Nrs: Chapter 695C - Health Maintenance Organizations

Link to law: https://www.leg.state.nv.us/NRS/NRS-695C.html
Published: 2015

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[Rev. 2/11/2015 12:27:11

PM--2014R2]

CHAPTER 695C - HEALTH MAINTENANCE

ORGANIZATIONS

GENERAL PROVISIONS

NRS 695C.010        Short

title.

NRS 695C.020        Legislative

declaration.

NRS 695C.030        Definitions.

NRS 695C.050        Applicability

of certain provisions.

NRS 695C.055        Applicability

of certain other provisions.

NRS 695C.057        Applicability

of certain provisions concerning portability and availability of health

insurance.

NRS 695C.060        Establishment

of organization.

NRS 695C.070        Certificate

of authority: Application.

NRS 695C.080        Certificate

of authority: Evaluation of application.

NRS 695C.090        Certificate

of authority: Issuance.

NRS 695C.100        Certificate

of authority: Denial.

NRS 695C.110        Governing

body: Composition; participation by enrollees.

NRS 695C.120        Powers

of organization.

NRS 695C.123        Contracts

with certain federally qualified health centers.

NRS 695C.125        Contract

between health maintenance organization and provider of health care: Form to

obtain information on provider of health care; modification; provision of

schedule of fees.

NRS 695C.128        Contracts

to provide services pursuant to certain state programs: Payment of interest on

claims.

NRS 695C.130        Notice

and approval required for exercise of powers; rules or regulations.

NRS 695C.140        Notice

and approval required for modification of operations; regulations.

NRS 695C.145        Accounting

principles required for certain reports and transactions; health maintenance

organization subject to requirements for certain insurers.

NRS 695C.150        Fiduciary

responsibilities.

NRS 695C.160        Investments.

ELIGIBILITY FOR COVERAGE

NRS 695C.161        Eligibility

for coverage: Definitions.

NRS 695C.163        Eligibility

for coverage: Effect of eligibility for medical assistance under Medicaid;

assignment of rights to state agency.

NRS 695C.165        Eligibility

for coverage: Organization prohibited from asserting certain grounds to deny

enrollment of child pursuant to order if parent is enrolled in health care

plan.

NRS 695C.167        Eligibility

for coverage: Certain accommodations to be made when child is covered under

health care plan of noncustodial parent.

NRS 695C.169        Eligibility

for coverage: Organization to authorize enrollment of child of parent who is

required by order to provide medical coverage under certain circumstances;

termination of coverage of child.

COVERAGE GENERALLY

NRS 695C.1691      Required

provision concerning coverage for continued medical care.

NRS 695C.1693      Required

provision concerning coverage for treatment received as part of clinical trial

or study.

NRS 695C.1694      Required

provision concerning coverage of drug or device for contraception and of

hormone replacement therapy in certain circumstances; prohibited actions by

health maintenance organization; exceptions.

NRS 695C.1695      Required

provision concerning coverage of health care services related to contraceptives

and hormone replacement therapy in certain circumstances; prohibited actions by

health maintenance organization; exceptions.

NRS 695C.170        Evidence

of coverage: Issuance; form and contents.

NRS 695C.1703      Coverage

for prescription drugs: Provision of notice and information regarding use of

formulary.

NRS 695C.1705      Group

health care plan issued to replace discontinued policy or coverage:

Requirements; notice of reduction of benefits; statement of benefits;

applicability to self-insured employer.

NRS 695C.1707      Required

provision for continuation of coverage. [Repealed.]

NRS 695C.1709      Required

provision concerning coverage for enrollee on leave without pay as result of total

disability.

NRS 695C.171        Required

provision concerning coverage relating to mastectomy.

NRS 695C.1713      Required

provision concerning coverage of certain gynecological and obstetrical services

without authorization or referral from primary care physician.

NRS 695C.1717      Required

provision concerning coverage for autism spectrum disorders.

NRS 695C.172        Required

provision concerning coverage relating to complications of pregnancy.

NRS 695C.1723      Required

provision concerning coverage for treatment of certain inherited metabolic

diseases.

NRS 695C.1727      Required

provision concerning coverage for management and treatment of diabetes.

NRS 695C.173        Required

provision concerning coverage for newly born and adopted children and children

placed for adoption.

NRS 695C.1731      Required

provision concerning coverage for screening for colorectal cancer.

NRS 695C.1733      Required

provision concerning coverage for certain drugs for treatment of cancer.

NRS 695C.17335    Required

provision concerning coverage for orally administered chemotherapy.

NRS 695C.1734      Required

provision concerning coverage for prescription drug previously approved for

medical condition of enrollee.

NRS 695C.1735      Required

provision concerning coverage for cytologic screening tests and mammograms for

certain women.

NRS 695C.1745      Required

provision concerning coverage for human papillomavirus vaccine.

NRS 695C.1751      Required

provision concerning coverage for prostate cancer screening.

NRS 695C.1755      Required

provision concerning coverage for treatment of temporomandibular joint.

NRS 695C.176        Required

provision concerning coverage for hospice care.

REIMBURSEMENT

NRS 695C.1765      Reimbursement

for acupuncture.

NRS 695C.177        Reimbursement

for treatments by licensed psychologist.

NRS 695C.1773      Reimbursement

for treatment by licensed marriage and family therapist or licensed clinical

professional counselor.

NRS 695C.1775      Reimbursement

for treatment by licensed associate in social work, social worker, independent

social worker or clinical social worker.

NRS 695C.178        Reimbursement

for treatment by chiropractor.

NRS 695C.1783      Reimbursement

for treatment by podiatrist.

NRS 695C.1789      Reimbursement

for treatment by licensed clinical alcohol and drug abuse counselor.

NRS 695C.179        Reimbursement

for services provided by certain nurses; prohibited limitations; exceptions.

NRS 695C.1795      Reimbursement

to provider of medical transportation.

MISCELLANEOUS PROVISIONS

NRS 695C.180        Schedule

of charges. [Repealed.]

NRS 695C.185        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 695C.187        Schedule

for payment of claims: Mandatory inclusion in arrangements for provision of

health care.

NRS 695C.190        Commissioner

may require submission of information.

NRS 695C.193        Summary

of coverage: Contents of disclosure; approval by Commissioner; regulations.

[Repealed.]

NRS 695C.195        Summary

of coverage: Copy to be provided before policy issued; policy not to be offered

unless summary approved by Commissioner. [Repealed.]

NRS 695C.200        Approval

of forms and schedules.

NRS 695C.201        Offering

policy of health insurance for purposes of establishing health savings account.

NRS 695C.203        Denying

coverage solely because person was victim of domestic violence prohibited.

NRS 695C.205        Denying

coverage solely because insured was intoxicated or under the influence of

controlled substance prohibited; exceptions.

NRS 695C.207        Requiring

or using information concerning genetic testing.

NRS 695C.210        Annual

report and financial statement required; administrative penalty for failure to

file report or statement.

NRS 695C.220        Applications,

filings and reports open to public inspection.

NRS 695C.230        Fees.

NRS 695C.240        Information

required to be available for inspection.

NRS 695C.250        Open

enrollment. [Repealed.]

NRS 695C.260        Complaint

system.

NRS 695C.265        Required

procedure for arbitration of disputes concerning independent medical

evaluations.

NRS 695C.267        Provision

requiring binding arbitration authorized; procedures for arbitration;

declaratory relief.

NRS 695C.270        Bond

required; waiver.

NRS 695C.275        Commissioner

to adopt regulations for licensing of provider-sponsored organizations.

NRS 695C.280        Commissioner

authorized to adopt regulations for licensing of agents or brokers.

NRS 695C.290        Insurance

company may establish or contract with health maintenance organization.

NRS 695C.300        Prohibited

practices.

NRS 695C.310        Examinations.



NRS 695C.311        Periodic

examination by Commissioner to determine financial condition of health

maintenance organization.

NRS 695C.313        Financial

examination: Procedure; appointment of examiner; maintenance and use of

records; penalty for obstruction or interference.

NRS 695C.315        Financial

examination: Payment of expense.

NRS 695C.317        Statutory

procedures required for examination and hearing.

NRS 695C.320        Rehabilitation,

liquidation or conservation.

NRS 695C.325        Authorization

to offer health care plan to small employer for purpose of establishing medical

savings accounts.

NRS 695C.330        Disciplinary

proceedings: Grounds; effect of suspension or revocation.

NRS 695C.340        Disciplinary

proceedings: Notice; hearing; judicial review.

NRS 695C.350        Violations:

Remedies; penalties.

_________

_________

 

GENERAL PROVISIONS

      NRS 695C.010  Short title.  This

chapter may be cited as the Nevada Health Maintenance Organization Act.

      (Added to NRS by 1973, 1246)

      NRS 695C.020  Legislative declaration.  The

Legislature hereby declares that the rising cost of health services in recent

years has led government agencies, private organizations, and legislative

bodies to seek alternatives to the traditional medical delivery system which

would provide improved health care and would provide such health care at a

lower cost. The health maintenance organization is a concept which has received

much attention as one means through which an improvement in delivery might be

achieved. The Legislature therefore enacts this chapter to carry out this

objective.

      (Added to NRS by 1973, 1246)

      NRS 695C.030  Definitions.  As

used in this chapter, unless the context otherwise requires:

      1.  “Comprehensive health care services”

means medical services, dentistry, drugs, psychiatric and optometric and all

other care necessary for the delivery of services to the consumer.

      2.  “Enrollee” means a natural person who

has been voluntarily enrolled in a health care plan.

      3.  “Evidence of coverage” means any

certificate, agreement or contract issued to an enrollee setting forth the

coverage to which the enrollee is entitled.

      4.  “Health care plan” means any

arrangement whereby any person undertakes to provide, arrange for, pay for or

reimburse any part of the cost of any health care services and at least part of

the arrangement consists of arranging for or the provision of health care

services paid for by or on behalf of the enrollee on a periodic prepaid basis.

