretion of the Commissioner, may be properly eligible for
blanket accident and health insurance. The discretion of the Commissioner may
be exercised on the basis of an individual risk or class of risks, or both.
(Added to NRS by 1971, 1768; A 1983, 177; 2001, 2221)
NRS 689B.080 Authority to issue; required provisions. Any insurer authorized to write health
insurance in this state, including a nonprofit corporation for hospital,
medical or dental services that has a certificate of authority issued pursuant
to chapter 695B of NRS, may issue blanket
accident and health insurance. No blanket policy, except as provided in
subsection 5 of NRS 687B.120, may be
issued or delivered in this state unless a copy of the form thereof has been
filed in accordance with NRS 687B.120.
Every blanket policy must contain provisions which in the opinion of the Commissioner
are not less favorable to the policyholder and the individual insured than the
following:
1. A provision that the policy, including
endorsements and a copy of the application, if any, of the policyholder and the
persons insured constitutes the entire contract between the parties, and that
any statement made by the policyholder or by a person insured is in the absence
of fraud a representation and not a warranty, and that no such statements may
be used in defense to a claim under the policy, unless contained in a written
application. The insured or the beneficiary or assignee of the insured has the
right to make a written request to the insurer for a copy of an application,
and the insurer shall, within 15 days after the receipt of a request at its
home office or any branch office of the insurer, deliver or mail to the person
making the request a copy of the application. If a copy is not so delivered or
mailed, the insurer is precluded from introducing the application as evidence
in any action based upon or involving any statements contained therein.
2. A provision that written notice of
sickness or of injury must be given to the insurer within 20 days after the
date when the sickness or injury occurred. Failure to give notice within that
time does not invalidate or reduce any claim if it is shown that it was not
reasonably possible to give notice and that notice was given as soon as was
reasonably possible.
3. A provision that the insurer will
furnish to the claimant or to the policyholder for delivery to the claimant
such forms as are usually furnished by it for filing proof of loss. If the
forms are not furnished before the expiration of 15 days after giving written
notice of sickness or injury, the claimant shall be deemed to have complied with
the requirements of the policy as to proof of loss upon submitting, within the
time fixed in the policy for filing proof of loss, written proof covering the
occurrence, the character and the extent of the loss for which claim is made.
4. A provision that in the case of a claim
for loss of time for disability, written proof of the loss must be furnished to
the insurer within 90 days after the commencement of the period for which the
insurer is liable, and that subsequent written proofs of the continuance of the
disability must be furnished to the insurer at such intervals as the insurer
may reasonably require, and that in the case of a claim for any other loss,
written proof of the loss must be furnished to the insurer within 90 days after
the date of the loss. Failure to furnish such proof within that time does not
invalidate or reduce any claim if it is shown that it was not reasonably
possible to furnish proof and that the proof was furnished as soon as was
reasonably possible.
5. A provision that all benefits payable
under the policy other than benefits for loss of time will be payable
immediately upon receipt of written proof of loss, and that, subject to proof
of loss, all accrued benefits payable under the policy for loss of time will be
paid not less frequently than monthly during the continuance of the period for
which the insurer is liable, and that any balance remaining unpaid at the
termination of that period will be paid immediately upon receipt of proof.
6. A provision that the insurer at its own
expense has the right and opportunity to examine the person of the insured when
and so often as it may reasonably require during the pendency of claim under
the policy and also the right and opportunity to make an autopsy where it is
not prohibited by law.
7. A provision, if applicable, setting
forth the provisions of NRS 689B.035.
8. A provision for 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. A provision that no action at law or in
equity may be brought to recover under the policy before the expiration of 60
days after written proof of loss has been furnished in accordance with the
requirements of the policy and that no such action may 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, 1769; A 1973, 548; 1975, 448; 1985, 1775; 1993, 500; 2001, 2221; 2011, 3382)
NRS 689B.090 Application and certificates.
1. An individual application need not be
required from a person covered under a blanket health policy or contract, nor
shall it be necessary for the insurer to furnish each person a certificate, if
such person does not pay all or part of the premium for such insurance.
