Nrs: Chapter 689B - Group And Blanket Health Insurance

Link to law: https://www.leg.state.nv.us/NRS/NRS-689B.html
Published: 2015

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[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.]

_________

_________

 

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.)