[Rev. 11/21/2013 1:17:51 PM--2013]

CHAPTER 695B - NONPROFIT CORPORATIONS FOR HOSPITAL, MEDICAL AND DENTAL SERVICE

GENERAL PROVISIONS

NRS 695B.010        Short title.

NRS 695B.020        Scope.

NRS 695B.030        Definitions.

NRS 695B.035        Contract between corporation and provider of health care: Prohibiting corporation from charging provider of health care fee for inclusion on list of providers given to insureds; form for obtaining information on provider of health care; modification; schedule of fees.

ORGANIZATION

NRS 695B.040        Corporations authorized to undertake and operate plans.

NRS 695B.050        Manner of incorporation.

NRS 695B.060        Directors: Qualifications.

NRS 695B.070        Merger and consolidation: Procedure.

NRS 695B.080        Merger and consolidation: Continuance of contracts and contribution certificates.

NRS 695B.090        Merger and consolidation: Withdrawal of prior deposit of securities.

LICENSING; REGULATION

NRS 695B.110        Certificate of authority required; fees.

NRS 695B.120        Certificate of authority: Qualifications.

NRS 695B.130        Certificate of authority: Application; issuance.

NRS 695B.135        Certificate of authority: Expiration; renewal.

NRS 695B.140        Reserve fund: Minimum amounts; computation; contracts with hospitals; participation of physicians.

NRS 695B.150        Insolvency; determination of financial condition.

NRS 695B.160        Annual statement of condition and affairs; fees; examination by Commissioner.

NRS 695B.170        Acquisition costs and administrative expenses; effect of finding of excess costs.

NRS 695B.172        Summary of coverage: Contents of disclosure; approval by Commissioner.

NRS 695B.174        Summary of coverage: Copy to be provided before policy issued; policy not to be offered unless summary approved by Commissioner.

NRS 695B.176        Coverage for prescription drugs: Provision of notice and information regarding use of formulary.

CONTRACTS

General Provisions

NRS 695B.180        Required provisions.

NRS 695B.181        Provision in contract requiring binding arbitration authorized; procedures for arbitration; declaratory relief.

NRS 695B.182        Required procedure for arbitration of disputes concerning independent medical evaluations.

NRS 695B.185        Limitations on deductibles and copayments charged under group contract which offers difference of payment between preferred providers of health care and providers who are not preferred.

NRS 695B.187        Group contract issued to replace discontinued policy or coverage: Requirements; notice of reduction of benefits; statement of benefits; applicability to self-insured employer. [Effective through December 31, 2013.]

NRS 695B.187        Group contract issued to replace discontinued policy or coverage: Requirements; notice of reduction of benefits; statement of benefits; applicability to self-insured employer. [Effective January 1, 2014.]

NRS 695B.189        Continuation of coverage under group contract: Required provision. [Effective through December 31, 2013.]

NRS 695B.189        Continuation of coverage under group contract: Required provision. [Effective January 1, 2014.]

NRS 695B.190        Family contracts.

 

Coverage

NRS 695B.1901      Required provision concerning coverage for continued medical treatment.

NRS 695B.1903      Required provision concerning coverage for treatment as part of clinical trial or study.

NRS 695B.1905      Required provision concerning coverage for prescription drug previously approved for medical condition of insured.

NRS 695B.1907      Required provision concerning coverage for screening for colorectal cancer.

NRS 695B.1908      Required provision concerning coverage for certain drugs for treatment of cancer.

NRS 695B.1909      Required provision concerning coverage for orally administered chemotherapy.

NRS 695B.191        Required provision concerning coverage relating to mastectomy.

NRS 695B.1912      Required provision concerning coverage for cytologic screening tests and mammograms for certain women.

NRS 695B.1914      Required provision concerning coverage of certain gynecological and obstetrical services without authorization or referral from primary care physician.

NRS 695B.1916      Required provision concerning coverage of drug or device for contraception and of hormone replacement therapy in certain circumstances; prohibited actions by insurer; exceptions.

NRS 695B.1918      Required provision concerning coverage of health care services related to contraceptives and hormone replacement therapy in certain circumstances; prohibited actions by insurer; exceptions.

NRS 695B.192        Required provision concerning coverage relating to complications of pregnancy. [Effective through December 31, 2013.]

NRS 695B.192        Required provision concerning coverage relating to complications of pregnancy. [Effective January 1, 2014.]

NRS 695B.1923      Required provision concerning coverage for treatment of certain inherited metabolic diseases.

NRS 695B.1925      Required provision concerning coverage for human papillomavirus vaccine.

NRS 695B.1927      Required provision concerning coverage for management and treatment of diabetes.

NRS 695B.193        Required provision concerning coverage for newly born and adopted children and children placed for adoption.

NRS 695B.1931      Required provision concerning coverage relating to treatment of temporomandibular joint.

NRS 695B.1942      Required provision concerning coverage for prostate cancer screening.

NRS 695B.1944      Required provision concerning coverage for employee or member on leave without pay as result of total disability.

 

Reimbursement

NRS 695B.1951      Reimbursement for treatment by podiatrist.

NRS 695B.1955      Reimbursement for treatment by licensed clinical alcohol and drug abuse counselor.

NRS 695B.196        Reimbursement for acupuncture.

NRS 695B.197        Reimbursement for treatment by licensed psychologist.

NRS 695B.1973      Reimbursement for treatment by licensed marriage and family therapist or licensed clinical professional counselor.

NRS 695B.1975      Reimbursement for treatment by licensed associate in social work, social worker, independent social worker or clinical social worker.

NRS 695B.198        Reimbursement for treatment by chiropractor.

NRS 695B.199        Reimbursement for services provided by certain nurses; prohibited limitations; exception.

NRS 695B.1995      Reimbursement to provider of medical transportation.

 

Miscellaneous Provisions

NRS 695B.200        Group contracts written under master contract: Conditions required for issuance.

NRS 695B.210        Group master service contract: Required provisions.

NRS 695B.220        Blanket service contracts: Issuance to college, school or school personnel; pupils not to be compelled to accept service.

NRS 695B.225        Policies of group insurance: Order of benefits.

NRS 695B.230        Filing and approval of forms and schedules of premium rates.

NRS 695B.240        Provision of group service coverage before approval of forms.

NRS 695B.250        Extensions of time; automatic approval.

NRS 695B.2505      Approval or denial of claims; payment of claims and interest; requests for additional information; award of costs and attorney’s fees; compliance with requirements.

CONVERSION OF GROUP CONTRACTS TO INDIVIDUAL CONTRACTS

NRS 695B.251        Group subscriber contracts to contain provision for conversion to individual contracts; exceptions. [Effective through December 31, 2013.]

NRS 695B.251        Group subscriber contracts to contain provision for conversion to individual contracts; exceptions. [Effective January 1, 2014.]

NRS 695B.252        Conversion privilege available to spouse and children; conditions.

NRS 695B.253        Denial of converted contract because of overinsurance; notice concerning cancellation of other coverage.

NRS 695B.254        Choice of types of contracts must be offered.

NRS 695B.255        Benefits exceeding those provided under group contract not required; exclusions and limitations.

NRS 695B.2555      Benefits payable under converted contract may be reduced by amount payable under group contract.

NRS 695B.256        Issuance and effective date of converted contract; premiums; persons covered.

NRS 695B.2565      Renewal of converted contract: Request for information on sources of other benefits; grounds for refusal to renew; notice concerning cancellation of other coverage.

NRS 695B.257        Notice of conversion privilege.

NRS 695B.2575      Converted contract delivered outside Nevada: Form.

NRS 695B.258        Extension of coverage under existing group contract.

NRS 695B.2585      Group coverage may be provided in lieu of converted individual contract.

NRS 695B.259        Medical service corporation may continue identical coverage in lieu of converting contract. [Effective through December 31, 2013.]

NRS 695B.259        Medical service corporation may continue identical coverage in lieu of converting contract. [Effective January 1, 2014.]

MISCELLANEOUS PROVISIONS

NRS 695B.260        Suspension or revocation of permission to provide coverage before approval of forms.

NRS 695B.270        Disapproval of forms; issuance unlawful.

NRS 695B.280        Regulations; limitations.

NRS 695B.285        Use of Uniform Billing and Claims Forms authorized.

NRS 695B.290        Agent’s license required.

NRS 695B.300        Contracts with agencies or political subdivisions of United States or State of Nevada; acceptance of money; subcontracts.

NRS 695B.310        Corporation subject to same fees, licenses and supervision as domestic mutual insurer.

NRS 695B.315        Insurer to provide certain information regarding renewal of insurance policy upon request; fee.

NRS 695B.316        Corporation prohibited from denying coverage solely because person was victim of domestic violence.

NRS 695B.3165      Corporation prohibited from denying coverage solely because insured was intoxicated or under the influence of controlled substance; exceptions.

NRS 695B.317        Corporation that provides health insurance prohibited from requiring or using information concerning genetic testing; exceptions.

NRS 695B.318        Corporations are subject to certain provisions concerning portability and availability of health insurance. [Effective through December 31, 2013.]

NRS 695B.318        Corporations are subject to certain provisions concerning portability and availability of health insurance. [Effective January 1, 2014.]