      5.  “Health care services” means any

services included in the furnishing to any natural person of medical or dental

care or hospitalization or incident to the furnishing of such care or

hospitalization, as well as the furnishing to any person of any other services

for the purpose of preventing, alleviating, curing or healing human illness or

injury.

      6.  “Health maintenance organization” means

any person which provides or arranges for provision of a health care service or

services and is responsible for the availability and accessibility of such

service or services to its enrollees, which services are paid for or on behalf

of the enrollees on a periodic prepaid basis without regard to the dates health

services are rendered and without regard to the extent of services actually

furnished to the enrollees, except that supplementing the fixed prepayments by

nominal additional payments for services in accordance with regulations adopted

by the Commissioner shall not be deemed to render the arrangement not to be on

a prepaid basis. A health maintenance organization, in addition to offering

health care services, may offer indemnity or service benefits provided through

insurers or otherwise.

      7.  “Provider” means any physician,

hospital or other person who is licensed or otherwise authorized in this state

to furnish health care services.

      (Added to NRS by 1973, 1246; A 1985, 538; 1997, 1629)

      NRS 695C.050  Applicability of certain provisions.

      1.  Except as otherwise provided in this

chapter or in specific provisions of this title, the provisions of this title

are not applicable to any health maintenance organization granted a certificate

of authority under this chapter. This provision does not apply to an insurer

licensed and regulated pursuant to this title except with respect to its

activities as a health maintenance organization authorized and regulated

pursuant to this chapter.

      2.  Solicitation of enrollees by a health

maintenance organization granted a certificate of authority, or its

representatives, must not be construed to violate any provision of law relating

to solicitation or advertising by practitioners of a healing art.

      3.  Any health maintenance organization

authorized under this chapter shall not be deemed to be practicing medicine and

is exempt from the provisions of chapter 630

of NRS.

      4.  The provisions of NRS 695C.110, 695C.125, 695C.1691, 695C.1693, 695C.170 to 695C.173,

inclusive, 695C.1733 to 695C.200,

inclusive, and 695C.265 do not apply to a health

maintenance organization that provides health care services through managed

care to recipients of Medicaid under the State Plan for Medicaid or insurance

pursuant to the Children’s Health Insurance Program pursuant to a contract with

the Division of Health Care Financing and Policy of the Department of Health

and Human Services. This subsection does not exempt a health maintenance

organization from any provision of this chapter for services provided pursuant

to any other contract.

      5.  The provisions of NRS 695C.1694, 695C.1695

and 695C.1731 apply to a health maintenance

organization that provides health care services through managed care to

recipients of Medicaid under the State Plan for Medicaid.

      (Added to NRS by 1973, 1258; A 1983, 2030; 1995, 2720; 1997, 311, 1528; 1999, 418, 420, 1945, 2004, 2241; 2001, 141, 144, 864, 2734; 2003, 1335, 3366, 3531; 2007, 3240; 2009, 1473;

2013, 1999,

3638)

      NRS 695C.055  Applicability of certain other provisions.

      1.  The provisions of NRS 449.465, 679A.200, 679B.700, subsections 2, 4, 18, 19 and

32 of NRS 680B.010, NRS 680B.020 to 680B.060, inclusive, chapter 686A of NRS, NRS 687B.500 and chapter 695G of NRS apply to a health

maintenance organization.

      2.  For the purposes of subsection 1,

unless the context requires that a provision apply only to insurers, any

reference in those sections to “insurer” must be replaced by “health

maintenance organization.”

      (Added to NRS by 1987, 469; A 1995, 472, 988; 1997, 299, 311, 2958, 2962; 2001, 2735; 2003, 3333, 3367; 2013, 3458,

3639)

      NRS 695C.057  Applicability of certain provisions concerning portability and

availability of health insurance.

      1.  A health maintenance organization is

subject to the provisions of NRS 689B.340

to 689B.580, inclusive, and chapter 689C of NRS relating to the

portability and availability of health insurance offered by such organizations.

If there is a conflict between the provisions of this chapter and the

provisions of NRS 689B.340 to 689B.580, inclusive, and chapter 689C of NRS, the provisions of NRS 689B.340 to 689B.580, inclusive, and chapter 689C of NRS control.

      2.  For the purposes of subsection 1,

unless the context requires that a provision apply only to a group health plan

or a carrier that provides coverage under a group health plan, any reference in

those sections to “group health plan” or “carrier” must be replaced by “health

maintenance organization.”

      (Added to NRS by 1997, 2957; A 2013, 3639)

      NRS 695C.060  Establishment of organization.

      1.  Any person may apply to the

Commissioner for and obtain a certificate of authority to establish and operate

a health maintenance organization in compliance with this chapter. No person

shall operate a health maintenance organization without obtaining a certificate

of authority under this chapter. A foreign corporation may qualify under this

chapter, subject to its qualification to do business in this state as a foreign

corporation.

      2.  No person shall be certified to

establish or operate a health maintenance organization in this state, nor sell

or offer to sell, or solicit offers to purchase or receive advance or periodic

consideration in conjunction with health care plans unless such health

maintenance organization provides or arranges for the provision of

comprehensive health care services.

      3.  Every health maintenance organization

or person operating a health maintenance organization shall submit an

application for a certificate of authority under NRS

695C.070 within 30 days after July 1, 1973. Each such applicant may

continue to operate until the Commissioner acts upon the application. In the

event that an application is denied under NRS 695C.090

and 695C.100, the applicant shall thereafter be

treated as a health maintenance organization whose certificate of authority has

been revoked. For purposes of this subsection, a health maintenance organization

shall be deemed to be in operation only if health care services are being

provided to the public generally or to some group or groups thereof.

      (Added to NRS by 1973, 1247)

      NRS 695C.070  Certificate of authority: Application.  Each

application for a certificate of authority must be verified by an officer or

authorized representative of the applicant, must be in a form prescribed by the

Commissioner, and must set forth or be accompanied by the following:

      1.  A copy of the basic organizational

document, if any, of the applicant, and all amendments thereto;

      2.  A copy of the bylaws, rules or

regulations, or a similar document, if any, regulating the conduct of the

internal affairs of the applicant;

      3.  A list of the names, addresses and

official positions of the persons who will be responsible for the conduct of

the affairs of the applicant, including all members of the board of directors,

board of trustees, executive committee, or other governing board or committee,

the officers in the case of a corporation, and the partners or members in the

case of a partnership or association;

      4.  A copy of any contract made or to be

made between any providers or persons listed in subsection 3 and the applicant;

      5.  A statement generally describing the

health maintenance organization, its health care plan or plans, the location of

facilities at which health care services will be regularly available to

enrollees and the type of health care personnel who will provide the health

care services;

      6.  A copy of the form of evidence of

coverage to be issued to the enrollees;

      7.  A copy of the form of the group

contract, if any, which is to be issued to employers, unions, trustees or other

organizations;

      8.  Certified financial statements showing

the applicant’s assets, liabilities and sources of financial support;

      9.  The proposed method of marketing the

plan, a financial plan which includes a 3-year projection of the initial

operating results anticipated and the sources of working capital and any other

sources of funding;

      10.  A power of attorney, executed by the

applicant, appointing the Commissioner and the authorized deputies of the

Commissioner as the true and lawful attorney of such applicant in and for this

State upon whom all lawful process in any legal action or proceeding against

the health maintenance organization on a cause of action arising in this State

may be served;

      11.  A statement reasonably describing the

geographic area to be served;

      12.  A description of the procedures for

resolving complaints and procedures for external reviews to be used as required

under NRS 695C.260;

      13.  A description of the procedures and

programs to be implemented to meet the quality of health care requirements in NRS 695C.080;

      14.  A description of the mechanism by

which enrollees will be afforded an opportunity to participate in matters of

program content under subsection 2 of NRS 695C.110;

and

      15.  Such other information as the

Commissioner may require to make the determinations required in NRS 695C.080.

      (Added to NRS by 1973, 1247; A 2003, 777)

      NRS 695C.080  Certificate of authority: Evaluation of application.

      1.  The Commissioner shall determine

whether the applicant for a certificate of authority, with respect to health

care services to be furnished:

      (a) Has demonstrated the willingness and ability

to ensure that such health care services will be provided in a manner to ensure

both availability and accessibility of adequate personnel and facilities and in

a manner enhancing availability, accessibility and continuity of service;

      (b) Has organizational arrangements, established

in accordance with regulations promulgated by the Commissioner and in

consultation with the State Board of Health; and

      (c) Has a procedure established in accordance

with regulations of the Commissioner to develop, compile, evaluate and report

statistics relating to the cost of its operations, the pattern of utilization

of its services, the availability and accessibility of its services and such

other matters as may be reasonably required by the Commissioner.

      2.  Within 90 days of receipt of the

application for issuance of a certificate of authority, the Commissioner shall

certify whether the proposed health maintenance organization meets the

requirements of subsection 1. If the Commissioner certifies that the health

maintenance organization does not meet such requirements, it shall specify in

what respects it is deficient.

      (Added to NRS by 1973, 1249; A 2013, 3639)

      NRS 695C.090  Certificate of authority: Issuance.  The

Commissioner shall issue or deny a certificate of authority to any person

filing an application pursuant to NRS 695C.060

within 90 days after certification. Issuance of a certificate of authority must

be granted upon payment of the fees prescribed in NRS

695C.230 if the Commissioner is satisfied that the following conditions are

met:

      1.  The persons responsible for the conduct

of the affairs of the applicant are competent, trustworthy and possess good

reputations.

      2.  The Commissioner certifies, in

accordance with NRS 695C.080, that the health

maintenance organization’s proposed plan of operation meets the requirements of

subsection 1 of NRS 695C.080.

      3.  The health care plan furnishes

comprehensive health care services.

      4.  The health maintenance organization is

financially responsible and may reasonably be expected to meet its obligations

to enrollees and prospective enrollees. In making this determination, the

Commissioner may consider:

      (a) The financial soundness of the health care

plan’s arrangements for health care services and the schedule of charges used

in connection therewith;

      (b) The adequacy of working capital;

      (c) Any agreement with an insurer, a government,

or any other organization for insuring the payment of the cost of health care

services;

      (d) Any agreement with providers for the

provision of health care services; and

      (e) Any surety bond or deposit of cash or

securities submitted in accordance with NRS 695C.270

as a guarantee that the obligations will be duly performed.