2. The Commissioner may, by rule or
regulation, require the delivery of an individual certificate or a statement of
the coverage to individuals insured under such a blanket policy or contract who
are either required to make an individual written application or pay part or
all of the premium therefor, and applying to such classes of cases and
circumstances, specified in such rule or regulation, as the Commissioner may
find such delivery to be reasonably necessary and practicable.
(Added to NRS by 1971, 1770)
NRS 689B.100 Payment of benefits.
1. Except as provided in subsection 2, all
benefits under any blanket health policy or contract must be payable to the
person insured, or to the designated beneficiary or beneficiaries of the person
insured, or to the estate of the person insured, except that if the person
insured is a minor or otherwise not competent to give a valid release, these
benefits may be made payable to the parent or guardian of the person insured or
to another person actually supporting the person insured.
2. The policy may provide that all or a
portion of any indemnities provided by any such policy on account of hospital,
nursing, medical or surgical services, home health care or supportive services:
(a) May, at the option of the insurer and unless
the insured requests otherwise in writing not later than the time of filing
proofs of such loss; or
(b) Must, upon the written request of the
insured,
Ê be paid
directly to the hospital or person rendering those services. The policy may not
require that the service be rendered by a particular hospital or person.
Payment so made discharges the obligation of the insurer with respect to the
amount of insurance so paid.
3. If the insured assigns his or her
benefits pursuant to this section but the insurer after receiving a copy of the
assignment pays the benefits to the insured, the insurer shall also pay the
benefits to the assignee as soon as the insurer receives the notice of the
incorrect payment.
(Added to NRS by 1971, 1771; A 1975, 450; 1983, 880)
NRS 689B.110 Legal liability of policyholders for death of or injury to
insured member unaffected. Nothing
contained in NRS 689B.070 to 689B.100, inclusive, shall be deemed to affect the legal
liability of policyholders for death of or injury to any member insured under a
blanket insurance policy.
(Added to NRS by 1971, 1771)
NRS 689B.115 Access by Commissioner to information concerning rates;
confidentiality of information. An
insurer providing blanket health insurance shall make all information
concerning rates available to the Commissioner upon request. The information is
proprietary, constitutes a trade secret, and may not be disclosed by the
Commissioner to any person outside the Division except as agreed by the insurer
or ordered by a court of competent jurisdiction.
(Added to NRS by 2001, 2219)
CONVERSION OF GROUP POLICIES TO INDIVIDUAL POLICIES
NRS 689B.120 Policies of group health insurance to contain provision for
conversion; exceptions; conditions. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689B.130 Conversion privilege available to spouse and children;
conditions. Repealed. (See chapter
541, Statutes of Nevada 2013, at page 3661.)
NRS 689B.140 Denial of converted policy because of overinsurance; notice
concerning cancellation of other coverage. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689B.150 Choice of plans for converted policy. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689B.170 Benefits payable under converted policy may be reduced by amount
payable under group policy. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689B.180 Issuance and effective date of converted policy; premiums;
persons covered. Repealed. (See
chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689B.200 Notice of conversion privilege. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689B.210 Converted policy delivered outside Nevada: Form. Repealed. (See chapter 541, Statutes of Nevada
2013, at page 3661.)
CONTINUATION OF COVERAGE UNDER CERTAIN GROUP POLICIES
NRS 689B.245 Required provision concerning continuation of coverage. Repealed. (See chapter 541, Statutes of Nevada
2013, at page 3661.)
NRS 689B.246 Notice of eligibility or election to continue coverage. Repealed. (See chapter 541, Statutes of Nevada
2013, at page 3661.)
NRS 689B.247 Payment of premium for continued coverage. Repealed. (See chapter 541, Statutes of Nevada
2013, at page 3661.)
NRS 689B.248 New insurer to provide continued coverage. Repealed. (See chapter 541, Statutes of Nevada
2013, at page 3661.)
NRS 689B.249 Termination of continued coverage before end of period. Repealed. (See chapter 541, Statutes of Nevada
2013, at page 3661.)
MISCELLANEOUS PROVISIONS
NRS 689B.250 Acceptance of uniform forms for billing and claims. Every insurer under a group health insurance
contract or a blanket accident and 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; A 2001, 2224)
NRS 689B.255 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
group health insurance or blanket 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, 1648; 2001, 2730; 2003, 3358)
NRS 689B.260 Required provision concerning coverage relating to complications
of pregnancy.