NRS 695B.319        Offering policy of health insurance for purposes of establishing health savings account.

NRS 695B.320        Applicability of other provisions. [Effective through December 31, 2013.]

NRS 695B.320        Applicability of other provisions. [Effective January 1, 2014.]

ELIGIBILITY FOR COVERAGE

NRS 695B.330        Definitions.

NRS 695B.340        Effect of eligibility for medical assistance under Medicaid; assignment of rights to state agency.

NRS 695B.350        Corporation prohibited from asserting certain grounds to deny enrollment of child of insured pursuant to order.

NRS 695B.360        Certain accommodations to be made when child is covered under policy of noncustodial parent.

NRS 695B.370        Corporation to authorize enrollment of child of parent who is required by order to provide medical coverage under certain circumstances; termination of coverage of child.

SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS

NRS 695B.380        Approval; requirements; examination.

NRS 695B.390        Annual report; insurer to maintain records of complaints concerning something other than health care services.

NRS 695B.400        Written notice to insured explaining right to file complaint; notice to insured required when insurer denies coverage of health care service.

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GENERAL PROVISIONS

      NRS 695B.010  Short title.  This chapter may be cited as the Nonprofit Hospital, Medical and Dental Service Corporation Law.

      (Added to NRS by 1971, 1863)

      NRS 695B.020  Scope.

      1.  This chapter does not:

      (a) Apply to or govern any corporation which is organized for profit, which contemplates any pecuniary gain to its shareholders or members, or which conducts or is authorized by its articles of incorporation to conduct any business whatsoever on a profit basis.

      (b) Authorize and must not be construed to authorize, directly or indirectly, any corporation to operate a hospital or a medical or dental service plan on a profit basis.

      2.  Except as otherwise provided in subsection 3, a corporation subject to the provisions of this chapter shall not own or operate any hospital or engage in any business other than that of establishing, maintaining and operating a nonprofit hospital, medical or dental service plan.

      3.  A corporation subject to the provisions of this chapter may, with the approval of the Commissioner, engage in any business reasonably and necessarily incidental to the business of a nonprofit hospital, medical or dental service plan.

      (Added to NRS by 1971, 1863; A 1991, 654)

      NRS 695B.030  Definitions.  As used in this chapter:

      1.  “Dental services” means general and special dental services ordinarily provided by dentists licensed under the provisions of chapter 631 of NRS to practice in the State of Nevada in accordance with the generally accepted practices of the community at the time the service is rendered, and the furnishing of necessary appliances, drugs, medicines and supplies, prosthetic appliances, orthodontic appliances, metal, ceramic and other restorations.

      2.  “Hospital services” means the furnishing or providing of any or all of the following:

      (a) Maintenance and care in the hospital, including but not limited to, nursing care, drugs, medicines, supplies, physiotherapy, transportation and use of facilities and appliances.

      (b) Reimbursement of the beneficiary or subscriber for, but without requiring that the beneficiary or subscriber first pay, expenses incurred for any of the items included in paragraph (a).

      (c) Reimbursement, at a uniform rate, of the beneficiary or subscriber for, but without requiring that the beneficiary or subscriber first pay, the costs and expenses incurred for medical supplies.

      (d) Reimbursement for expenses incurred outside of the hospital for continued care and treatment following the subscriber’s discharge from the hospital, for nursing service, necessary appliances, drugs, medicines, supplies and any other services which would have been available in the hospital (excluding physicians’ services), whether or not provided through a hospital.

      (e) Reimbursement for ambulance service expenses.

      3.  “Medical services” means the furnishing or providing of any or all of the following:

      (a) Medical or surgical services, in or out of a hospital, by a physician licensed to practice under the laws of Nevada.

      (b) Reimbursement for expenses incurred for nursing services, necessary appliances, drugs, medicines, supplies and any other health care services.

      (Added to NRS by 1971, 1863; A 1977, 966)

      NRS 695B.035  Contract between corporation and provider of health care: Prohibiting corporation from charging provider of health care fee for inclusion on list of providers given to insureds; form for obtaining information on provider of health care; modification; schedule of fees.

      1.  A corporation subject to the provisions of this chapter shall not charge a provider of health care a fee to include the name of the provider on a list of providers of health care given by the corporation to its insureds.

      2.  A corporation specified in subsection 1 shall not contract with a provider of health care to provide health care to an insured unless the corporation uses the form prescribed by the Commissioner pursuant to NRS 629.095 to obtain any information related to the credentials of the provider of health care.

      3.  A contract between a corporation specified in subsection 1 and a provider of health care may be modified:

      (a) At any time pursuant to a written agreement executed by both parties.

      (b) Except as otherwise provided in this paragraph, by the corporation upon giving to the provider 45 days’ written notice of the modification of the corporation’s schedule of payments, including any changes to the fee schedule applicable to the provider’s practice. If the provider fails to object in writing to the modification within the 45-day period, the modification becomes effective at the end of that period. If the provider objects in writing to the modification within the 45-day period, the modification must not become effective unless agreed to by both parties as described in paragraph (a).

      4.  If a corporation specified in subsection 1 contracts with a provider of health care to provide health care to an insured, the corporation shall:

      (a) If requested by the provider of health care at the time the contract is made, submit to the provider of health care the schedule of payments applicable to the provider of health care; or

      (b) If requested by the provider of health care at any other time, submit to the provider of health care the schedule of payments, including any changes to the fee schedule applicable to the provider’s practice, specified in paragraph (a) within 7 days after receiving the request.

      5.  As used in this section, “provider of health care” means a provider of health care who is licensed pursuant to chapter 630, 631, 632 or 633 of NRS.

      (Added to NRS by 1999, 1650; A 2001, 2732; 2003, 3364; 2011, 2534)

ORGANIZATION

      NRS 695B.040  Corporations authorized to undertake and operate plans.  Any corporation which is organized under the laws of the State of Nevada, or the laws of any other state, without capital stock, for the purpose of maintaining and operating a hospital, medical or dental service plan, and which does not contemplate pecuniary gain or profit to its members, may undertake and operate a hospital, medical or dental service plan for rendering hospital, medical or dental service to its subscribers under and subject to the provisions of this chapter.

      (Added to NRS by 1971, 1864; A 1991, 654)

      NRS 695B.050  Manner of incorporation.  Persons desiring to form a nonprofit hospital, medical or dental service corporation shall incorporate pursuant to the provisions of this chapter, and the provisions of the nonprofit corporation laws of the State of Nevada, including NRS 81.410 to 81.540, inclusive, or chapter 82 of NRS, as applicable, so far as the provisions of such laws are applicable and not inconsistent with this chapter.

      (Added to NRS by 1971, 1864; A 2013, 1289)

      NRS 695B.060  Directors: Qualifications.

      1.  A majority of the board of directors of a corporation providing or rendering hospital services shall be persons who are not duly appointed representatives of hospitals with which the corporation has contracts for the rendering of hospital services.

      2.  A majority of the board of directors of a corporation providing medical services shall be persons who are not physicians or duly appointed representatives of the physicians who have signed participating agreements with the corporation for the rendering of medical services.

      3.  A majority of the board of directors of a corporation providing dental services shall be persons who are not dentists or duly appointed representatives of the dentists who have signed participating agreements with the corporation for the rendering of dental services.

      4.  This section does not apply to any duly appointed representative of a hospital, physician or dentist who is a member of the board of directors of a corporation on July 1, 1977. Such a person may continue to serve as a member of the board of directors until the term of the person expires.

      (Added to NRS by 1971, 1864; A 1971, 1956; 1977, 624)

      NRS 695B.070  Merger and consolidation: Procedure.  Any corporation operating under this chapter may merge and consolidate with any other corporation operating or to operate under this chapter as follows:

      1.  The agreement of merger and consolidation shall be submitted to and approved by a two-thirds vote of the members of the ceding corporation present in person or by proxy at a meeting called to consider that agreement. A written or printed notice of such meeting shall be mailed or personally delivered to each member at least 30 days before the day fixed for the meeting.

      2.  Before the merger and consolidation is effected, the corporation which proposes to assume the liabilities of the ceding corporation shall submit to its members the question of merger and consolidation and a similar notice shall be given and a similar vote required as in the case of members of the ceding corporation.

      3.  If the vote in the case of both corporations is in the affirmative by the required majority, a certified copy of all proceedings relating to the proposed merger and consolidation shall be filed with the Commissioner. If the Commissioner finds that the proceedings have been in accordance with law, the Commissioner shall approve the agreement.

      4.  Upon the approval by the Commissioner of such agreement, the consolidated corporation shall issue certificates of assumption to each and every subscriber of the ceding corporation. Such certificates shall be in a form approved by the Commissioner.

      5.  The approval of the Commissioner of the agreement of merger and consolidation shall operate to dissolve the ceding corporation, and all its liability upon its insurance contracts or benefit certificates shall thereupon cease, but its officers may thereafter perform any act necessary to close its affairs. The officers of the ceding corporation shall file a certified copy of the agreement in the Office of the Secretary of State. Such certified copy shall be in lieu of any certificate of dissolution required by the provisions of the general corporation law.

      6.  The consolidated corporation shall be entitled to all the assets of the ceding corporation and shall assume all its liabilities.