      5.  The enrollees will be afforded an

opportunity to participate in matters of program content pursuant to NRS 695C.110.

      6.  Nothing in the proposed method of

operation, as shown by the information submitted pursuant to NRS 695C.060, 695C.070

and 695C.140, or by independent investigation is

contrary to the public interest.

      (Added to NRS by 1973, 1249; A 1987, 469; 1993, 2400; 2013, 3640)

      NRS 695C.100  Certificate of authority: Denial.  A

certificate of authority shall be denied only after compliance with the

requirements of NRS 695C.340.

      (Added to NRS by 1973, 1250)

      NRS 695C.110  Governing body: Composition; participation by enrollees.

      1.  The governing body of any health

maintenance organization may include providers, other individuals or both.

      2.  Such governing body shall establish a

mechanism to afford the enrollees an opportunity to participate in matters of

program content through the establishment of advisory panels, by the use of

advisory referenda on major policy decisions or through the use of other

mechanisms. In addition there shall be a provider advisory board to advise the

health plan in the matter of quality of care. There shall be a joint board of

consumers and providers to advise on consumer satisfaction.

      (Added to NRS by 1973, 1250)

      NRS 695C.120  Powers of organization.  The

powers of a health maintenance organization include, but are not limited to,

the following:

      1.  The purchase, lease, construction,

renovation, operation or maintenance of hospitals, medical facilities, or both,

and their ancillary equipment, and such property as may reasonably be required

for its principal office or for such other purposes as may be necessary in the

transaction of the business of the organization;

      2.  The making of loans to a medical group

under contract with it in furtherance of its program or the making of loans to

a corporation under its control for the purpose of acquiring or constructing

medical facilities and hospitals or in furtherance of a program providing

health care services to enrollees;

      3.  The furnishing of health care service

through providers which are under contract with or employed by the health

maintenance organization;

      4.  The contracting with any person for the

performance on its behalf of certain functions such as marketing, enrollment

and administration; and

      5.  The contracting with an insurance

company licensed in this state or authorized to do business in this state for

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

of health care services provided by the health maintenance organization.

      (Added to NRS by 1973, 1250; A 1995, 2166; 1999, 1834)

      NRS 695C.123  Contracts with certain federally qualified health centers.

      1.  Except as otherwise provided in NRS 422.273, a health maintenance

organization that furnishes health care services through providers which are

under contract with the organization shall use its best efforts to contract

with at least one health center in each geographic area served by the

organization to provide such services to enrollees if the health center:

      (a) Meets all conditions imposed by the

organization on similarly situated providers of health care that are under

contract with the organization, including, without limitation:

             (1) Certification for participation in the

Medicaid or Medicare program; and

             (2) Requirements relating to the

appropriate credentials for providers of health care; and

      (b) Agrees to reasonable reimbursement rates that

are generally consistent with those offered by the organization to similarly

situated providers of health care that are under contract with the

organization.

      2.  As used in this section, “health

center” has the meaning ascribed to it in 42 U.S.C. § 254b.

      (Added to NRS by 2001, 1924)

      NRS 695C.125  Contract between health maintenance organization and provider of

health care: Form to obtain information on provider of health care;

modification; provision of schedule of fees.

      1.  A health maintenance organization shall

not contract with a provider of health care to provide health care to an

insured unless the health maintenance organization 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.

      2.  A contract between a health maintenance

organization 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 health maintenance organization upon giving to the provider

45 days’ written notice of the modification of the health maintenance

organization’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).

      3.  If a health maintenance organization

contracts with a provider of health care to provide health care to an enrollee,

the health maintenance organization 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.

      4.  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, 1651; A 2001, 2735; 2003, 3367; 2011, 2535)

      NRS 695C.128  Contracts to provide services pursuant to certain state

programs: Payment of interest on claims.  Any

contract or other agreement entered into or renewed by a health maintenance

organization on or after October 1, 2001:

      1.  To provide health care services through

managed care to recipients of Medicaid under the state plan for Medicaid; or

      2.  With the Division of Health Care

Financing and Policy of the Department of Health and Human Services to provide

insurance pursuant to the Children’s Health Insurance Program,

Ê must require

the health maintenance organization to pay interest to a provider of health

care services on a claim that is not paid within the time provided in the

contract or agreement 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.

      (Added to NRS by 2001, 2734)

      NRS 695C.130  Notice and approval required for exercise of powers; rules or

regulations.

      1.  A health maintenance organization shall

file notice, with adequate supporting information, with the Commissioner prior

to the exercise of any power granted in subsections 1 and 2 of NRS 695C.120. The Commissioner shall disapprove such

exercise of power if in the opinion of the Commissioner it would substantially

and adversely affect the financial soundness of the health maintenance

organization and endanger its ability to meet its obligations. If the

Commissioner does not disapprove within 60 days of the filing, it is deemed

approved.

      2.  The Commissioner may promulgate rules

or regulations.

      (Added to NRS by 1973, 1250)

      NRS 695C.140  Notice and approval required for modification of operations;

regulations.

      1.  A health maintenance organization

shall, unless otherwise provided for in this chapter, file notice with the

Commissioner before any material modification of the operations described in

the information required by NRS 695C.070. If the

Commissioner does not disapprove within 90 days after filing of the notice, the

modification is deemed approved.

      2.  The Commissioner may adopt regulations

to carry out the provisions of this section.

      (Added to NRS by 1973, 1248; A 1995, 1632; 2013, 3640)

      NRS 695C.145  Accounting principles required for certain reports and

transactions; health maintenance organization subject to requirements for

certain insurers.

      1.  A health maintenance organization shall

use accounting principles that are recognized by the laws of this state or

approved by the Commissioner for:

      (a) All financial reports;

      (b) The accounting of investments and deposits;

and

      (c) Transactions between affiliates and holding

companies.

      2.  A health maintenance organization is

subject to the requirements for insurers for:

      (a) Administrators, agents, brokers and

solicitors, pursuant to chapter 683A of

NRS;

      (b) Borrowing, pursuant to NRS 693A.180;

      (c) Impairment of capital, surplus or assets,

pursuant to NRS 693A.260, 693A.270 and 693A.280;

      (d) Management and agency contracts executed on

or after January 1, 1992; and

      (e) Officers, pursuant to NRS 693A.120 and 693A.130.

      3.  A domestic health maintenance

organization is subject to the requirements for insurers for corporations

pursuant to NRS 693A.040 to 693A.070, inclusive.

      (Added to NRS by 1991, 2036)

      NRS 695C.150  Fiduciary responsibilities.  Any

director, officer, partner, member or employee of a health maintenance

organization who receives, collects, disburses or invests funds in connection

with the activities of such organization shall be responsible for such funds in

a fiduciary relationship to the enrollees.

      (Added to NRS by 1973, 1250)

      NRS 695C.160  Investments.  With

the exception of investments made in accordance with subsections 1 and 2 of NRS 695C.120 and NRS

695C.130, the investable funds of a health maintenance organization shall

be invested only in securities or other investments permitted by the laws of

this state for the investment of assets constituting the legal reserves of life

insurance companies or such other securities or investments as the Commissioner

may permit.

      (Added to NRS by 1973, 1253)

ELIGIBILITY FOR COVERAGE

      NRS 695C.161  Eligibility for coverage: Definitions.  As

used in NRS 695C.161 to 695C.169,

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 health

care plan to a child pursuant to the provisions of 42 U.S.C. § 1396g-1.

      (Added to NRS by 1995, 2435)

      NRS 695C.163  Eligibility for coverage: Effect of eligibility for medical

assistance under Medicaid; assignment of rights to state agency.

      1.  A health maintenance organization shall

not, when considering eligibility for coverage or making payments under a

health care plan, consider the availability of, or eligibility of a person for,

medical assistance under Medicaid.

      2.  To the extent that payment has been

made by Medicaid for health care, a health maintenance organization:

      (a) Shall treat Medicaid as having a valid and

enforceable assignment of benefits due an enrollee or claimant under the

enrollee regardless of any exclusion of Medicaid or the absence of a written

assignment; and

      (b) May, as otherwise allowed by its plan,

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 enrollee.

      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 health care plan,

Ê the

organization responsible for the health care plan shall not impose any

requirements upon the state agency except requirements it imposes upon the

agents or assignees of other persons covered by the same plan.

      4.  If a state agency is assigned any

rights of an enrollee who is eligible for medical assistance under Medicaid, a

health maintenance organization shall:

      (a) Upon request of the state agency, provide to

the state agency information regarding the enrollee to determine:

             (1) Any period during which the enrollee,

the spouse or a dependent of the enrollee may be or may have been covered by

the health care plan; and

             (2) The nature of the coverage that is or

was provided by the organization, including, without limitation, the name and

address of the enrollee and the identifying number of the health care plan;

      (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, 2435; A 2007, 2406)

      NRS 695C.165  Eligibility for coverage: Organization prohibited from asserting

certain grounds to deny enrollment of child pursuant to order if parent is

enrolled in health care plan.  An

organization shall not deny the enrollment of a child pursuant to an order for

medical coverage under a health care plan in which a parent of the child is

enrolled, 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 organization’s geographic area of service.

      (Added to NRS by 1995, 2436)

      NRS 695C.167  Eligibility for coverage: Certain accommodations to be made when

child is covered under health care plan of noncustodial parent.  If a child has coverage under a health care

plan in which a noncustodial parent of the child is enrolled, the organization

responsible for that plan 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 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 or an

agency of this or another state responsible for the administration of Medicaid.