1. No group health or blanket health
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 689B.270 Required procedure for arbitration of disputes concerning
independent medical evaluations.
1. Each policy of group or blanket 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 a policy of group or blanket health 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 receiving 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 689B.275 Contents, approval and provision of summary of coverage;
provision of information about guaranteed availability of certain plans for
benefits.
1. An insurer shall provide to each
policyholder, or producer of insurance acting on behalf of a policyholder, on a
form approved by the Commissioner, a summary of the coverage provided by each
policy of group or blanket health insurance offered by the insurer. The summary
must disclose any:
(a) Significant exception, reduction or
limitation that applies to the policy;
(b) Restriction on payment for care in an
emergency, including related definitions of emergency and medical necessity;
(c) Right of the insurer to change the rate of
premium and the factors, other than claims experienced, which affect changes in
rate;
(d) Provisions relating to renewability;
(e) Provisions relating to preexisting
conditions; and
(f) Other information that the Commissioner finds
necessary for full and fair disclosure of the provisions of the policy.
2. The language of the disclosure must be
easily understood. The disclosure must state that it is only a summary of the
policy and that the policy should be read to ascertain the governing
contractual provisions.
3. The Commissioner shall not approve a
proposed disclosure that does not satisfy the requirements of this section and
of applicable regulations.
4. In addition to the disclosure, the
insurer shall provide information about guaranteed availability of basic and
standard plans for benefits to an eligible person.
5. The insurer shall provide the summary
before the policy is issued.
(Added to NRS by 2001, 2219)
NRS 689B.280 Disclosure of information concerning medication of insured
prohibited.
1. Except as otherwise provided in
subsection 2, an insurer or any agent or employee of an insurer who delivers or
issues for delivery a policy of group health or blanket health insurance in
this State shall not disclose to the policyholder or any agent or employee of
the policyholder:
(a) The fact that an insured is taking a
prescribed drug or medicine; or
(b) The identity of that drug or medicine.
2. The provisions of subsection 1 do not
prohibit disclosure to an administrator who acts as an intermediary for claims
for insurance coverage.
(Added to NRS by 1989, 1978)
NRS 689B.283 Mandatory renewal of coverage under conversion health benefit
plan. Repealed. (See chapter 541,
Statutes of Nevada 2013, at page 3661.)
NRS 689B.285 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, 2137)
NRS 689B.287 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 group 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 group 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 group 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 group
health insurance 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 group health insurance
solely because of such a claim; or
(c) Refuse to issue a policy of group 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 group health insurance that provides
coverage for long-term care or disability income.
(Added to NRS by 2005, 2344; A 2007, 84)
ELIGIBILITY FOR COVERAGE UNDER GROUP POLICY
NRS 689B.290 Definitions. As
used in NRS 689B.290 to 689B.330,
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 group health
policy to a child pursuant to the provisions of 42 U.S.C. § 1396g-1.
(Added to NRS by 1995, 2428)
NRS 689B.300 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 group health policy,
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), or other organization that has issued a
group health policy:
(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 rights 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 group health policy,
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 spouse or dependent of the insured 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;
(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, 2429; A 2007, 2403)
NRS 689B.310 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 group health policy 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, 2429)
NRS 689B.320 Certain accommodations to be made when child is covered under
policy of noncustodial parent. If
a child has coverage under a group health policy pursuant to which a
noncustodial parent of the child is insured, the health 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, 2429)
NRS 689B.330 Insurer to authorize enrollment of child of parent who is
required by order to provide medical coverage for child. If a parent is required by an order for
medical coverage to provide coverage under a group health policy for a child
and the parent is eligible for coverage of members of his or her family under a
group health policy, 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, 2429)
PORTABILITY AND ACCOUNTABILITY
NRS 689B.340 Definitions. As
used in NRS 689B.340 to 689B.580,
inclusive, unless the context otherwise requires, the words and terms defined
in NRS 689B.350 to 689B.460,
inclusive, have the meanings ascribed to them in those sections.