      (Added to NRS by 1971, 1865)

      NRS 695B.080  Merger and consolidation: Continuance of contracts and contribution certificates.  In the event of any merger and consolidation as provided by this chapter, contracts and contribution certificates issued in compliance with the provisions of this chapter and outstanding at the time of the date of the merger and consolidation may be continued in force, reinstated, renewed and repaid without change of provisions, except as such change may be necessary or advisable at or following the next renewal or reinstatement.

      (Added to NRS by 1971, 1865)

      NRS 695B.090  Merger and consolidation: Withdrawal of prior deposit of securities.  Upon approval by the Commissioner of any such merger and consolidation, the merged and consolidated corporation may withdraw any securities therefore deposited pursuant to any requirements of this chapter.

      (Added to NRS by 1971, 1866)

LICENSING; REGULATION

      NRS 695B.110  Certificate of authority required; fees.  A corporation shall not establish, maintain or operate a nonprofit service plan as authorized by the provisions of this chapter unless it has:

      1.  Procured a certificate of authority from the Commissioner for the establishment, maintenance and operation of the plan.

      2.  Paid to the Commissioner the fees required of insurers by NRS 680B.010 for:

      (a) The filing of the initial application;

      (b) The issuance of the certificate of authority;

      (c) Each annual continuation of the certificate of authority; and

      (d) The filing of each annual report.

      3.  Paid, in addition to any other fee or charge, all applicable fees required pursuant to NRS 680C.110.

      (Added to NRS by 1971, 1866; A 1987, 468; 2009, 1815)

      NRS 695B.120  Certificate of authority: Qualifications.  The Commissioner shall not issue or renew a certificate of authority to any corporation proposing to establish, maintain or operate a nonprofit hospital, medical or dental service plan until such corporation establishes:

      1.  If a nonprofit hospital service corporation, that it has entered into contracts with hospitals in the State of Nevada having an aggregate bed capacity sufficient to render the services contemplated to be furnished under the hospital service plan to persons in the State of Nevada.

      2.  That the hospital, medical or dental service contract proposed to be entered into by such corporation with those who may become subscribers is not such as will work a fraud or injustice upon such subscribers or any person.

      3.  That a schedule of the rates, dues, fees or other periodic charges to be paid by subscribers has been filed with the Commissioner and the same are not such as will, after providing for such legal reserves as are required by NRS 695B.140, result in profit to, or in the accumulation of excessive reserves or surpluses by, such corporation and are such as will enable such corporation to furnish or provide the hospital, medical or dental services which it proposes to make available to its beneficiaries and subscribers without impairment of its legal reserves and without a constant depletion of the assets of such corporation. A reserve or surplus over and above all approved and required reserves in an amount in excess of the average annual gross income of such corporation for the immediately preceding 3 calendar years shall be prima facie an excessive accumulation.

      (Added to NRS by 1971, 1866)

      NRS 695B.130  Certificate of authority: Application; issuance.

      1.  An application for a certificate of authority must be filed with the Commissioner in writing by the corporation for medical service which is applying for the certificate on forms furnished or accepted by the Commissioner. The application must set forth such information concerning the applicant and its qualifications and in other respects as the Commissioner may reasonably require.

      2.  The application must be accompanied by:

      (a) A copy of the applicant’s charter or articles of incorporation, certified by the public officer with whom the original is required to be filed in its state of domicile;

      (b) A copy of the applicant’s bylaws, certified by the corporate secretary;

      (c) A copy of each contract the applicant has made or proposed to make with hospitals, or physicians or dentists in this state;

      (d) A copy of each service contract proposed to be issued to its subscribers in this state;

      (e) The schedule of the rates, dues, fees or other periodical charges proposed to be charged for such service contracts; and

      (f) All applicable fees for an initial application and the issuance of a certificate of authority.

      3.  If upon completion of the application the Commissioner determines that the applicant is fully qualified and entitled to a certificate of authority under this chapter, the Commissioner shall promptly issue a certificate of authority to the applicant. If the Commissioner refuses to issue the certificate of authority, the Commissioner shall give the applicant written notice of the refusal setting forth the grounds therefor.

      (Added to NRS by 1971, 1867; A 1971, 1956; 1987, 468; 2009, 1815)

      NRS 695B.135  Certificate of authority: Expiration; renewal.

      1.  A certificate of authority issued pursuant to this chapter expires on March 1 of the year following its date of issuance or renewal.

      2.  To renew a certificate of authority a corporation for medical service must:

      (a) File a written request for renewal with the Commissioner; and

      (b) Pay all applicable fees for renewal for a certificate of authority.

      3.  The Commissioner may accept a request for renewal received by the Commissioner within 30 days after the expiration of the certificate if the request is accompanied by a fee for renewal of 150 percent of all applicable fees otherwise required, except for any fee required pursuant to NRS 680C.110.

      (Added to NRS by 1987, 467; A 2009, 1816)

      NRS 695B.140  Reserve fund: Minimum amounts; computation; contracts with hospitals; participation of physicians.

      1.  No corporation subject to the provisions of this chapter may establish, maintain or operate a hospital, medical or dental service plan unless it has and at all times maintains a reserve fund equal to the following minimum amounts in relation to the number of natural persons entitled to hospital, medical or dental services under contracts issued by the corporation:

 

                                                                                                                             Amount of

   Number of Natural Persons                                                                                  Reserve

        Entitled to Benefits                                                                                            Fund

 

             1 to 1,000, inclusive..................................................................................... $100,000

             1,001 to 10,000, inclusive............................................................................. 500,000

             10,000 or more................................................................................................ 750,000

 

but such a reserve fund is not required of a corporation acting only as a fiscal administrator of programs funded by public agencies, authorized insurers and other authorized health service plans.

      2.  In computing the amount of a reserve fund, the Commissioner shall include the amounts agreed to be paid by contracting hospitals to the corporation or its equivalent value of hospital service to be rendered without charge by the contracting hospital to the hospital service corporation.

      3.  In addition to the reserve fund provided for in this chapter, the Commissioner shall require every corporation subject to this chapter to make, and to maintain in force, such contracts with enough hospitals in the State of Nevada to be adequate, in the opinion of the Commissioner, to provide care for all natural persons entitled to hospital benefits in the State of Nevada under contracts issued by such a corporation.

      4.  In addition, the Commissioner shall require medical or dental service corporations to give evidence of the participation of a sufficient number of physicians or dentists, in the judgment of the Commissioner, to render the medical or dental services specified under the contract.

      (Added to NRS by 1971, 1868; A 1971, 1957; 1985, 613)

      NRS 695B.150  Insolvency; determination of financial condition.  A corporation organized under this chapter shall be deemed to be insolvent if its reserve fund is impaired so as to be less than the amounts set forth in NRS 695B.140. For the purposes of determining such insolvency and the financial condition of the corporation, for the purposes of preparation of annual statements, and for all other purposes not otherwise expressly provided for in this chapter, the corporation is subject to all requirements of the laws of the State of Nevada as to assets, liabilities and reserves which are applicable to mutual nonassessable life or health insurers.

      (Added to NRS by 1971, 1868; A 2005, 2158)

      NRS 695B.160  Annual statement of condition and affairs; fees; examination by Commissioner.

      1.  Every corporation subject to the provisions of this chapter shall annually:

      (a) On or before March 1, file in the Office of the Commissioner a statement verified by at least two of the principal officers of the corporation, showing its condition and affairs as of December 31 of the preceding calendar year. The statement must be in the form required by the Commissioner and must contain statements relative to the matters required to be established as a condition precedent to maintaining or operating a nonprofit hospital, medical or dental service plan and to other matters which the Commissioner may prescribe.

      (b) Pay all applicable fees for the renewal of a certificate of authority and the fee for the filing of an annual statement.

      2.  The Commissioner may examine, as often as the Commissioner deems it desirable, the affairs of every corporation subject to the provisions of this chapter. The Commissioner shall, if practicable, examine each such corporation at least once in every 3 years, and in any event, at least once in every 5 years, as to its condition, fulfillment of its contractual obligations and compliance with applicable laws. For examining the financial condition of every such corporation the Commissioner shall collect the actual expenses of the examination. Such expenses must be paid by the corporation. The Commissioner shall refuse to issue a certificate of authority or shall revoke a certificate of authority issued to any corporation which neglects or refuses to pay such expenses.

      (Added to NRS by 1971, 1869; A 1987, 468; 2009, 1816)

      NRS 695B.170  Acquisition costs and administrative expenses; effect of finding of excess costs.  All acquisition costs in connection with the solicitation of subscribers to such hospital, medical or dental service plan shall at all times be subject to the approval of the Commissioner, and the administrative expenses for any calendar year, excluding the first full year of operation, of any such corporation, including acquisition costs, shall be limited to 25 percent of the aggregate amount of rates, dues, fees and other periodic charges actually received during that year. If the Commissioner finds that acquisition costs of any corporation operating under the provisions of this chapter are excessive, or that the administrative expenses exceed the amount above stated, such finding shall be sufficient ground to justify the Commissioner in revoking the consent of the Commissioner to the establishment, maintenance and operation by such corporation of the hospital, medical or dental service plan.