      (Added to NRS by 1995, 2436)

      NRS 695C.169  Eligibility for coverage: Organization to authorize enrollment

of child of parent who is required by order to provide medical coverage under

certain circumstances; termination of coverage of child.  If a parent is required by an order for

medical coverage to provide coverage for a child and the parent is eligible for

coverage of members of the parent’s family under a health care plan, the

organization responsible for that plan:

      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 organization 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, 2436)

COVERAGE GENERALLY

      NRS 695C.1691  Required provision concerning coverage for continued medical

care.

      1.  The provisions of this section apply to

a health care plan offered or issued by a health maintenance organization if an

insured covered by the health care plan receives health care through a defined

set of providers of health care who are under contract with the health

maintenance organization.

      2.  Except as otherwise provided in this

section, if an insured who is covered by a health care plan described in

subsection 1 is receiving medical treatment for a medical condition from a

provider of health care whose contract with the health maintenance organization

is terminated during the course of the medical treatment, the health care plan

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 health maintenance organization 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 health

maintenance organization 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 health maintenance organization; 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 health maintenance

organization.

      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 health maintenance organization and the health maintenance

organization terminated that contract because of the medical incompetence or

professional misconduct of the provider of health care; and

      (b) The health maintenance organization did not

enter into another contract with the provider of health care after the contract

was terminated pursuant to paragraph (a).

      5.  An evidence of coverage for a health

care plan 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

evidence of coverage 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, 3365)

      NRS 695C.1693  Required provision concerning coverage for treatment received as

part of clinical trial or study.

      1.  Except as otherwise provided in NRS 695C.050, a health care plan issued by a health

maintenance organization must provide coverage for medical treatment which an

enrollee 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 enrollee has signed, before participating

in the clinical trial or study, a statement of consent indicating that the

enrollee 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 enrollee.

      (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 health care plan.

      (c) The cost of any routine health care services

that would otherwise be covered under the health care plan for an enrollee in a

Phase I clinical trial or study.

      (d) The initial consultation to determine whether

the enrollee is eligible to participate in the clinical trial or study.

      (e) Health care services required for the

clinically appropriate monitoring of the enrollee 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 enrollee 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 695C.1691, 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 health maintenance

organization has contracted for such services. If the health maintenance

organization has not contracted for the provision of such services, the health

maintenance organization shall pay the provider the rate of reimbursement that

is paid to other providers with whom the health maintenance organization 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 an enrollee 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 enrollee.

      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 enrollee’s health care plan, 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 enrollee 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 enrollee.

      (h) Any costs for the management of research

relating to the clinical trial or study.

      5.  A health maintenance organization that

delivers or issues for delivery a health care plan 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 enrollee,

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.  A health maintenance organization that

delivers or issues for delivery a health care plan specified in subsection 1

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 plan.

      7.  A health care plan 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 plan that conflicts with

this section is void.

      8.  A health maintenance organization that

delivers or issues for delivery a health care plan specified in subsection 1 is

immune from liability for:

      (a) Any injury to an enrollee caused by:

             (1) Any medical treatment provided to the

enrollee 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 enrollee 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 enrollee’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, 3528; A 2005, 2018; 2013, 3641)

      NRS 695C.1694  Required provision concerning coverage of drug or device for

contraception and of hormone replacement therapy in certain circumstances; prohibited

actions by health maintenance organization; exceptions.

      1.  Except as otherwise provided in

subsection 5, a health maintenance organization which offers or issues a health

care plan that provides coverage for prescription drugs or devices shall include

in the plan 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.  A health maintenance organization that

offers or issues a health care plan that provides coverage for prescription

drugs shall not:

      (a) Require an enrollee 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 plan;

      (b) Refuse to issue a health care plan or cancel

a health care plan solely because the person applying for or covered by the

plan 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 enrollee to discourage the enrollee 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 enrollee, 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 enrollee.

      3.  Except as otherwise provided in

subsection 5, evidence of coverage 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 evidence of coverage or the renewal which is in conflict

with this section is void.

      4.  The provisions of this section do not:

      (a) Require a health maintenance organization to

provide coverage for fertility drugs.

      (b) Prohibit a health maintenance organization

from requiring an enrollee 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 enrollee is required to pay for other prescription drugs covered by the

plan.

      5.  A health maintenance organization which

offers or issues a health care plan and which is affiliated with a religious

organization is not required to provide the coverage required by paragraph (a)

of subsection 1 if the health maintenance organization objects on religious

grounds. The health maintenance organization shall, before the issuance of a

health care plan and before renewal of enrollment in such a plan, provide to

the group policyholder or prospective enrollee, as applicable, written notice

of the coverage that the health maintenance organization refuses to provide

pursuant to this subsection. The health maintenance organization shall provide

notice to each enrollee, at the time the enrollee receives his or her evidence

of coverage, that the health maintenance organization refused to provide

coverage pursuant to this subsection.

      6.  If a health maintenance organization

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, 2001)

      NRS 695C.1695  Required provision concerning coverage of health care services

related to contraceptives and hormone replacement therapy in certain

circumstances; prohibited actions by health maintenance organization;

exceptions.

      1.  Except as otherwise provided in

subsection 5, a health maintenance organization that offers or issues a health

care plan which provides coverage for outpatient care shall include in the plan

coverage for any health care service related to contraceptives or hormone

replacement therapy.

      2.  A health maintenance organization that

offers or issues a health care plan that provides coverage for outpatient care

shall not:

      (a) Require an enrollee 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 plan;

      (b) Refuse to issue a health care plan or cancel

a health care plan solely because the person applying for or covered by the

plan 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 enrollee to discourage the enrollee 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 enrollee, 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 enrollee.

      3.  Except as otherwise provided in

subsection 5, evidence of coverage 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 evidence of coverage or the renewal which is in conflict

with this section is void.

      4.  The provisions of this section do not

prohibit a health maintenance organization from requiring an enrollee to pay a

deductible, copayment or coinsurance for the coverage required by subsection 1

that is the same as the enrollee is required to pay for other outpatient care

covered by the plan.

      5.  A health maintenance organization which

offers or issues a health care plan 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 health maintenance

organization objects on religious grounds. The health maintenance organization

shall, before the issuance of a health care plan and before renewal of

enrollment in such a plan, provide to the group policyholder or prospective

enrollee, as applicable, written notice of the coverage that the health

maintenance organization refuses to provide pursuant to this subsection. The

health maintenance organization shall provide notice to each enrollee, at the

time the enrollee receives his or her evidence of coverage, that the health

maintenance organization refused to provide coverage pursuant to this

subsection.

      6.  If a health maintenance organization

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, 2002)

      NRS 695C.170  Evidence of coverage: Issuance; form and contents.

      1.  Every enrollee residing in this state

is entitled to evidence of coverage under a health care plan. If the enrollee

obtains coverage under a health care plan through an insurance policy, whether

by option or otherwise, the insurer shall issue the evidence of coverage.

Otherwise, the health maintenance organization shall issue the evidence of

coverage.

      2.  Evidence of coverage or amendment

thereto must not be issued or delivered to any person in this state until a

copy of the form of the evidence of coverage or amendment thereto has been

filed with and approved by the Commissioner.

      3.  An evidence of coverage:

      (a) Must not contain any provisions or statements

which are unjust, unfair, inequitable, misleading, deceptive, which encourage

misrepresentation or which are untrue, misleading or deceptive as defined in

subsection 1 of NRS 695C.300; and

      (b) Must contain a clear and complete statement,

if a contract, or a reasonably complete summary if a certificate, of:

             (1) The health care services and the

insurance or other benefits, if any, to which the enrollee is entitled under

the health care plan;

             (2) Any limitations on the services, kind

of services, benefits, or kind of benefits, to be provided, including any

deductible or copayment feature;

             (3) Where and in what manner the services

may be obtained; and

             (4) The total amount of payment for health

care services and the indemnity or service benefits, if any, which the enrollee

is obligated to pay.

Ê Any

subsequent change may be evidenced in a separate document issued to the

enrollee.

      4.  A copy of the form of the evidence of

coverage to be used in this state and any amendment thereto is subject to the

requirements for filing and approval of subsection 2 unless it is subject to

the jurisdiction of the Commissioner under the laws governing health insurance,

in which event the provisions for filing and approval of those laws apply. To

the extent that such provisions do not apply to the requirements in subsection

3, such provisions are amended to incorporate the requirements of subsection 3

in approving or disapproving an evidence of coverage required by subsection 2.

      (Added to NRS by 1973, 1251; A 1975, 1852; 1979, 1182; 1983, 2041; 2009, 1817)

      NRS 695C.1703  Coverage for prescription drugs: Provision of notice and

information regarding use of formulary.

      1.  A health maintenance organization or

insurer that offers or issues evidence of coverage which provides coverage for

prescription drugs shall include with any evidence of that coverage provided to

an enrollee, notice of whether a formulary is used and, if so, of the

opportunity to secure information regarding the formulary from the organization

or 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

organization or insurer for making a request for information regarding the formulary

pursuant to subsection 2.

      2.  If a health maintenance organization or

insurer offers or issues evidence of coverage which provides coverage for

prescription drugs and a formulary is used, the organization or insurer shall:

      (a) Provide to any enrollee 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 organization or 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, 863)

      NRS 695C.1705  Group health care plan issued to replace discontinued policy or

coverage: Requirements; notice of reduction of benefits; statement of benefits;

applicability to self-insured employer.  Except

as otherwise provided in the provisions of NRS

689B.340 to 689B.580, inclusive,

and chapter 689C of NRS relating to the

portability and accountability of health insurance:

      1.  A group health care plan issued by a

health maintenance organization 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 plan

is issued within 60 days after the date on which the previous policy or

coverage was discontinued.

      2.  If an employer obtains a replacement

plan 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 pursuant to NRS 608.1577.

      3.  Any health maintenance organization

which issues a replacement plan pursuant to subsection 1 may submit a written

request to the insurer which 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 shall give a written statement to the

organization indicating what benefits were provided and what exclusions or

reductions were in effect under the previous policy or coverage.

      4.  If an employee or enrollee was a

recipient of benefits under the coverage provided pursuant to NRS 695C.1709, the employee or enrollee is not

entitled to have issued to him or her by a health maintenance organization a

replacement plan unless the employee or enrollee has reported for his or her

normal employment for a period of 90 consecutive days after last being eligible

to receive any benefits under the coverage provided pursuant to NRS 695C.1709.