(Added to NRS by 1997, 2900; A 2001, 1923, 2224; 2013, 3620)
NRS 689B.350 “Affiliation period” defined. “Affiliation
period” means a period not to exceed 60 days for new enrollees and 90 days for
late enrollees during which no premiums may be collected from, and coverage
issued would not become effective for, an employee or a dependent of the
employee, if the affiliation period is applied uniformly and without regard to
any health status-related factors.
(Added to NRS by 1997, 2900)
NRS 689B.355 “Blanket accident and health insurance” defined. “Blanket accident and health insurance” has
the meaning ascribed to it in NRS 689B.070.
(Added to NRS by 2001, 2219)
NRS 689B.360 “Carrier” defined. “Carrier”
means any person who provides health insurance in this state, including a
fraternal benefit society, a health maintenance organization, a nonprofit
hospital and health service corporation, a health insurance company and any
other person providing a plan of health insurance or health benefits subject to
this Title.
(Added to NRS by 1997, 2900)
NRS 689B.370 “Contribution” defined. “Contribution”
means the minimum employer contribution toward the premium for enrollment of
participants and beneficiaries in a health benefit plan.
(Added to NRS by 1997, 2900)
NRS 689B.380 “Creditable coverage” defined. “Creditable
coverage” means health benefits or coverage provided to a person 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 accident and health
insurance policy.
(Added to NRS by 1997, 2900; A 1999, 2240, 2806; 2001, 2224)
NRS 689B.390 “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 any 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, 2900)
NRS 689B.400 “Group participation” defined. “Group
participation” means the minimum number of participants or beneficiaries that
must be enrolled in a health benefit plan in relation to a specified percentage
or number of eligible persons or employees of the employer.
(Added to NRS by 1997, 2901)
NRS 689B.410 “Health benefit plan” defined. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689B.420 “Health status-related factor” defined. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689B.430 “Open enrollment” defined. “Open
enrollment” means the period designated for enrollment in a health benefit
plan.
(Added to NRS by 1997, 2903)
NRS 689B.440 “Plan sponsor” defined. “Plan
sponsor” has the meaning ascribed to it in section 3(16)(B) of the Employee
Retirement Income Security Act of 1974, as that section existed on July 16,
1997.
(Added to NRS by 1997, 2903)
NRS 689B.450 “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 immediately 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, 2903)
NRS 689B.460 “Waiting period” defined. “Waiting
period” means the period established by a plan of health insurance that must
pass before a person who is an eligible participant or beneficiary in a plan is
covered for benefits under the terms of the plan. The term includes the period
from the date a person submits an application to an individual carrier for
coverage under a health benefit plan until the first day of coverage under that
health benefit plan.
(Added to NRS by 1997, 2903; A 1999, 2808)
NRS 689B.470 Certain plan, fund or program to be treated as employee welfare
benefit plan which is group health plan; partnership deemed employer of each
partner. Repealed. (See chapter
541, Statutes of Nevada 2013, at page 3661.)
NRS 689B.480 Determination of applicable creditable coverage of person; determination
of period of creditable coverage of person; required statement.
1. In determining the applicable
creditable coverage of a person for the purposes of NRS
689B.340 to 689B.580, inclusive, a period of
creditable coverage must not be included if, after the expiration of that
period but before the enrollment date, there was a 63-day period during all of
which the person was not covered under any creditable coverage. To establish a
period of creditable coverage, a person must present any certificates of
coverage provided to the person in accordance with NRS
689B.490 and such other evidence of coverage as required by regulations
adopted by the Commissioner. For the purposes of this subsection, any waiting
period for coverage or an affiliation period must not be considered in
determining the applicable period of creditable coverage.
2. In determining the period of creditable
coverage of a person, a carrier shall include each applicable period of
creditable coverage without regard to the specific benefits covered during that
period, except that the carrier may elect to include applicable periods of
creditable coverage based on coverage of specific benefits as specified in the
regulations of the United States Department of Health and Human Services, if
such an election is made on a uniform basis for all participants and
beneficiaries of the health benefit plan or coverage. Pursuant to such an
election, the carrier shall include each applicable period of creditable
coverage with respect to any class or category of benefits if any level of
benefits is covered within that class or category, as specified by those
regulations.
3. Regardless of whether coverage is
actually provided, if a carrier elects in accordance with subsection 2 to
determine creditable coverage based on specified benefits, a statement that such
an election has been made and a description of the effect of the election must
be:
(a) Included prominently in any disclosure
statement concerning the health benefit plan; and
(b) Provided to each person at the time of
enrollment in the health benefit plan.