      (Added to NRS by 1971, 1869)

      NRS 695B.172  Summary of coverage: Contents of disclosure; approval by Commissioner.

      1.  The Commissioner shall adopt regulations which require an insurer to file with the Commissioner, for approval by the Commissioner, a disclosure summarizing the coverage provided by each contract for hospital or medical service offered by the insurer. The disclosure must include:

      (a) Any significant exception, reduction or limitation that applies to the contract; and

      (b) Any other information,

Ê that the Commissioner finds necessary to provide for full and fair disclosure of the provisions of the contract.

      2.  The disclosure must be written in language which is easily understood and must include a statement that the disclosure is a summary of the contract only, and that the contract itself should be read to determine the governing contractual provisions.

      3.  The Commissioner shall not approve any proposed disclosure submitted to the Commissioner pursuant to this section which does not comply with the requirements of this section and the applicable regulations.

      (Added to NRS by 1989, 1251)

      NRS 695B.174  Summary of coverage: Copy to be provided before policy issued; policy not to be offered unless summary approved by Commissioner.  An insurer shall provide to the group policyholder to whom it offers a contract for hospital or medical service a copy of the disclosure approved for that contract pursuant to NRS 695B.172 before the contract is issued. An insurer shall not offer a contract for hospital or medical service unless the disclosure for that contract has been approved by the Commissioner.

      (Added to NRS by 1989, 1251)

      NRS 695B.176  Coverage for prescription drugs: Provision of notice and information regarding use of formulary.

      1.  An insurer that offers or issues a contract for hospital or medical services which provides coverage for prescription drugs shall include with any summary, certificate or evidence of that coverage provided to an insured, notice of whether a formulary is used and, if so, of the opportunity to secure information regarding the formulary from the insurer pursuant to subsection 2. The notice required by this subsection must:

      (a) Be in a language that is easily understood and in a format that is easy to understand;

      (b) Include an explanation of what a formulary is; and

      (c) If a formulary is used, include:

             (1) An explanation of:

                   (I) How often the contents of the formulary are reviewed; and

                   (II) The procedure and criteria for determining which prescription drugs are included in and excluded from the formulary; and

             (2) The telephone number of the insurer for making a request for information regarding the formulary pursuant to subsection 2.

      2.  If an insurer offers or issues a contract for hospital or medical services which provides coverage for prescription drugs and a formulary is used, the insurer shall:

      (a) Provide to any insured or participating provider of health care, upon request:

             (1) Information regarding whether a specific drug is included in the formulary.

             (2) Access to the most current list of prescription drugs in the formulary, organized by major therapeutic category, with an indication of whether any listed drugs are preferred over other listed drugs. If more than one formulary is maintained, the insurer shall notify the requester that a choice of formulary lists is available.

      (b) Notify each person who requests information regarding the formulary, that the inclusion of a drug in the formulary does not guarantee that a provider of health care will prescribe that drug for a particular medical condition.

      (Added to NRS by 2001, 861)

CONTRACTS

General Provisions

      NRS 695B.180  Required provisions.  A contract for hospital, medical or dental services must not be entered into between a corporation proposing to furnish or provide any one or more of the services authorized under this chapter and a subscriber:

      1.  Unless the entire consideration therefor is expressed in the contract.

      2.  Unless the times at which the benefits or services to the subscriber take effect and terminate are stated in a portion of the contract above the evidence of its execution.

      3.  If the contract purports to entitle more than one person to benefits or services, except for family contracts issued under NRS 695B.190, group contracts issued under NRS 695B.200, and blanket contracts issued under NRS 695B.220.

      4.  Unless every printed portion and any endorsement or attached papers are plainly printed in type of which the face is not smaller than 10 points.

      5.  Except for group contracts and blanket contracts issued under NRS 695B.220, unless the exceptions of the contract are printed with greater prominence than the benefits to which they apply.

      6.  Except for group contracts and blanket contracts issued under NRS 695B.230, unless, if any portion of the contract purports, by reason of the circumstances under which an illness, injury or disablement is incurred to reduce any service to less than that provided for the same illness, injury or disablement incurred under ordinary circumstances, that portion is printed in boldface type and with greater prominence than any other text of the contract.

      7.  If the contract contains any provisions purporting to make any portion of the charter, constitution or bylaws of a nonprofit corporation a part of the contract unless that portion is set forth in full in the contract.

      8.  Unless the contract provides benefits for expenses incurred for hospice care.

      9.  Unless the contract for service in a hospital contains in blackface type, not less than 10 points, the following provisions:

 

       This contract does not restrict or interfere with the right of any person entitled to service and care in a hospital to select the contracting hospital or to make a free choice of an attending physician, who must be the holder of a valid and unrevoked physician’s license and a member of, or acceptable to, the attending staff and board of directors of the hospital in which the services are to be provided.

 

      (Added to NRS by 1971, 1869; A 1975, 1851; 1979, 1180; 1983, 1935, 2039; 1985, 1777; 1989, 515, 1033; 2009, 1816)

      NRS 695B.181  Provision in contract requiring binding arbitration authorized; procedures for arbitration; declaratory relief.

      1.  Except as otherwise provided in NRS 695B.182 and subject to the approval of the Commissioner, any contract which is authorized pursuant to this chapter may include a provision which requires the parties to the contract to submit for binding arbitration any dispute between the parties concerning any matter directly or indirectly related to, or associated with, the contract. If such a provision is included in the contract:

      (a) A person who elects to be covered by the contract must be given the opportunity to decline to participate in binding arbitration at the time the person elects to be covered by the contract.

      (b) It must clearly state that the parties to the contract who have not declined to participate in binding arbitration agree to forego their right to resolve any such dispute in a court of law or equity.

      2.  Except as otherwise provided in subsection 3, the arbitration must be conducted pursuant to the rules for commercial arbitration established by the American Arbitration Association. The insurer is responsible for any administrative fees and expenses relating to the arbitration, except that the insurer is not responsible for attorney’s fees and fees for expert witnesses unless those fees are awarded by the arbitrator.

      3.  If a dispute required to be submitted to binding arbitration requires an immediate resolution to protect the physical health of a person insured under the contract, any party to the dispute may waive arbitration and seek declaratory relief in a court of competent jurisdiction.

      4.  If a provision described in subsection 1 is included in a contract, 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, 2558)

      NRS 695B.182  Required procedure for arbitration of disputes concerning independent medical evaluations.

      1.  Each contract for hospital or medical services must include a procedure for binding arbitration to resolve disputes concerning independent medical evaluations pursuant to the rules of the American Arbitration Association.

      2.  If a corporation subject to the provisions of this chapter, for any final determination of benefits or care, requires an independent evaluation of the medical or chiropractic care of any person for whom such care is covered under a contract for hospital or medical services, only a physician or chiropractor who is certified to practice in the same field of practice as the primary treating physician or chiropractor or who is formally educated in that field may conduct the independent evaluation.

      3.  The independent evaluation must include a physical examination of the patient, unless the patient is deceased, and a personal review of all X rays and reports prepared by the primary treating physician or chiropractor. A certified copy of all reports of findings must be sent to the primary treating physician or chiropractor and the insured person within 10 working days after the evaluation. If the insured person disagrees with the finding of the evaluation, the insured person must submit an appeal to the insurer pursuant to the procedure for binding arbitration set forth in the contract for services within 30 days after the insured person receives the finding of the evaluation. Upon its receipt of an appeal, the insurer shall so notify in writing the primary treating physician or chiropractor.

      4.  The insurer shall not limit or deny coverage for care related to a disputed claim while the dispute is in arbitration, except that, if the insurer prevails in the arbitration, the primary treating physician or chiropractor may not recover any payment from either the insurer, insured person or the patient for services that the primary treating physician or chiropractor provided to the patient after receiving written notice from the insurer pursuant to subsection 3 concerning the appeal of the insured person.

      (Added to NRS by 1989, 2116)

      NRS 695B.185  Limitations on deductibles and copayments charged under group contract which offers difference of payment between preferred providers of health care and providers who are not preferred.  A group contract for hospital, medical or dental services which offers a difference of payment between preferred providers of health care and providers of health care who are not preferred:

      1.  May not require a deductible of more than $600 difference per admission to a facility for inpatient treatment which is not a preferred provider of health care.

      2.  May not require a deductible of more than $500 difference per treatment, other than inpatient treatment at a hospital, by a provider which is not preferred.

      3.  May not require an insured, another insurer who issues policies of group health insurance, a nonprofit medical service corporation or a health maintenance organization to pay any amount in excess of the deductible or coinsurance due from the insured based on the rates agreed upon with a provider.

      4.  May not provide for a difference in percentage rates of payment for coinsurance of more than 30 percentage points between the copayment required to be paid by the insured to a preferred provider of health care and the copayment required to be paid by the insured to a provider of health care who is not preferred.

      5.  Must require that the deductible and payment for coinsurance paid by the insured to a preferred provider of health care be applied to the negotiated reduced rates of that provider.

      6.  Must include for providers of health care who are not preferred a provision establishing the point at which an insured’s payment for coinsurance is no longer required to be paid if such a provision is included for preferred providers of health care. Such provisions must be based on a calendar year. The point at which an insured’s payment for coinsurance is no longer required to be paid for providers of health care who are not preferred must not be greater than twice the amount for preferred providers of health care, regardless of the method of payment.