      5.  The provisions of this section apply to

a self-insured employer who provides health benefits to the employees of the

self-insured employer and replaces those benefits with a group health care plan

issued by a health maintenance organization.

      (Added to NRS by 1987, 850; A 1989, 1253; 1997, 2958; 2013, 3644)

      NRS 695C.1707  Required provision for continuation of coverage.  Repealed. (See chapter 541, Statutes of Nevada

2013, at page 3661.)

 

      NRS 695C.1709  Required provision concerning coverage for enrollee 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

enrollee, because of an injury or illness, to perform substantially the duties

related to his or her employment for which the enrollee is otherwise qualified.

      2.  No policy of group insurance to which

an enrollee is entitled under a health care plan provided by a health

maintenance organization may be delivered or issued for delivery in this state

unless it provides continuing coverage for an enrollee and dependents of the

enrollee who are otherwise covered by the policy while the enrollee is on leave

without pay as a result of a total disability. The coverage must be for any

injury or illness suffered by the enrollee which is not related to the total

disability or for any injury or illness suffered by a dependent of the

enrollee. The coverage 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

enrollee is terminated;

      (b) The date on which the enrollee obtains another

policy of health insurance;

      (c) The date on which the policy of group

insurance is terminated; or

      (d) After a period of 12 months in which benefits

under such coverage are provided to the enrollee,

Ê whichever

occurs first.

      (Added to NRS by 1989, 1253)

      NRS 695C.171  Required provision concerning coverage relating to mastectomy.

      1.  A health maintenance plan 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, but is not limited to, augmentation

mammoplasty, reduction mammoplasty and mastopexy.

      (Added to NRS by 1983, 615; A 1989, 1891; 2001, 2250)

      NRS 695C.1713  Required provision concerning coverage of certain gynecological

and obstetrical services without authorization or referral from primary care

physician.

      1.  A health care plan must include a provision

authorizing a woman covered by the plan 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 health care plan to designate an obstetrician or

gynecologist as her primary care physician.

      3.  An evidence of coverage 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 evidence of coverage 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 695C.1717  Required provision concerning coverage for autism spectrum

disorders.

      1.  A health care plan issued by a health

maintenance organization must provide coverage for screening for and diagnosis

of autism spectrum disorders and for treatment of autism spectrum disorders to

persons covered by the health care plan 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 health care plan

to the same extent as other medical services or prescription drugs covered by

the plan.

      3.  A health care plan issued by a health

maintenance organization that provides coverage for outpatient care shall not:

      (a) Require an enrollee 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 plan; or

      (b) Refuse to issue a health care plan or cancel

a health care plan solely because the person applying for or covered by the

plan uses or may use in the future any of the services listed in subsection 1.

      4.  Except as provided in subsections 1 and

2, a health maintenance organization shall not limit the number of visits an

enrollee 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 A health

maintenance organization may request a copy of and review a treatment plan

created pursuant to this subsection.

      6.  Evidence of coverage 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 evidence of coverage or the

renewal which is in conflict with subsection 1 or 2 is void.

      7.  Nothing in this section shall be

construed as requiring a health maintenance organization 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, 1471)

      NRS 695C.172  Required provision concerning coverage relating to complications

of pregnancy.

      1.  No health maintenance organization may

issue evidence of coverage under a health care plan to any enrollee 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 and complies with the provisions of NRS 689B.340 to 689B.580, inclusive, and chapter 689C of NRS relating to the

portability and accountability of health insurance.

      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.  Evidence of coverage under a health

care plan subject to the provisions of this chapter which is issued on or after

July 1, 1977, has the legal effect of including the coverage required by this

section, and any provision which is in conflict with this section is void.

      (Added to NRS by 1977, 416; A 1997, 2959; 2013, 3644)

      NRS 695C.1723  Required provision concerning coverage for treatment of certain

inherited metabolic diseases.

      1.  A health maintenance plan 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 health

maintenance plan was purchased.

      3.  Any evidence of coverage 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 evidence of coverage 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, 1527)

      NRS 695C.1727  Required provision concerning coverage for management and

treatment of diabetes.

      1.  No evidence of coverage that provides

coverage for hospital, medical or surgical expenses may be delivered or issued

for delivery in this state unless the evidence of coverage 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 an evidence of coverage specified in subsection 1 shall provide the

coverage required by this section subject to the same deductible, copayment,

coinsurance and other such conditions for the evidence of coverage that are

required under the evidence of coverage.

      3.  Evidence of coverage 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 evidence of coverage 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 enrollee after the enrollee 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 enrollee and which

requires modification of the enrollee’s program of self-management of diabetes;

and

             (3) Training and education which is

medically necessary because of the development of new techniques and treatment

for diabetes.

      (c) “Diabetes” includes type I, type II and

gestational diabetes.

      (Added to NRS by 1997, 745; A 2013, 3645)

      NRS 695C.173  Required provision concerning coverage for newly born and

adopted children and children placed for adoption.

      1.  All individual and group health care

plans which provide coverage for a family member of the enrollee must as to

such coverage provide that the health care services applicable for children are

payable with respect to:

      (a) A newly born child of the enrollee 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 enrollee 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 plans

must provide the coverage specified in subsection 3, and must not exclude

premature births.

      2.  The evidence of coverage 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 charge, if any, must be furnished to the health maintenance

organization 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 preventive health care

services as well as 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.

      4.  A health maintenance organization shall

not restrict the coverage of a dependent child adopted or placed for adoption

solely because of a preexisting condition the child has at the time the child

would otherwise become eligible for coverage pursuant to that plan. Any

provision relating to an exclusion for a preexisting condition must comply with

NRS 689B.500 or 689C.190, as appropriate.

      5.  For covered services provided to the

child, the health maintenance organization shall reimburse noncontracted

providers of health care to an amount equal to the average amount of payment

for which the organization has agreements, contracts or arrangements for those

covered services.

      (Added to NRS by 1975, 1110; A 1989, 741; 1995, 2436; 1997, 2959)

      NRS 695C.1731  Required provision concerning coverage for screening for

colorectal cancer.

      1.  A health care plan issued by a health

maintenance organization 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.  An evidence of coverage for a health

care plan 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

evidence of coverage that conflicts with the provisions of this section is

void.

      (Added to NRS by 2003, 1335)

      NRS 695C.1733  Required provision concerning coverage for certain drugs for

treatment of cancer.  Except as

otherwise provided in NRS 695C.1693:

      1.  No evidence of coverage 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 evidence of coverage 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 enrollee.

      (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.  Any evidence of coverage 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 evidence of coverage that

conflicts with the provisions of this section is void.

      (Added to NRS by 1999, 761; A 2003, 3531)

      NRS 695C.17335  Required provision concerning coverage for orally administered

chemotherapy.

      1.  A health maintenance organization that

offers or issues a health care plan 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

such 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.  Evidence of coverage 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

evidence of coverage or the renewal which is in conflict with this section is

void.

      3.  Nothing in this section shall be

construed as requiring a health maintenance organization 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, 1999;

A 2013,

3659)

      NRS 695C.1734  Required provision concerning coverage for prescription drug

previously approved for medical condition of enrollee.

      1.  Except as otherwise provided in this

section, evidence of coverage 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 health maintenance organization or insurer for a medical condition of an

enrollee and the enrollee’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

enrollee; and

      (b) Is appropriately prescribed and considered

safe and effective for treating the medical condition of the enrollee.

      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 health maintenance organization or

insurer from charging a deductible, copayment or coinsurance for the provision

of benefits for prescription drugs to the enrollee 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 evidence of coverage that is medically

appropriate for the enrollee; 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 evidence of coverage.

      3.  Any provision of an evidence of

coverage 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, 863; A 2003, 2300)

      NRS 695C.1735  Required provision concerning coverage for cytologic screening

tests and mammograms for certain women.

      1.  A health

maintenance plan 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 health

maintenance plan 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, 1891; A 1997, 1730)

      NRS 695C.1745  Required provision concerning coverage for human papillomavirus

vaccine.

      1.  A health care plan of a health

maintenance organization 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 health care plan of a health

maintenance organization must not require an insured to obtain prior

authorization for any service provided pursuant to subsection 1.

      3.  Any evidence of coverage 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 evidence of coverage 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, 3239; A 2013, 3645)

      NRS 695C.1751  Required provision concerning coverage for prostate cancer

screening.

      1.  A health care plan of a health

maintenance organization 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 health care plan of a health

maintenance organization 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.  Any evidence of coverage for a health

care plan of a health maintenance organization 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 evidence of coverage or the

renewal which is in conflict with subsection 1 is void.

      (Added to NRS by 2007, 3239)

      NRS 695C.1755  Required provision concerning coverage for treatment of

temporomandibular joint.

      1.  Except as otherwise provided in this

section, no evidence of coverage 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 evidence of

coverage or by a claims settlement practice. An evidence of coverage 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 health maintenance organization 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 enrollee, but in

no case more than 50 percent of the maximum benefits provided by the evidence

of coverage for such treatment; and

      (b) Treatment which is medically necessary.

      3.  Any provision of an evidence of

coverage 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, 2139)

      NRS 695C.176  Required provision concerning coverage for hospice care.  Each health care plan must provide benefits

for hospice care.

      (Added to NRS by 1983, 1936; A 1985, 1779; 1989, 1033)

REIMBURSEMENT

      NRS 695C.1765  Reimbursement for acupuncture.  If

any evidence of coverage 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)

      NRS 695C.177  Reimbursement for treatments by licensed psychologist.  If any evidence of coverage provides coverage

for treatment of an illness which is within the authorized scope of the

practice of a qualified psychologist, the insured is entitled to reimbursement for

treatments by a psychologist who is licensed pursuant to chapter 641 of NRS.