4. The provisions of this section apply
only to grandfathered plans.
(Added to NRS by 1997, 2903; A 2013, 3620)
NRS 689B.490 Written certification of coverage required for purpose of
determining period of creditable coverage accumulated by person.
1. For the purpose of determining the
period of creditable coverage of a person accumulated under a health benefit
plan, blanket accident and health insurance or group health insurance, the
insurer shall provide written certification on a form prescribed by the
Commissioner of coverage to the person which certifies the length of:
(a) The period of creditable coverage that the
person accumulated under the plan and any coverage 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; and
(b) Any waiting and affiliation period imposed on
the person pursuant to that coverage.
2. The certification of coverage must be
provided to the person who was insured:
(a) At the time that the person ceases to be
covered under the plan, if the person does not otherwise become 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 person becomes covered under such a
provision, at the time that the person ceases to be covered by that provision;
and
(c) Upon request, if the request is made not
later than 24 months after the date on which the person ceased to be covered as
described in paragraphs (a) and (b).
(Added to NRS by 1997, 2904; A 2001, 2225)
NRS 689B.500 Coverage of preexisting conditions. A
carrier that issues a group health plan or coverage under blanket accident and
health insurance or group health insurance shall not deny, exclude or limit a
benefit for a preexisting condition.
(Added to NRS by 1997, 2904; A 1999, 2808; 2001, 2225; 2013, 3621)
NRS 689B.510 Carrier authorized to modify coverage for insurance product
under certain circumstances. A
carrier may modify the health insurance coverage for a product offered pursuant
to a group health plan by the carrier at the time of renewal of such coverage
if the modification is consistent with the provisions of this chapter.
(Added to NRS by 1997, 2906)
NRS 689B.520 Group plan or coverage that includes coverage for maternity care
and pediatric care: Required to allow minimum stay in hospital in connection
with childbirth; prohibited acts.
1. Except as otherwise provided in this
subsection, a group health plan or coverage offered under group health
insurance 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 or coverage 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 group health plan or health insurance coverage 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 group health plan or health
insurance coverage 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. A group health plan or coverage under
group health insurance 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 a group health plan or carrier 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
a group health plan or carrier 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 a group health plan or carrier 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, 2906)
NRS 689B.530 Carrier required to permit eligible employee or dependent of
employee to enroll for coverage under certain circumstances. A carrier offering group health insurance
shall permit an employee or a dependent of an employee covered by the group
health insurance who is eligible, but not enrolled, for coverage in connection
with the group health insurance to enroll for coverage under the terms of the group
health insurance if:
1. The employee or dependent was covered
under a different group health insurance or had other health insurance coverage
at the time coverage was previously offered to the employee or dependent;
2. The employee stated in writing at that
time that the other coverage was the reason for declining enrollment, but only
if the plan sponsor or carrier required such a written statement and informed
the employee of that requirement and the consequences of the requirement; and
3. The employee or dependent:
(a) Was covered under any provision of the
Consolidated Omnibus Budget Reconciliation Act of 1985 relating to the
continuation of coverage and such continuation of coverage was exhausted; or
(b) Was not covered under such a provision and
his or her insurance coverage was lost as a result of cessation of
contributions by his or her employer, termination of employment or eligibility,
reduction in the number of hours of employment, or the death of, or divorce or
legal separation from, a covered spouse.
(Added to NRS by 1997, 2907)
NRS 689B.540 Manner and period for enrollment of dependent of covered employee;
period of special enrollment.
1. A carrier that offers group health
insurance which makes coverage available to the dependent of an employee
covered by the group health plan shall permit the employee to enroll a
dependent after the close of a period of open enrollment if:
(a) The employee is a participant in the group
health plan, or has met any waiting period applicable to becoming a participant
and is eligible to be enrolled under the plan, except for a failure to enroll
during a previous period of open enrollment; and
(b) The person to be enrolled became a dependent
of the employee through marriage, birth, adoption or placement for adoption.