      7.  Must provide that if there is a particular service which a preferred provider of health care does not provide and the provider of health care who is treating the insured determines that the use of the service is necessary for the health of the insured, the service shall be deemed to be provided by the preferred provider of health care.

      8.  Must require the corporation to process a claim of a provider of health care who is not preferred not later than 30 working days after the date on which proof of the claim is received.

      (Added to NRS by 1987, 1782; A 1989, 515; 1991, 1331; 1995, 1631)

      NRS 695B.187  Group contract issued to replace discontinued policy or coverage: Requirements; notice of reduction of benefits; statement of benefits; applicability to self-insured employer. [Effective through December 31, 2013.]  Except as otherwise provided by the provisions of NRS 689B.340 to 689B.590, inclusive, and chapter 689C of NRS relating to the portability and availability of health insurance:

      1.  A group contract for hospital, medical or dental services issued by a nonprofit hospital, medical or dental service corporation 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 the 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 contract is issued within 60 days after the date on which the previous policy or coverage was discontinued.

      2.  If an employer obtains a replacement contract pursuant to subsection 1 to cover the employees of the employer, any benefits provided by the previous policy or coverage may be reduced if notice of the reduction is given to the employees of the employer pursuant to NRS 608.1577.

      3.  Any corporation which issues a replacement contract 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 corporation which indicates what benefits were provided and what exclusions or reductions were in effect under the previous policy or coverage.

      4.  The provisions of this section 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 contract for hospital, medical or dental services issued by a nonprofit hospital, medical or dental service corporation.

      (Added to NRS by 1987, 849; A 1997, 2954)

      NRS 695B.187  Group contract issued to replace discontinued policy or coverage: Requirements; notice of reduction of benefits; statement of benefits; applicability to self-insured employer. [Effective January 1, 2014.]  Except as otherwise provided by the provisions of NRS 689B.340 to 689B.580, inclusive, and chapter 689C of NRS relating to the portability and availability of health insurance:

      1.  A group contract for hospital, medical or dental services issued by a nonprofit hospital, medical or dental service corporation 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 the 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 contract is issued within 60 days after the date on which the previous policy or coverage was discontinued.

      2.  If an employer obtains a replacement contract pursuant to subsection 1 to cover the employees of the employer, any benefits provided by the previous policy or coverage may be reduced if notice of the reduction is given to the employees of the employer pursuant to NRS 608.1577.

      3.  Any corporation which issues a replacement contract 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 corporation which indicates what benefits were provided and what exclusions or reductions were in effect under the previous policy or coverage.

      4.  The provisions of this section 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 contract for hospital, medical or dental services issued by a nonprofit hospital, medical or dental service corporation.

      (Added to NRS by 1987, 849; A 1997, 2954; 2013, 3636, effective January 1, 2014)

      NRS 695B.189  Continuation of coverage under group contract: Required provision. [Effective through December 31, 2013.]  A group contract issued by a corporation under the provisions of this chapter must contain a provision which permits the continuation of coverage pursuant to the provisions of NRS 689B.245 to 689B.249, inclusive, and 689B.340 to 689B.590, inclusive, and chapter 689C of NRS relating to the portability and availability of health insurance.

      (Added to NRS by 1987, 2235; A 1997, 2955)

      NRS 695B.189  Continuation of coverage under group contract: Required provision. [Effective January 1, 2014.]  A group contract issued by a corporation under the provisions of this chapter must contain a provision which permits the continuation of coverage pursuant 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.

      (Added to NRS by 1987, 2235; A 1997, 2955; 2013, 3637, effective January 1, 2014)

      NRS 695B.190  Family contracts.  Family hospital or family medical or dental service contracts may be issued to a family consisting of an individual and one or more persons dependent upon the individual, or of one or more persons dependent upon an individual, and may include a spouse of the individual, whether or not dependent upon the individual. Such contracts shall contain a provision to the effect that to the family originally covered may be added from time to time all new members of the family group eligible for coverage and that the head of the family shall give the corporation notice of the addition to the family of any person eligible for coverage under the contracts.

      (Added to NRS by 1971, 1870)

Coverage

      NRS 695B.1901  Required provision concerning coverage for continued medical treatment.

      1.  The provisions of this section apply to a policy of health insurance offered or issued by a hospital or medical service corporation if an insured covered by the policy receives health care through a defined set of providers of health care who are under contract with the hospital or medical service corporation.

      2.  Except as otherwise provided in this section, if an insured who is covered by a policy described in subsection 1 is receiving medical treatment for a medical condition from a provider of health care whose contract with the hospital or medical service corporation is terminated during the course of the medical treatment, the policy must provide that:

      (a) The insured may continue to obtain medical treatment for the medical condition from the provider of health care pursuant to this section, if:

             (1) The insured is actively undergoing a medically necessary course of treatment; and

             (2) The provider of health care and the insured agree that the continuity of care is desirable.

      (b) The provider of health care is entitled to receive reimbursement from the hospital or medical service corporation 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 hospital or medical service corporation 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 hospital or medical service corporation; 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 hospital or medical service corporation.

      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 hospital or medical service corporation and the hospital or medical service corporation terminated that contract because of the medical incompetence or professional misconduct of the provider of health care; and

      (b) The hospital or medical service corporation did not enter into another contract with the provider of health care after the contract was terminated pursuant to paragraph (a).

      5.  A policy subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 2003, has the legal effect of including the coverage required by this section, and any provision of the policy or renewal thereof that is in conflict with this section is void.

      6.  The Commissioner shall adopt regulations to carry out the provisions of this section.

      (Added to NRS by 2003, 3363)

      NRS 695B.1903  Required provision concerning coverage for treatment as part of clinical trial or study.

      1.  A policy of health insurance issued by a medical services corporation must provide coverage for medical treatment which a person insured under the policy receives as part of a clinical trial or study if:

      (a) The medical treatment is provided in a Phase I, Phase II, Phase III or Phase IV study or clinical trial for the treatment of cancer or in a Phase II, Phase III or Phase IV study or clinical trial for the treatment of chronic fatigue syndrome;

      (b) The clinical trial or study is approved by:

             (1) An agency of the National Institutes of Health as set forth in 42 U.S.C. § 281(b);

             (2) A cooperative group;

             (3) The Food and Drug Administration as an application for a new investigational drug;

             (4) The United States Department of Veterans Affairs; or

             (5) The United States Department of Defense;

      (c) In the case of:

             (1) A Phase I clinical trial or study for the treatment of cancer, the medical treatment is provided at a facility authorized to conduct Phase I clinical trials or studies for the treatment of cancer; or

             (2) A Phase II, Phase III or Phase IV study or clinical trial for the treatment of cancer or chronic fatigue syndrome, the medical treatment is provided by a provider of health care and the facility and personnel for the clinical trial or study have the experience and training to provide the treatment in a capable manner;

      (d) There is no medical treatment available which is considered a more appropriate alternative medical treatment than the medical treatment provided in the clinical trial or study;

      (e) There is a reasonable expectation based on clinical data that the medical treatment provided in the clinical trial or study will be at least as effective as any other medical treatment;

      (f) The clinical trial or study is conducted in this State; and

      (g) The insured has signed, before participating in the clinical trial or study, a statement of consent indicating that the insured has been informed of, without limitation:

             (1) The procedure to be undertaken;

             (2) Alternative methods of treatment; and

             (3) The risks associated with participation in the clinical trial or study, including, without limitation, the general nature and extent of such risks.

      2.  Except as otherwise provided in subsection 3, the coverage for medical treatment required by this section is limited to:

      (a) Coverage for any drug or device that is approved for sale by the Food and Drug Administration without regard to whether the approved drug or device has been approved for use in the medical treatment of the insured person.

      (b) The cost of any reasonably necessary health care services that are required as a result of the medical treatment provided in a Phase II, Phase III or Phase IV clinical trial or study or as a result of any complication arising out of the medical treatment provided in a Phase II, Phase III or Phase IV clinical trial or study, to the extent that such health care services would otherwise be covered under the policy of health insurance.

      (c) The cost of any routine health care services that would otherwise be covered under the policy of health insurance for an insured participating in a Phase I clinical trial or study.

      (d) The initial consultation to determine whether the insured is eligible to participate in the clinical trial or study.

      (e) Health care services required for the clinically appropriate monitoring of the insured during a Phase II, Phase III or Phase IV clinical trial or study.

      (f) Health care services which are required for the clinically appropriate monitoring of the insured during a Phase I clinical trial or study and which are not directly related to the clinical trial or study.

Ê Except as otherwise provided in NRS 695B.1901, 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 medical services corporation has contracted for such services. If the medical services corporation has not contracted for the provision of such services, the medical services corporation shall pay the provider the rate of reimbursement that is paid to other providers with whom the medical services corporation has contracted for similar services and the provider shall accept that rate of reimbursement as payment in full.

      3.  Particular medical treatment described in subsection 2 and provided to a person insured under the policy is not required to be covered pursuant to this section if that particular medical treatment is provided by the sponsor of the clinical trial or study free of charge to the person insured under the policy.