      (Added to NRS by 1981, 576; A 1989, 1553)

      NRS 695C.1773  Reimbursement for treatment by licensed marriage and family

therapist or licensed clinical professional counselor.  If

any evidence of coverage 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, 2134; A 2007, 3094)

      NRS 695C.1775  Reimbursement for treatment by licensed associate in social

work, social worker, independent social worker or clinical social worker.  If any evidence of coverage 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 695C.178  Reimbursement for treatment by chiropractor.

      1.  If any evidence of coverage 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, 328)

      NRS 695C.1783  Reimbursement for treatment by podiatrist.

      1.  If any evidence of coverage 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 695C.1789  Reimbursement for treatment by licensed clinical alcohol and

drug abuse counselor.  If any

evidence of coverage 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, 3094)

      NRS 695C.179  Reimbursement for services provided by certain nurses;

prohibited limitations; exceptions.

      1.  If any evidence of coverage 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 evidence of coverage

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, 1448)

      NRS 695C.1795  Reimbursement to provider of medical transportation.

      1.  Except as otherwise provided in

subsection 3, every evidence of coverage 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 enrollee or the provider may submit

the claim for reimbursement. The provider shall not demand payment from the

enrollee until after that reimbursement has been granted or denied.

      3.  Subsection 1 does not apply to any

agreement between a health maintenance organization and a provider of medical

transportation for the direct payment by the organization for the provider’s

services.

      (Added to NRS by 1989, 1274)

MISCELLANEOUS PROVISIONS

      NRS 695C.180  Schedule of charges.  Repealed.

(See chapter 541, Statutes of Nevada 2013, at page 3661.)

 

      NRS 695C.185  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, a health maintenance organization shall approve or deny a claim

relating to a health care plan within 30 days after the health maintenance

organization receives the claim. If the claim is approved, the health

maintenance organization 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 health maintenance organization 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 health maintenance organization

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 health maintenance organization

shall notify the provider of health care services of all the specific reasons

for the delay in approving or denying the claim. The health maintenance

organization shall approve or deny the claim within 30 days after receiving the

additional information. If the claim is approved, the health maintenance

organization shall pay the claim within 30 days after it receives the

additional information. If the approved claim is not paid within that period,

the health maintenance organization shall pay interest on the claim in the

manner prescribed in subsection 1.

      3.  A health maintenance organization shall

not request a claimant to resubmit information that the claimant has already provided

to the health maintenance organization, unless the health maintenance

organization 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.  A health maintenance organization 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 health maintenance organization.

      7.  The Commissioner may require a health

maintenance organization to provide evidence which demonstrates that the health

maintenance organization 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 a

health maintenance organization is not in substantial compliance with the

requirements set forth in this section, the Commissioner may require the health

maintenance organization to pay an administrative fine in an amount to be

determined by the Commissioner. Upon a second or subsequent determination that

a health maintenance organization 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 health maintenance organization.

      (Added to NRS by 1991, 1331; A 1999, 1651; 2001, 2735; 2003, 3368)

      NRS 695C.187  Schedule for payment of claims: Mandatory inclusion in

arrangements for provision of health care.

      1.  A health maintenance organization shall

not:

      (a) Enter into any contract or agreement, or make

any other arrangements, with a provider for the provision of health care; or

      (b) Employ a provider pursuant to a contract, an

agreement or any other arrangement to provide health care,

Ê unless the

contract, agreement or other arrangement specifically provides that the health

maintenance organization and provider agree to the schedule for the payment of

claims set forth in NRS 695C.185.

      2.  Any contract, agreement or other

arrangement between a health maintenance organization and a provider that is

entered into or renewed on or after October 1, 2001, that does not specifically

include a provision concerning the schedule for the payment of claims as

required by subsection 1 shall be deemed to conform with the requirements of

subsection 1 by operation of law.

      (Added to NRS by 2001, 2734)

      NRS 695C.190  Commissioner may require submission of information.  The Commissioner may require the submission of

whatever relevant information the Commissioner deems necessary in determining

whether to approve or disapprove a filing made pursuant to NRS 695C.170 to 695C.200,

inclusive.

      (Added to NRS by 1973, 1252; A 1985, 1448; 1989, 1274)

      NRS 695C.193  Summary of coverage: Contents of disclosure; approval by

Commissioner; regulations.  Repealed.

(See chapter 541, Statutes of Nevada 2013, at page 3661.)

 

      NRS 695C.195  Summary of coverage: Copy to be provided before policy issued;

policy not to be offered unless summary approved by Commissioner.  Repealed. (See chapter 541, Statutes of Nevada

2013, at page 3661.)

 

      NRS 695C.200  Approval of forms and schedules.  The

Commissioner shall within a reasonable period approve any form if the

requirements of NRS 695C.170 are met. It is

unlawful to issue such form or to use such schedule of charges until approved.

If the Commissioner disapproves such filing, the Commissioner shall notify the

filer. In the notice, the Commissioner shall specify the reasons for

disapproval. A hearing will be granted within 90 days after a request in

writing by the person filing.

      (Added to NRS by 1973, 1251; A 2013, 3646)

      NRS 695C.201  Offering policy of health insurance for purposes of establishing

health savings account.  A health

maintenance organization 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, 2158)

      NRS 695C.203  Denying coverage solely because person was victim of domestic

violence prohibited.  A health

maintenance organization shall not deny a claim, refuse to issue a policy or cancel

a policy 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 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 695C.205  Denying coverage solely because insured was intoxicated or under

the influence of controlled substance prohibited; exceptions.

      1.  Except as otherwise provided in

subsection 2, a health maintenance organization shall not:

      (a) Deny a claim under a health care plan solely

because the claim involves an injury sustained by an enrollee as a consequence

of being intoxicated or under the influence of a controlled substance.

      (b) Cancel participation under a health care plan

solely because an enrollee has made a claim involving an injury sustained by

the enrollee as a consequence of being intoxicated or under the influence of a

controlled substance.

      (c) Refuse participation under a health care plan

to an eligible applicant solely because the applicant has made a claim

involving an injury sustained by the applicant as a consequence of being

intoxicated or under the influence of a controlled substance.

      2.  The provisions of subsection 1 do not

prohibit a health maintenance organization from enforcing a provision included

in a health care plan 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 participation under a health care plan

solely because of such a claim; or

      (c) Refuse participation under a health care plan

to an eligible applicant solely because of such a claim.

      3.  The provisions of this section do not

apply to a health maintenance organization under a health care plan that

provides coverage for long-term care or disability income.

      (Added to NRS by 2005, 2345; A 2007, 86)

      NRS 695C.207  Requiring or using information concerning genetic testing.

      1.  A health maintenance organization shall

not:

      (a) Require an enrollee or any member of the

family of the enrollee to take a genetic test;

      (b) Require an enrollee to disclose whether the

enrollee or any member of the family of the enrollee has taken a genetic test

or the genetic information of the enrollee or a member of the family of the

enrollee; or

      (c) Determine the rates or any other aspect of

the coverage or benefits for health care provided to an enrollee based on:

             (1) Whether the enrollee or any member of

the family of the enrollee has taken a genetic test; or

             (2) Any genetic information of the

enrollee or any member of the family of the enrollee.

      2.  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 which 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, 1461)

      NRS 695C.210  Annual report and financial statement required; administrative

penalty for failure to file report or statement.

      1.  Every health maintenance organization

shall file with the Commissioner on or before March 1 of each year a report

showing its financial condition on the last day of the preceding calendar year.

The report must be verified by at least two principal officers of the

organization.

      2.  The report must be on forms prescribed

by the Commissioner and must include:

      (a) A financial statement of the organization,

including its balance sheet and receipts and disbursements for the preceding

calendar year;

      (b) Any material changes in the information

submitted pursuant to NRS 695C.070;

      (c) The number of persons enrolled during the

year, the number of enrollees as of the end of the year, the number of

enrollments terminated during the year and, if requested by the Commissioner, a

compilation of the reasons for such terminations;

      (d) The number and amount of malpractice claims

initiated against the health maintenance organization and any of the providers

used by it during the year broken down into claims with and without form of

legal process, and the disposition, if any, of each such claim, if requested by

the Commissioner;

      (e) A summary of information compiled pursuant to

paragraph (c) of subsection 1 of NRS 695C.080 in

such form as required by the Commissioner; and

      (f) Such other information relating to the

performance of the health maintenance organization as is necessary to enable

the Commissioner to carry out his or her duties pursuant to this chapter.

      3.  Every health maintenance organization

shall file with the Commissioner annually an audited financial statement of the

organization prepared by an independent certified public accountant. The

statement must cover the preceding 12-month period and must be filed with the

Commissioner within 120 days after the end of the organization’s fiscal year.

Upon written request, the Commissioner may grant a 30-day extension.

      4.  If an organization fails to file timely

the report or financial statement required by this section, it shall pay an

administrative penalty of $100 per day until the report or statement is filed,

except that the total penalty must not exceed $3,000. The Attorney General

shall recover the penalty in the name of the State of Nevada.

      5.  The Commissioner may grant a reasonable

extension of time for filing the report or financial statement required by this

section, if the request for an extension is submitted in writing and shows good

cause.

      (Added to NRS by 1973, 1252; A 1991, 2204; 1995, 1632, 2681; 2013, 3646)

      NRS 695C.220  Applications, filings and reports open to public inspection.  All applications, filings and reports required

under this chapter shall be treated as public documents except as otherwise

provided in this chapter.

      (Added to NRS by 1973, 1258)

      NRS 695C.230  Fees.

      1.  Every health maintenance organization

subject to this chapter shall pay to the Commissioner the following fees:

      (a) For filing an application for a certificate

of authority, $2,450.

      (b) For issuance of a certificate of authority,

$250.

      (c) For an amendment to a certificate of

authority, $100.

      (d) For the renewal of a certificate of

authority, $2,450.

      (e) For filing each annual report, $25.

      (f) In addition to any other fee or charge, all

applicable fees required pursuant to NRS

680C.110.

      2.  At the time of filing the annual report

the health maintenance organization shall forward to the department of taxation

the tax and any penalty for nonpayment or delinquent payment of the tax in

accordance with the provisions of chapter 680B

of NRS.