2. The group health plan or carrier shall
provide a period of special enrollment for the enrollment of a dependent of an
employee pursuant to this section. Such a period must be not less than 30 days
and must begin on:
(a) The date specified by the group health plan
or carrier for the period of special enrollment; or
(b) The date of the marriage, birth, adoption or
placement for adoption, as appropriate.
3. If an employee seeks to enroll a
dependent during the first 30 days of the period for special enrollment
provided pursuant to subsection 2, the coverage of the dependent becomes
effective:
(a) In the case of a marriage, not later than the
first day of the first month beginning after the date on which the completed
request for enrollment is received;
(b) In the case of a birth, on the date of the
birth; and
(c) In the case of an adoption or placement for
adoption, on the date of the adoption or the placement for adoption.
4. In the case of a birth, an adoption or
a placement for adoption of a child of an employee, the spouse of the employee
may be enrolled as a dependent pursuant to this section if the spouse is
otherwise eligible for coverage under the group health plan.
(Added to NRS by 1997, 2908)
NRS 689B.550 Carrier prohibited from imposing restriction on participation
inconsistent with chapter; restrictions on rules of eligibility that may be
established; premiums to be equitable.
1. A carrier shall not place any
restriction on a person or a dependent of the person as a condition of being a
participant in or a beneficiary of a policy of blanket accident and health
insurance or group health insurance that is inconsistent with the provisions of
this chapter.
2. A carrier that offers coverage under a
policy of blanket accident and health insurance or group health insurance
pursuant to this chapter shall not establish rules of eligibility, including
rules which define applicable waiting periods, for the initial or continued
enrollment under a group health plan offered by the carrier that are based on
the following factors relating to the employee or a dependent of the employee:
(a) Health status.
(b) Medical condition, including physical and
mental illnesses, or both.
(c) Claims experience.
(d) Receipt of health care.
(e) Medical history.
(f) Genetic information.
(g) Evidence of insurability, including
conditions which arise out of acts of domestic violence.
(h) Disability.
3. Except as otherwise provided in NRS 689B.500, the provisions of subsection 1 do not:
(a) Require a carrier to provide particular
benefits other than those that would otherwise be provided under the terms of
the blanket health and accident insurance or group health insurance or
coverage; or
(b) Prevent a carrier from establishing
limitations or restrictions on the amount, level, extent or nature of the
benefits or coverage for similarly situated persons.
4. As a condition of enrollment or
continued enrollment under a policy of blanket accident and health insurance or
group health insurance, a carrier shall not require an employee to pay a
premium or contribution that is greater than the premium or contribution for a
similarly situated person covered by similar coverage on the basis of any
factor described in subsection 2 in relation to the employee or a dependent of
the employee.
5. This section does not:
(a) Restrict the amount that an employer or
employee may be charged for coverage by a carrier;
(b) Prevent a carrier from establishing premium
discounts or rebates or from modifying otherwise applicable copayments or
deductibles in return for adherence by the insured person to programs of health
promotion and disease prevention; or
(c) Preclude a carrier from establishing rules
relating to employer contribution or group participation when offering health
insurance coverage to small employers in this state.
(Added to NRS by 1997, 2908; A 2001, 2227)
NRS 689B.560 Carrier required to renew coverage at option of plan sponsor;
exceptions; discontinuation of form of product of group health insurance;
discontinuation of group health insurance through bona fide association.
1. Except as otherwise provided in this
section, coverage under a policy of group health insurance must be renewed by
the carrier at the option of the plan sponsor, unless:
(a) The plan sponsor has failed to pay premiums
or contributions in accordance with the terms of the group health insurance or
the carrier has not received timely premium payments;
(b) The plan sponsor 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 plan sponsor has failed to comply with
any material provision of the group health insurance relating to employer
contributions and group participation; or
(d) The carrier decides to discontinue offering
coverage under group health insurance. If the carrier decides to discontinue
offering and renewing such insurance, the carrier shall:
(1) Provide notice of its intention to the
Commissioner and the chief regulatory officer for insurance in each state in
which the 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 discontinued insurance 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
discontinuance of any group health plan by the carrier.
(3) Discontinue all health insurance
issued or delivered for issuance for persons in this state and not renew
coverage under any group health insurance issued to such persons.