      4.  The coverage for medical treatment required by this section does not include:

      (a) Any portion of the clinical trial or study that is customarily paid for by a government or a biotechnical, pharmaceutical or medical industry.

      (b) Coverage for a drug or device described in paragraph (a) of subsection 2 which is paid for by the manufacturer, distributor or provider of the drug or device.

      (c) Health care services that are specifically excluded from coverage under the insured’s policy of health insurance, regardless of whether such services are provided under the clinical trial or study.

      (d) Health care services that are customarily provided by the sponsors of the clinical trial or study free of charge to the participants in the trial or study.

      (e) Extraneous expenses related to participation in the clinical trial or study including, without limitation, travel, housing and other expenses that a participant may incur.

      (f) Any expenses incurred by a person who accompanies the insured during the trial or study.

      (g) Any item or service that is provided solely to satisfy a need or desire for data collection or analysis that is not directly related to the clinical management of the insured.

      (h) Any costs for the management of research relating to the clinical trial or study.

      5.  A medical services corporation that delivers or issues for delivery a policy of health insurance specified in subsection 1 may require copies of the approval or certification issued pursuant to paragraph (b) of subsection 1, the statement of consent signed by the insured, protocols for the clinical trial or study and any other materials related to the scope of the clinical trial or study relevant to the coverage of medical treatment pursuant to this section.

      6.  A medical services corporation that delivers or issues for delivery a policy of health insurance specified in subsection 1 shall:

      (a) Include in the disclosure required pursuant to NRS 695B.172 notice to each person insured under the policy of the availability of the benefits required by this section.

      (b) Provide the coverage required by this section subject to the same deductible, copayment, coinsurance and other such conditions for coverage that are required under the policy.

      7.  A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2006, has the legal effect of including the coverage required by this section, and any provision of the policy that conflicts with this section is void.

      8.  A medical services corporation that delivers or issues for delivery a policy of health insurance specified in subsection 1 is immune from liability for:

      (a) Any injury to the insured caused by:

             (1) Any medical treatment provided to the insured in connection with his or her participation in a clinical trial or study described in this section; or

             (2) An act or omission by a provider of health care who provides medical treatment or supervises the provision of medical treatment to the insured in connection with his or her participation in a clinical trial or study described in this section.

      (b) Any adverse or unanticipated outcome arising out of an insured’s participation in a clinical trial or study described in this section.

      9.  As used in this section:

      (a) “Cooperative group” means a network of facilities that collaborate on research projects and has established a peer review program approved by the National Institutes of Health. The term includes:

             (1) The Clinical Trials Cooperative Group Program; and

             (2) The Community Clinical Oncology Program.

      (b) “Facility authorized to conduct Phase I clinical trials or studies for the treatment of cancer” means a facility or an affiliate of a facility that:

             (1) Has in place a Phase I program which permits only selective participation in the program and which uses clear-cut criteria to determine eligibility for participation in the program;

             (2) Operates a protocol review and monitoring system which conforms to the standards set forth in the Policies and Guidelines Relating to the Cancer-Center Support Grant published by the Cancer Centers Branch of the National Cancer Institute;

             (3) Employs at least two researchers and at least one of those researchers receives funding from a federal grant;

             (4) Employs at least three clinical investigators who have experience working in Phase I clinical trials or studies conducted at a facility designated as a comprehensive cancer center by the National Cancer Institute;

             (5) Possesses specialized resources for use in Phase I clinical trials or studies, including, without limitation, equipment that facilitates research and analysis in proteomics, genomics and pharmacokinetics;

             (6) Is capable of gathering, maintaining and reporting electronic data; and

             (7) Is capable of responding to audits instituted by federal and state agencies.

      (c) “Provider of health care” means:

             (1) A hospital; or

             (2) A person licensed pursuant to chapter 630, 631 or 633 of NRS.

      (Added to NRS by 2003, 3525; A 2005, 2015)

      NRS 695B.1905  Required provision concerning coverage for prescription drug previously approved for medical condition of insured.

      1.  Except as otherwise provided in this section, a contract for hospital or medical services which provides coverage for prescription drugs must not limit or exclude coverage for a drug if the drug:

      (a) Had previously been approved for coverage by the insurer for a medical condition of an insured and the insured’s provider of health care determines, after conducting a reasonable investigation, that none of the drugs which are otherwise currently approved for coverage are medically appropriate for the insured; and

      (b) Is appropriately prescribed and considered safe and effective for treating the medical condition of the insured.

      2.  The provisions of subsection 1 do not:

      (a) Apply to coverage for any drug that is prescribed for a use that is different from the use for which that drug has been approved for marketing by the Food and Drug Administration;

      (b) Prohibit:

             (1) The insurer from charging a deductible, copayment or coinsurance for the provision of benefits for prescription drugs to the insured or from establishing, by contract, limitations on the maximum coverage for prescription drugs;

             (2) A provider of health care from prescribing another drug covered by the contract that is medically appropriate for the insured; or

             (3) The substitution of another drug pursuant to NRS 639.23286 or 639.2583 to 639.2597, inclusive; or

      (c) Require any coverage for a drug after the term of the contract.

      3.  Any provision of a contract for hospital or medical services 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, 862; A 2003, 2300)

      NRS 695B.1907  Required provision concerning coverage for screening for colorectal cancer.

      1.  A policy of health insurance issued by a hospital or medical service corporation that provides coverage for the treatment of colorectal cancer must provide coverage for colorectal cancer screening in accordance with:

      (a) The guidelines concerning colorectal cancer screening which are published by the American Cancer Society; or

      (b) Other guidelines or reports concerning colorectal cancer screening which are published by nationally recognized professional organizations and which include current or prevailing supporting scientific data.

      2.  A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 2003, has the legal effect of including the coverage required by this section, and any provision of the policy that conflicts with the provisions of this section is void.

      (Added to NRS by 2003, 1335)

      NRS 695B.1908  Required provision concerning coverage for certain drugs for treatment of cancer.  Except as otherwise provided in NRS 695B.1903:

      1.  No contract for hospital or medical services 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 contract 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 a person covered under the contract.

      (b) Does not include coverage for any:

             (1) Experimental drug used for the treatment of cancer if that drug has not been approved by the Food and Drug Administration; or

             (2) Use of a drug that is contraindicated by the Food and Drug Administration.

      3.  A contract for hospital or medical services 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 contract that conflicts with the provisions of this section is void.

      (Added to NRS by 1999, 760; A 2003, 3528)

      NRS 695B.1909  Required provision concerning coverage for orally administered chemotherapy.

      1.  An insurer that offers or issues a contract for hospital or medical service which provides coverage for the treatment of cancer through the use of chemotherapy shall not:

      (a) Require a copayment, deductible or coinsurance amount for chemotherapy administered orally by means of a prescription drug in a combined amount that is more than $100 per prescription. The limitation on the amount of the deductible that may be required pursuant to this paragraph does not apply to a health benefit plan, as defined in NRS 687B.470, if the health benefit plan is a high deductible health plan, as defined in 26 U.S.C. § 223, and the amount of the annual deductible has not been satisfied.

      (b) Make the coverage subject to monetary limits that are less favorable for chemotherapy administered orally by means of a prescription drug than the monetary limits applicable to chemotherapy which is administered by injection or intravenously.

      (c) Decrease the monetary limits applicable to chemotherapy administered orally by means of a prescription drug or to chemotherapy which is administered by injection or intravenously to meet the requirements of this section.

      2.  A contract 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 contract or renewal which is in conflict with this section is void.

      3.  Nothing in this section shall be construed as requiring an insurer to provide coverage for the treatment of cancer through the use of chemotherapy administered by injection or intravenously or administered orally by means of a prescription drug.

      (Added to NRS by 2013, 1998; A 2013, 3659)

      NRS 695B.191  Required provision concerning coverage relating to mastectomy.

      1.  A policy of health insurance, issued by a medical service corporation, which provides coverage for the surgical procedure known as a mastectomy must also provide commensurate coverage for:

      (a) Reconstruction of the breast on which the mastectomy has been performed;

      (b) Surgery and reconstruction of the other breast to produce a symmetrical structure; and

      (c) Prostheses and physical complications for all stages of mastectomy, including lymphedemas.

      2.  The provision of services must be determined by the attending physician and the patient.

      3.  The plan or issuer may require deductibles and coinsurance payments if they are consistent with those established for other benefits.

      4.  Written notice of the availability of the coverage must be given upon enrollment and annually thereafter. The notice must be sent to all participants:

      (a) In the next mailing made by the plan or issuer to the participant or beneficiary; or

      (b) As part of any annual information packet sent to the participant or beneficiary,

Ê whichever is earlier.

      5.  A plan or issuer may not:

      (a) Deny eligibility, or continued eligibility, to enroll or renew coverage, in order to avoid the requirements of subsections 1 to 4, inclusive; or

      (b) Penalize, or limit reimbursement to, a provider of care, or provide incentives to a provider of care, in order to induce the provider not to provide the care listed in subsections 1 to 4, inclusive.

      6.  A plan or issuer may negotiate rates of reimbursement with providers of care.

      7.  If reconstructive surgery is begun within 3 years after a mastectomy, the amount of the benefits for that surgery must equal those amounts provided for in the policy at the time of the mastectomy. If the surgery is begun more than 3 years after the mastectomy, the benefits provided are subject to all of the terms, conditions and exclusions contained in the policy at the time of the reconstructive surgery.