      3.  All fees paid pursuant to this section

shall be deemed earned when paid and may not be refunded.

      (Added to NRS by 1973, 1257; A 1987, 470; 1991, 1634; 1993, 1923; 2009, 1818)

      NRS 695C.240  Information required to be available for inspection.  Every health maintenance organization shall have

available for inspection the following information:

      1.  A current statement of financial

condition including a balance sheet and summary of receipts and disbursements;

      2.  A description of the organizational

structure and operation of the health maintenance organization and a summary of

any material changes since the issuance of the last report;

      3.  A description of services and

information as to where and how to secure them; and

      4.  A clear and understandable description

of the health maintenance organization’s method for resolving enrollee

complaints.

      (Added to NRS by 1973, 1252)

      NRS 695C.250  Open enrollment.  Repealed.

(See chapter 541, Statutes of Nevada 2013, at page 3661.)

 

      NRS 695C.260  Complaint system.  Each

health maintenance organization shall establish:

      1.  A system for resolving complaints which

complies with the provisions of NRS

695G.200 to 695G.230, inclusive;

and

      2.  A system for conducting external

reviews of adverse determinations that complies with the provisions of NRS 695G.241 to 695G.310, inclusive.

      (Added to NRS by 1973, 1253; A 1997, 311; 2003, 778; 2011, 3395)

      NRS 695C.265  Required procedure for arbitration of disputes concerning

independent medical evaluations.

      1.  If a health maintenance organization,

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 provided under the evidence of coverage:

      (a) The evidence of coverage must include a

procedure for binding arbitration to resolve disputes concerning independent

medical evaluations pursuant to the rules of the American Arbitration

Association; and

      (b) 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.

      2.  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

evidence of coverage within 30 days after the insured person receives the

finding of the evaluation. Upon its receipt of an appeal, the insurer shall so

notify in writing the primary treating physician or chiropractor.

      3.  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 2 concerning the appeal

of the insured person.

      (Added to NRS by 1989, 2116)

      NRS 695C.267  Provision requiring binding arbitration authorized; procedures

for arbitration; declaratory relief.

      1.  Except as otherwise provided in NRS 695C.265 and subject to the approval of the

Commissioner, a health maintenance organization may include in any evidence of

coverage issued by the organization a provision which requires an enrollee to

whom the evidence of coverage is issued and the health maintenance organization

to submit for binding arbitration any dispute between the enrollee and the

organization concerning any matter directly or indirectly related to, or

associated with, the evidence of coverage or the health care plan or health

care services of the health maintenance organization. If such a provision is

included in the evidence of coverage:

      (a) An enrollee must be given the opportunity to

decline to participate in binding arbitration at the time of his or her

enrollment.

      (b) It must clearly state that the health

maintenance organization and an enrollee 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

health maintenance organization is responsible for any administrative fees and

expenses relating to the arbitration, except that the health maintenance

organization 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 an enrollee, 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 any evidence of coverage issued by a health maintenance

organization, 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, 2559)

      NRS 695C.270  Bond required; waiver.  Each

health maintenance organization shall furnish a surety bond in an amount

satisfactory to the Commissioner or deposit with the Commissioner cash or

securities acceptable to the Commissioner in at least the same amount as a

guarantee that the obligations to the enrollees will be performed. The

Commissioner may waive this requirement whenever satisfied that the assets of

the organization and its contracts with insurers, governments, or other

organizations are sufficient to reasonably assure the performance of its

obligations.

      (Added to NRS by 1973, 1253)

      NRS 695C.275  Commissioner to adopt regulations for licensing of

provider-sponsored organizations.

      1.  To the extent authorized by federal

law, the Commissioner shall adopt regulations for the licensing of

provider-sponsored organizations in this State.

      2.  As used in this section,

“provider-sponsored organization” has the meaning ascribed to it in 42 U.S.C. §

1395w-25(d).

      (Added to NRS by 1999, 2817)

      NRS 695C.280  Commissioner authorized to adopt regulations for licensing of

agents or brokers.  The

Commissioner may adopt such reasonable regulations as are necessary to provide

for the licensing of agents or brokers. An agent is a person directly or

indirectly associated with a health care plan who engages in solicitation or

enrollment. A broker is a person who is directly involved with the insured in

the manner provided in chapter 683A of NRS.

      (Added to NRS by 1973, 1254; A 1981, 107; 1993, 2401)

      NRS 695C.290  Insurance company may establish or contract with health

maintenance organization.

      1.  An insurance company licensed in this

State may either directly or through a subsidiary or affiliate organize and

operate a health maintenance organization under the provisions of this chapter.

Notwithstanding any other law which may be inconsistent herewith, any two or

more such insurance companies or subsidiaries or affiliates thereof may jointly

organize and operate a health maintenance organization. The business of

insurance is deemed to include the providing of health care by a health

maintenance organization owned or operated by an insurer or a subsidiary

thereof.

      2.  An insurer may contract with a health

maintenance organization to provide insurance or similar protection against the

cost of care provided through health maintenance organizations and to provide

coverage in the event of the failure of the health maintenance organization to

meet its obligations. Among other things, under such contracts the insurer may

make benefit payments to health maintenance organizations for health care

services rendered by providers pursuant to the health care plan.

      (Added to NRS by 1973, 1254)

      NRS 695C.300  Prohibited practices.

      1.  No health maintenance organization or

representative thereof may cause or knowingly permit the use of advertising

which is untrue or misleading, solicitation which is untrue or misleading or

any form of evidence of coverage which is deceptive. For purposes of this

chapter:

      (a) A statement or item of information shall be

deemed to be untrue if it does not conform to fact in any respect which is or

may be significant to an enrollee of, or person considering enrollment in, a

health care plan.

      (b) A statement or item of information shall be

deemed to be misleading, whether or not it may be literally untrue if, in the

total context in which such statement is made or such item of information is

communicated, such statement or item of information may be reasonably

understood by a reasonable person not possessing special knowledge regarding

health care coverage, as indicating any benefit or advantage or the absence of

any exclusion, limitation or disadvantage of possible significance to an

enrollee of, or person considering enrollment in, a health care plan if such

benefit or advantage or absence of limitation, exclusion or disadvantage does

not in fact exist.

      (c) An evidence of coverage shall be deemed to be

deceptive if the evidence of coverage taken as a whole, and with consideration

given to typography and format as well as language, shall be such as to cause a

reasonable person not possessing special knowledge regarding health care plans

and evidences of coverage therefor to expect benefits, services, charges or

other advantages which the evidence of coverage does not provide or which the

health care plan issuing such evidence of coverage does not regularly make

available for enrollees covered under such evidence of coverage.

      2.  NRS

686A.010 to 686A.310, inclusive,

shall be construed to apply to health maintenance organizations, health care

plans and evidences of coverage except to the extent that the nature of health

maintenance organizations, health care plans and evidences of coverage render

the sections therein clearly inappropriate.

      3.  An enrollee may not be cancelled or not

renewed except for the failure to pay the charge for such coverage or for cause

as determined in the master contract.

      4.  No health maintenance organization,

unless licensed as an insurer, may use in its name, contracts, or literature

any of the words “insurance,” “casualty,” “surety,” “mutual” or any other words

descriptive of the insurance, casualty or surety business or deceptively

similar to the name or description of any insurance or surety corporation doing

business in this State.

      5.  No person not certificated under this

chapter shall use in its name, contracts or literature the phrase “health

maintenance organization” or the initials “HMO.”

      (Added to NRS by 1973, 1253)

      NRS 695C.310  Examinations.

      1.  The Commissioner shall make an

examination of the affairs of any health maintenance organization and providers

with whom such organization has contracts, agreements or other arrangements

pursuant to its health care plan as often as the Commissioner deems it

necessary for the protection of the interests of the people of this State. An

examination must be made not less frequently than once every 3 years.

      2.  The Commissioner shall make an

examination concerning the quality of health care services of any health

maintenance organization and providers with whom such organization has

contracts, agreements or other arrangements pursuant to its health care plan as

often as it deems necessary for the protection of the interests of the people

of this State. An examination must be made not less frequently than once every

3 years.

      3.  Every health maintenance organization

and provider shall submit its books and records relating to the health care

plan to an examination made pursuant to subsection 1 or 2 and in every way

facilitate the examination. Medical records of natural persons and records of

physicians providing service pursuant to a contract to the health maintenance

organization are not subject to such examination, although the records are

subject to subpoena upon a showing of good cause. For the purpose of

examinations, the Commissioner may administer oaths to, and examine the

officers and agents of the health maintenance organization and the principals

of such providers concerning their business.

      4.  The expenses of examinations pursuant

to this section must be assessed against the organization being examined and

remitted to the Commissioner.

      5.  In lieu of such examination, the

Commissioner may accept the report of an examination made by the insurance

commissioner or the state board of health of another state.

      (Added to NRS by 1973, 1255; A 1991, 2036; 2013, 3647)

      NRS 695C.311  Periodic examination by Commissioner to determine financial

condition of health maintenance organization.

      1.  For the purpose of determining its

financial condition, fulfillment of its contractual obligations and compliance

with law, the Commissioner shall, as often as the Commissioner deems advisable,

examine the affairs, transactions, accounts, records and assets of a health

maintenance organization and of any person as to any matter relevant to the

financial affairs of the health maintenance organization or to the examination.

Except as otherwise provided in this Code, the Commissioner shall examine each

health maintenance organization at least once every 3 years.

      2.  The Commissioner shall examine each

health maintenance organization applying for an initial certificate of

authority.

      3.  In lieu of making his or her own

examination, the Commissioner may, in the discretion of the Commissioner,

accept a full report of the last recent examination of a foreign or alien

health maintenance organization, certified to by the supervisory officer of

insurance of another state.

      4.  To the extent that it is practical, the

examination of a foreign or alien health maintenance organization must be made

in cooperation with the insurance supervisory officers of other states in which

the organization transacts business.