2. A carrier may discontinue the issuance
and renewal of a form of a product of group health insurance if the
Commissioner finds that the form of the product offered by the carrier is
obsolete and is being replaced with comparable coverage. A form of a product
may be discontinued by the carrier pursuant to this subsection only if:
(a) The carrier notifies the Commissioner and the
chief regulatory officer 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 carrier notifies each person covered by
the discontinued insurance and the Commissioner and the chief regulatory
officer in each state in which such a person is known to reside of the decision
of the carrier to discontinue offering the form of the product. The notice must
be made at least 180 days before the date on which the carrier will discontinue
offering the form of the product.
(c) The carrier offers to each person covered by
the discontinued insurance the option to purchase any other health benefit plan
currently offered by the carrier to large groups 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 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 person or beneficiary who may become
eligible for such coverage.
3. A carrier may discontinue the issuance
and renewal of any type of group health insurance offered by the carrier in
this state that is made available pursuant to this chapter only to a member of
a bona fide association if:
(a) The membership of the person in the bona fide
association was the basis for the provision of coverage under the group health
insurance;
(b) The membership of the person in the bona fide
association ceases; and
(c) Coverage is terminated pursuant to this
subsection for all such former members uniformly without regard to any health
status-related factor relating to the former member.
4. A carrier that elects not to renew
group health insurance pursuant to paragraph (d) of subsection 1 shall not
write new business pursuant to this chapter for 5 years after the date on which
notice is provided to the Commissioner pursuant to subparagraph (2) of
paragraph (d) of subsection 1.
5. If the carrier does business in only
one geographic service area of this state, the provisions of this section apply
only to the operations of the carrier in that service area.
6. As used in this section, “bona fide
association” has the meaning ascribed to it in NRS 689A.485.
(Added to NRS by 1997, 2909; A 2013, 3623)
NRS 689B.570 Carrier that offers coverage through network plan not required
to offer coverage to employer that does not employ enrollees who reside or work
in geographic service area for which carrier is authorized to transact
insurance.
1. A carrier that offers coverage through
a network plan is not required to offer coverage to or accept an application
from an employer that does not employ or no longer employs any enrollees who
reside or work in the geographic service area of the carrier, provided that
such coverage is refused or terminated uniformly without regard to any health
status-related factor for any employee of the employer.
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, including items and services paid for
as medical care, are provided, in whole or in part, through a defined set of
providers under contract with the carrier. The term does not include an
arrangement for the financing of premiums.
(Added to NRS by 1997, 2911; A 2013, 3624)
NRS 689B.575 Carrier that offers coverage through network plan: Contracts
with certain federally qualified health centers. Repealed.
(See chapter 541, Statutes of Nevada 2013, at page 3661.)
NRS 689B.580 Plan sponsor of governmental plan authorized to elect to exclude
governmental plan from compliance with certain statutes; duties of plan
sponsor.
1. A plan sponsor of a governmental plan
that is a group health plan to which the provisions of NRS
689B.340 to 689B.580, inclusive, otherwise
apply may elect to exclude the governmental plan from compliance with those
sections. Such an election:
(a) Must be made in such a form and in such a
manner as the Commissioner prescribes by regulation.
(b) Is effective for a single specified year of
the plan or, if the plan is provided pursuant to a collective bargaining
agreement, for the term of that agreement.
(c) May be extended by subsequent elections.
(d) Excludes the governmental plan from those
provisions in this chapter that apply only to group health plans.
2. If a plan sponsor of a governmental
plan makes an election pursuant to this section, the plan sponsor shall:
(a) Annually and at the time of enrollment, notify
the enrollees in the plan of the election and the consequences of the election;
and
(b) Provide certification and disclosure of
creditable coverage under the plan with respect to those enrollees pursuant to NRS 689B.490.
3. As used in this section, “governmental
plan” has the meaning ascribed to in section 3(32) of the Employee Retirement
Income Security Act of 1974, as that section existed on July 16, 1997.
(Added to NRS by 1997, 2911; A 2013, 3624)
NRS 689B.590 Converted policies: Carrier may only offer choice of basic and
standard plans; election of basic or standard plan; premium; rates must be same
for persons with similar case characteristics; losses must be spread across
book. Repealed. (See chapter 541,
Statutes of Nevada 2013, at page 3661.)