      8.  A policy subject to the provisions of this chapter which is delivered, issued for delivery or renewed on or after October 1, 2001, has the legal effect of including the coverage required by this section, and any provision of the policy or the renewal which is in conflict with this section is void.

      9.  For the purposes of this section, “reconstructive surgery” means a surgical procedure performed following a mastectomy on one breast or both breasts to re-establish symmetry between the two breasts. The term includes augmentation mammoplasty, reduction mammoplasty and mastopexy.

      (Added to NRS by 1983, 615; A 1989, 1890; 2001, 2249)

      NRS 695B.1912  Required provision concerning coverage for cytologic screening tests and mammograms for certain women.

      1.  A policy of health insurance issued by a hospital or medical service corporation must provide coverage for benefits payable for expenses incurred for:

      (a) An annual cytologic screening test for women 18 years of age or older;

      (b) A baseline mammogram for women between the ages of 35 and 40; and

      (c) An annual mammogram for women 40 years of age or older.

      2.  A policy of health insurance issued by a hospital or medical service corporation 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, 1890; A 1997, 1730)

      NRS 695B.1914  Required provision concerning coverage of certain gynecological and obstetrical services without authorization or referral from primary care physician.

      1.  A contract for hospital or medical service must include a provision authorizing a woman covered by the contract 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 contract for hospital or medical service to designate an obstetrician or gynecologist as her primary care physician.

      3.  A contract 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 contract 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 695B.1916  Required provision concerning coverage of drug or device for contraception and of hormone replacement therapy in certain circumstances; prohibited actions by insurer; exceptions.

      1.  Except as otherwise provided in subsection 5, an insurer that offers or issues a contract for hospital or medical service which provides coverage for prescription drugs or devices shall include in the contract coverage for:

      (a) Any type of drug or device for contraception; and

      (b) Any type of hormone replacement therapy,

Ê which is lawfully prescribed or ordered and which has been approved by the Food and Drug Administration.

      2.  An insurer that offers or issues a contract for hospital or medical service that provides coverage for prescription drugs shall not:

      (a) Require an insured to pay a higher deductible, copayment or coinsurance or require a longer waiting period or other condition for coverage for a prescription for a contraceptive or hormone replacement therapy than is required for other prescription drugs covered by the contract;

      (b) Refuse to issue a contract for hospital or medical service or cancel a contract for hospital or medical service solely because the person applying for or covered by the contract uses or may use in the future any of the services listed in subsection 1;

      (c) Offer or pay any type of material inducement or financial incentive to an insured to discourage the insured from accessing any of the services listed in subsection 1;

      (d) Penalize a provider of health care who provides any of the services listed in subsection 1 to an insured, including, without limitation, reducing the reimbursement of the provider of health care; or

      (e) Offer or pay any type of material inducement, bonus or other financial incentive to a provider of health care to deny, reduce, withhold, limit or delay any of the services listed in subsection 1 to an insured.

      3.  Except as otherwise provided in subsection 5, a contract 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 contract or the renewal which is in conflict with this section is void.

      4.  The provisions of this section do not:

      (a) Require an insurer to provide coverage for fertility drugs.

      (b) Prohibit an insurer from requiring an insured to pay a deductible, copayment or coinsurance for the coverage required by paragraphs (a) and (b) of subsection 1 that is the same as the insured is required to pay for other prescription drugs covered by the contract.

      5.  An insurer which offers or issues a contract for hospital or medical service and which is affiliated with a religious organization is not required to provide the coverage required by paragraph (a) of subsection 1 if the insurer objects on religious grounds. Such an insurer shall, before the issuance of a contract for hospital or medical service and before the renewal of such a contract, provide to the group policyholder or prospective insured, as applicable, written notice of the coverage that the insurer refuses to provide pursuant to this subsection. The insurer shall provide notice to each insured, at the time the insured receives his or her certificate of coverage or evidence of coverage, that the insurer refused to provide coverage pursuant to this subsection.

      6.  If an insurer refuses, pursuant to subsection 5, to provide the coverage required by paragraph (a) of subsection 1, an employer may otherwise provide for the coverage for the employees of the employer.

      7.  As used in this section, “provider of health care” has the meaning ascribed to it in NRS 629.031.

      (Added to NRS by 1999, 1999)

      NRS 695B.1918  Required provision concerning coverage of health care services related to contraceptives and hormone replacement therapy in certain circumstances; prohibited actions by insurer; exceptions.

      1.  Except as otherwise provided in subsection 5, an insurer that offers or issues a contract for hospital or medical service which provides coverage for outpatient care shall include in the contract coverage for any health care service related to contraceptives or hormone replacement therapy.

      2.  An insurer that offers or issues a contract for hospital or medical service that provides coverage for outpatient care shall not:

      (a) Require an insured to pay a higher deductible, copayment or coinsurance or require a longer waiting period or other condition for coverage for outpatient care related to contraceptives or hormone replacement therapy than is required for other outpatient care covered by the contract;

      (b) Refuse to issue a contract for hospital or medical service or cancel a contract for hospital or medical service solely because the person applying for or covered by the contract uses or may use in the future any of the services listed in subsection 1;

      (c) Offer or pay any type of material inducement or financial incentive to an insured to discourage the insured from accessing any of the services listed in subsection 1;

      (d) Penalize a provider of health care who provides any of the services listed in subsection 1 to an insured, including, without limitation, reducing the reimbursement of the provider of health care; or

      (e) Offer or pay any type of material inducement, bonus or other financial incentive to a provider of health care to deny, reduce, withhold, limit or delay any of the services listed in subsection 1 to an insured.

      3.  Except as otherwise provided in subsection 5, a contract 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 contract or the renewal which is in conflict with this section is void.

      4.  The provisions of this section do not prohibit an insurer from requiring an insured to pay a deductible, copayment or coinsurance for the coverage required by subsection 1 that is the same as the insured is required to pay for other outpatient care covered by the contract.

      5.  An insurer which offers or issues a contract for hospital or medical service and which is affiliated with a religious organization is not required to provide the coverage for health care service related to contraceptives required by this section if the insurer objects on religious grounds. Such an insurer shall, before the issuance of a contract for hospital or medical service and before the renewal of such a contract, provide to the group policyholder or prospective insured, as applicable, written notice of the coverage that the insurer refuses to provide pursuant to this subsection. The insurer shall provide notice to each insured, at the time the insured receives his or her certificate of coverage or evidence of coverage, that the insurer refused to provide coverage pursuant to this subsection.

      6.  If an insurer refuses, pursuant to subsection 5, to provide the coverage required by paragraph (a) of subsection 1, an employer may otherwise provide for the coverage for the employees of the employer.

      7.  As used in this section, “provider of health care” has the meaning ascribed to it in NRS 629.031.

      (Added to NRS by 1999, 2000)

      NRS 695B.192  Required provision concerning coverage relating to complications of pregnancy. [Effective through December 31, 2013.]

      1.  No hospital, medical or dental service contract issued by a corporation pursuant to the provisions of this chapter may contain any exclusion, reduction or other limitation of coverage relating to complications of pregnancy, unless the provision applies generally to all benefits payable under the contract and complies with the provisions of NRS 689B.340 to 689B.590, inclusive, and chapter 689C of NRS relating to the portability and availability 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.  A contract subject to the provisions of this chapter which is issued or delivered on or after July 1, 1977, has the legal effect of including the coverage required by this section, and any provision of the contract which is in conflict with this section is void.

      (Added to NRS by 1977, 416; A 1997, 2955)

      NRS 695B.192  Required provision concerning coverage relating to complications of pregnancy. [Effective January 1, 2014.]

      1.  No hospital, medical or dental service contract issued by a corporation pursuant to the provisions of this chapter may contain any exclusion, reduction or other limitation of coverage relating to complications of pregnancy, unless the provision applies generally to all benefits payable under the contract and complies with the provisions of NRS 689B.340 to 689B.580, inclusive, and chapter 689C of NRS relating to the portability and availability 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.  A contract subject to the provisions of this chapter which is issued or delivered on or after July 1, 1977, has the legal effect of including the coverage required by this section, and any provision of the contract which is in conflict with this section is void.

      (Added to NRS by 1977, 416; A 1997, 2955; 2013, 3637, effective January 1, 2014)

      NRS 695B.1923  Required provision concerning coverage for treatment of certain inherited metabolic diseases.

      1.  A contract for hospital or medical service 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 contract was purchased.

      3.  A contract 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 contract 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 695B.1925  Required provision concerning coverage for human papillomavirus vaccine.

      1.  A policy of health insurance issued by a hospital or medical service corporation must provide coverage for benefits payable for expenses incurred for administering the human papillomavirus vaccine to women and girls at such ages as recommended for vaccination by a competent authority, including, without limitation, the Centers for Disease Control and Prevention of the United States Department of Health and Human Services, the Food and Drug Administration or the manufacturer of the vaccine.

      2.  A policy of health insurance issued by a hospital or medical service corporation must not require an insured to obtain prior authorization for any service provided pursuant to subsection 1.