      (Added to NRS by 1991, 2035)

      NRS 695C.313  Financial examination: Procedure; appointment of examiner;

maintenance and use of records; penalty for obstruction or interference.

      1.  If the Commissioner determines to

examine a health maintenance organization pursuant to NRS

695C.311, the Commissioner shall designate one or more examiners and

instruct them as to the scope of the examination. The examiner shall, upon

demand, exhibit his or her official credentials to the health maintenance

organization being examined.

      2.  The Commissioner shall conduct each

examination in an expeditious, fair and impartial manner.

      3.  The Commissioner, or the examiner if

the examiner is authorized in writing by the Commissioner, may administer oaths

and examine under oath any person concerning any matter relevant to the

examination.

      4.  Every health maintenance organization

and its officers, attorneys, employees, agents and representatives shall make

available to the Commissioner or the examiners of the Commissioner the

accounts, records, documents, files, information, assets and matters of the

health maintenance organization in his or her possession or control relating to

the subject of the examination and shall facilitate the examination.

      5.  If the Commissioner or examiner finds

any accounts or records to be inadequate or inadequately kept or posted, he or

she shall so notify the health maintenance organization and give the health

maintenance organization a reasonable opportunity to reconstruct, rewrite, post

or balance the account or record. If the health maintenance organization fails

to maintain, complete or correct the records or accounting after the

Commissioner or examiner has given the health maintenance organization written

notice and a reasonable opportunity to do so, the Commissioner may employ

experts to reconstruct, rewrite, post or balance the account or record at the

expense of the health maintenance organization being examined.

      6.  The Commissioner or an examiner shall

not remove any record, account, document, file or other property of the health

maintenance organization being examined from the office or place of business of

the health maintenance organization unless the Commissioner or examiner has the

written consent of an officer of the health maintenance organization before the

removal or pursuant to an order of court. This provision does not prohibit the

Commissioner or examiner from making or removing copies or abstracts of a

record, account, document or file.

      7.  Any person who, without just cause,

refuses to be examined under oath or who willfully obstructs or interferes with

an examiner in the exercise of his or her authority is guilty of a misdemeanor.

      (Added to NRS by 1991, 2035)

      NRS 695C.315  Financial examination: Payment of expense.

      1.  The health maintenance organization

being examined shall pay the expense of an examination. The expenses to be paid

include only the reasonable and proper travel and lodging expenses of the

Commissioner and the examiners and assistants of the Commissioner, including

expert assistance, reasonable compensation to the examiners and assistants and

incidental expenses as necessarily incurred in the examination. The

Commissioner shall consider the scales and limitations recommended by the

National Association of Insurance Commissioners regarding the expense and

compensation for an examination.

      2.  The health maintenance organization

shall promptly pay to the Commissioner the expenses of the examination upon

presentation by the Commissioner of a reasonably detailed written statement

thereof.

      (Added to NRS by 1991, 2036)

      NRS 695C.317  Statutory procedures required for examination and hearing.  The Commissioner shall use the procedures

required by:

      1.  NRS

679B.230 to 679B.290, inclusive,

when conducting an examination of a health maintenance organization.

      2.  NRS

679B.310 to 679B.370, inclusive,

when conducting a hearing involving a health maintenance organization.

      (Added to NRS by 1991, 2036)

      NRS 695C.320  Rehabilitation, liquidation or conservation.  Any rehabilitation, liquidation or

conservation of a health maintenance organization shall be deemed to be the

rehabilitation, liquidation or conservation of an insurance company and shall

be conducted under the supervision of the Commissioner pursuant to the law

governing the rehabilitation, liquidation, or conservation of insurance companies.

      (Added to NRS by 1973, 1256)

      NRS 695C.325  Authorization to offer health care plan to small employer for

purpose of establishing medical savings accounts.  A

health maintenance organization may offer to a small employer who has not less

than 2 and not more than 50 employees, a health care plan that has a high

deductible and that is in compliance with 26 U.S.C. § 220 for the purposes of

establishing medical savings accounts for any person insured by the health care

plan.

      (Added to NRS by 1997, 2957)

      NRS 695C.330  Disciplinary proceedings: Grounds; effect of suspension or

revocation.

      1.  The Commissioner may suspend or revoke

any certificate of authority issued to a health maintenance organization

pursuant to the provisions of this chapter if the Commissioner finds that any

of the following conditions exist:

      (a) The health maintenance organization is

operating significantly in contravention of its basic organizational document,

its health care plan or in a manner contrary to that described in and

reasonably inferred from any other information submitted pursuant to NRS 695C.060, 695C.070

and 695C.140, unless any amendments to those

submissions have been filed with and approved by the Commissioner;

      (b) The health maintenance organization issues

evidence of coverage or uses a schedule of charges for health care services

which do not comply with the requirements of NRS

695C.1691 to 695C.200, inclusive, or 695C.207;

      (c) The health care plan does not furnish

comprehensive health care services as provided for in NRS

695C.060;

      (d) The Commissioner certifies that the health

maintenance organization:

             (1) Does not meet the requirements of

subsection 1 of NRS 695C.080; or

             (2) Is unable to fulfill its obligations

to furnish health care services as required under its health care plan;

      (e) The health maintenance organization is no

longer financially responsible and may reasonably be expected to be unable to

meet its obligations to enrollees or prospective enrollees;

      (f) The health maintenance organization has

failed to put into effect a mechanism affording the enrollees an opportunity to

participate in matters relating to the content of programs pursuant to NRS 695C.110;

      (g) The health maintenance organization has

failed to put into effect the system required by NRS

695C.260 for:

             (1) Resolving complaints in a manner

reasonably to dispose of valid complaints; and

             (2) Conducting external reviews of adverse

determinations that comply with the provisions of NRS 695G.241 to 695G.310, inclusive;

      (h) The health maintenance organization or any

person on its behalf has advertised or merchandised its services in an untrue,

misrepresentative, misleading, deceptive or unfair manner;

      (i) The continued operation of the health

maintenance organization would be hazardous to its enrollees;

      (j) The health maintenance organization fails to

provide the coverage required by NRS 695C.1691;

or

      (k) The health maintenance organization has

otherwise failed to comply substantially with the provisions of this chapter.

      2.  A certificate of authority must be

suspended or revoked only after compliance with the requirements of NRS 695C.340.

      3.  If the certificate of authority of a

health maintenance organization is suspended, the health maintenance

organization shall not, during the period of that suspension, enroll any

additional groups or new individual contracts, unless those groups or persons

were contracted for before the date of suspension.

      4.  If the certificate of authority of a

health maintenance organization is revoked, the organization shall proceed,

immediately following the effective date of the order of revocation, to wind up

its affairs and shall conduct no further business except as may be essential to

the orderly conclusion of the affairs of the organization. It shall engage in

no further advertising or solicitation of any kind. The Commissioner may, by

written order, permit such further operation of the organization as the

Commissioner may find to be in the best interest of enrollees to the end that

enrollees are afforded the greatest practical opportunity to obtain continuing

coverage for health care.

      (Added to NRS by 1973, 1255; A 1985, 1448; 1997, 745, 1462, 1629; 1999, 417, 419, 761, 2004; 2001, 141, 144; 2003, 778, 1336, 3369, 3532; 2007, 3240; 2009, 1474;

2011, 3395;

2013, 2000,

3647)

      NRS 695C.340  Disciplinary proceedings: Notice; hearing; judicial review.

      1.  When the Commissioner has cause to

believe that grounds for the denial of an application for a certificate of

authority exist, or that grounds for the suspension or revocation of a

certificate of authority exist, the Commissioner shall notify the health

maintenance organization in writing specifically stating the grounds for

denial, suspension or revocation and fixing a time at least 30 days thereafter

for a hearing on the matter.

      2.  After the hearing, or upon the failure

of the health maintenance organization to appear at the hearing, the

Commissioner shall take action as is deemed advisable on written findings which

must be mailed to the health maintenance organization. The action of the

Commissioner is subject to review by the First Judicial District Court of the

State of Nevada in and for Carson City. The court may, in disposing of the

issue before it, modify, affirm or reverse the order of the Commissioner in

whole or in part.

      (Added to NRS by 1973, 1256; A 1981, 107; 2013, 3649)

      NRS 695C.350  Violations: Remedies; penalties.

      1.  The Commissioner may, in lieu of

suspension or revocation of a certificate of authority under NRS 695C.330, levy an administrative penalty in an

amount not more than $2,500 for each act or violation, if reasonable notice in

writing is given of the intent to levy the penalty.

      2.  Any person who violates the provisions

of this chapter is guilty of a misdemeanor.

      3.  If the Commissioner for any reason has

cause to believe that any violation of this chapter has occurred or is

threatened, the Commissioner may give notice to the health maintenance

organization and to the representatives, or other persons who appear to be

involved in the suspected violation, to arrange a conference with the alleged

violators or their authorized representatives to attempt to determine the facts

relating to the suspected violation, and, if it appears that any violation has

occurred or is threatened, to arrive at an adequate and effective means of

correcting or preventing the violation.

      4.  The proceedings conducted pursuant to

the provisions of subsection 3 must not be governed by any formal procedural

requirements, and may be conducted in such manner as the Commissioner may deem

appropriate under the circumstances.

      5.  The Commissioner may issue an order

directing a health maintenance organization or a representative of a health

maintenance organization to cease and desist from engaging in any act or

practice in violation of the provisions of this chapter.

      6.  Within 30 days after service of the

order to cease and desist, the respondent may request a hearing on the question

of whether acts or practices in violation of this chapter have occurred. The

hearing must be conducted pursuant to the provisions of chapter 233B of NRS and judicial review must

be available as provided therein.

      7.  In the case of any violation of the

provisions of this chapter, if the Commissioner elects not to issue a cease and

desist order, or in the event of noncompliance with a cease and desist order

issued pursuant to subsection 5, the Commissioner may institute a proceeding to

obtain injunctive relief, or seek other appropriate relief in the district

court of the judicial district of the county in which the violator resides.

      (Added to NRS by 1973, 1257; A 1999, 2817; 2013, 3649)