      3.  A policy subject to the provisions of this chapter which is delivered, issued for delivery or renewed on or after July 1, 2007, has the legal effect of including the coverage required by subsection 1, and any provision of the policy or the renewal which is in conflict with subsection 1 is void.

      4.  For the purposes of this section, “human papillomavirus vaccine” means the Quadrivalent Human Papillomavirus Recombinant Vaccine or its successor which is approved by the Food and Drug Administration for the prevention of human papillomavirus infection and cervical cancer.

      (Added to NRS by 2007, 3238)

      NRS 695B.1927  Required provision concerning coverage for management and treatment of diabetes.

      1.  No contract for hospital or medical service that provides coverage for hospital, medical or surgical expenses may be delivered or issued for delivery in this state unless the contract includes coverage for the management and treatment of diabetes, including, without limitation, coverage for the self-management of diabetes.

      2.  An insurer who delivers or issues for delivery a contract specified in subsection 1:

      (a) Shall include in the disclosure required pursuant to NRS 695B.172 notice to each policyholder or subscriber covered under the contract of the availability of the benefits required by this section.

      (b) Shall provide the coverage required by this section subject to the same deductible, copayment, coinsurance and other such conditions for coverage that are required under the contract.

      3.  A contract for hospital or medical service 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 contract 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 a person covered under the contract after the person is initially diagnosed with diabetes which is medically necessary for the care and management of diabetes, including, without limitation, counseling in nutrition and the proper use of equipment and supplies for the treatment of diabetes;

             (2) Training and education which is medically necessary as a result of a subsequent diagnosis that indicates a significant change in the symptoms or condition of the person covered under the contract and which requires modification of the person’s program of self-management of diabetes; and

             (3) Training and education which is medically necessary because of the development of new techniques and treatment for diabetes.

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

      (Added to NRS by 1997, 744)

      NRS 695B.193  Required provision concerning coverage for newly born and adopted children and children placed for adoption.

      1.  All individual and group service or indemnity-type contracts issued by a nonprofit corporation which provide coverage for a family member of the subscriber must as to such coverage provide that the health benefits applicable for children are payable with respect to:

      (a) A newly born child of the subscriber 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 subscriber 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 contracts must provide the coverage specified in subsection 3, and must not exclude premature births.

      2.  The contract may require that notification of:

      (a) The birth of a newly born child;

      (b) The effective date of adoption of a child; or

      (c) The date of placement of a child for adoption,

Ê and payments of the required fees, if any, must be furnished to the nonprofit service corporation within 31 days after the date of birth, adoption or placement for adoption in order to have the coverage continue beyond the 31-day period.

      3.  The coverage for newly born and adopted children and children placed for adoption consists of coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities and, within the limits of the policy, necessary transportation costs from place of birth to the nearest specialized treatment center under major medical policies, and with respect to basic policies to the extent such costs are charged by the treatment center.

      4.  A corporation 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 contract. Any provision relating to an exclusion for a preexisting condition must comply with NRS 689C.190.

      5.  For covered services provided to the child, the corporation 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, 2434; 1997, 2956)

      NRS 695B.1931  Required provision concerning coverage relating to treatment of temporomandibular joint.

      1.  Except as otherwise provided in this section, no contract for hospital or medical service 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 contract or by a claims settlement practice. A contract for hospital or medical service 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.  Pursuant to a contract for hospital or medical service, a corporation 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 a subscriber, but in no case more than 50 percent of the maximum benefits provided by the contract for such treatment; and

      (b) Treatment which is medically necessary.

      3.  Any provision of a contract subject to the provisions of this chapter and issued or delivered on or after January 1, 1990, which is in conflict with this section is void.

      (Added to NRS by 1989, 2138)

      NRS 695B.1942  Required provision concerning coverage for prostate cancer screening.

      1.  A policy of health insurance issued by a hospital or medical service corporation that provides coverage for the treatment of prostate cancer must provide coverage for prostate cancer screening in accordance with:

      (a) The guidelines concerning prostate cancer screening which are published by the American Cancer Society; or

      (b) Other guidelines or reports concerning prostate cancer screening which are published by nationally recognized professional organizations and which include current or prevailing supporting scientific data.

      2.  A policy of health insurance issued by a hospital or medical service corporation that provides coverage for the treatment of prostate cancer must not require an insured to obtain prior authorization for any service provided pursuant to subsection 1.

      3.  A policy of health insurance issued by a hospital or medical service corporation that provides coverage for the treatment of prostate cancer which is delivered, issued for delivery or renewed on or after July 1, 2007, has the legal effect of including the coverage required by subsection 1, and any provision of the policy or the renewal which is in conflict with subsection 1 is void.

      (Added to NRS by 2007, 3238)

      NRS 695B.1944  Required provision concerning coverage for employee or member on leave without pay as result of total disability.

      1.  As used in this section, “total disability” and “totally disabled” mean the continuing inability of the employee or member, because of an injury or illness, to perform substantially the duties related to his or her employment for which the employee or member is otherwise qualified.

      2.  No group subscriber contract for hospital, medical or dental service may be delivered or issued for delivery in this state unless it provides continuing coverage for an employee or member and dependents of the employee or member who are otherwise covered by the policy while the employee or member is on leave without pay as a result of a total disability. The coverage must be for any injury or illness suffered by the employee or member which is not related to the total disability or for any injury or illness suffered by a dependent of the employee or member. The coverage for such injury or illness must be equal to or greater than the coverage otherwise provided by the policy.

      3.  The coverage required pursuant to subsection 2 must continue until:

      (a) The date on which the employment of the employee or member is terminated;

      (b) The date on which the employee or member obtains another policy of health insurance;

      (c) The date on which the group subscriber contract is terminated; or

      (d) After a period of 12 months in which benefits under such coverage are provided to the employee or member,

Ê whichever occurs first.

      (Added to NRS by 1989, 1251)

Reimbursement

      NRS 695B.1951  Reimbursement for treatment by podiatrist.

      1.  If any contract for hospital or medical services 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 695B.1955  Reimbursement for treatment by licensed clinical alcohol and drug abuse counselor.  If any contract for hospital or medical service 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 695B.196  Reimbursement for acupuncture.  If any contract for hospital or medical services 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 695B.197  Reimbursement for treatment by licensed psychologist.  If any contract for hospital or medical service 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 695B.1973  Reimbursement for treatment by licensed marriage and family therapist or licensed clinical professional counselor.  If any contract for hospital or medical service provides coverage for treatment of an illness which is within the authorized scope of practice of a licensed marriage and family therapist or licensed clinical professional counselor, the insured is entitled to reimbursement for treatment by a marriage and family therapist or clinical professional counselor who is licensed pursuant to chapter 641A of NRS.

      (Added to NRS by 1987, 2133; A 2007, 3094)

      NRS 695B.1975  Reimbursement for treatment by licensed associate in social work, social worker, independent social worker or clinical social worker.  If any contract for hospital or medical service 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 695B.198  Reimbursement for treatment by chiropractor.

      1.  If any contract for hospital or medical service 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 695B.199  Reimbursement for services provided by certain nurses; prohibited limitations; exception.

      1.  If any contract for medical service 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 contract must not limit:

      (a) Coverage for services provided by such a registered nurse to a number of occasions less than for services provided by another provider of health care.

      (b) Reimbursement for services provided by such a registered nurse to an amount less than that reimbursed for similar services provided by another provider of health care.

      3.  An insurer is not required to pay for services provided by such a registered nurse which duplicate services provided by another provider of health care.

      (Added to NRS by 1985, 1447)

      NRS 695B.1995  Reimbursement to provider of medical transportation.

      1.  Except as otherwise provided in subsection 3, every contract for medical service 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 subscriber or the provider may submit the claim for reimbursement. The provider shall not demand payment from the subscriber until after that reimbursement has been granted or denied.

      3.  Subsection 1 does not apply to any agreement between a corporation for medical service and a provider of medical transportation for the direct payment by the corporation for the provider’s services.

      (Added to NRS by 1989, 1274)

Miscellaneous Provisions

      NRS 695B.200  Group contracts written under master contract: Conditions required for issuance.  Group hospital or group medical or dental service contracts written under a master hospital or medical or dental service contract may be issued to cover groups of two or more persons, formed for a purpose other than of obtaining insurance.

      (Added to NRS by 1971, 1871)

      NRS 695B.210  Group master service contract: Required provisions.  Every group master hospital or group medical or dental service contract issued shall contain the following provisions:

      1.  A provision that the contract, the application of the employer, or executive officer or trustee of any association or trustees, and the individual applications, if any, of the employees or members covered shall constitute the entire contract between the parties, and that all statements made by the employer, or the executive officer, or trustee or trustees, or by the individual employee or member shall, in the absence of fraud, be deemed representations and not warranties, and that no such statement shall be used in defense to a claim under the contract, unless it is contained in a written application.

      2.  A provision that the corporation will issue to the employer or to the executive officer or trustee of the association or to the trustees, for delivery to each of the employees or members who are covered under such contract, an individual certificate setting forth a statement as to the hospital or medical or dental service to which he or she is entitled.

      3.  A provision that to the group or class thereof originally covered shall be added from time to time all new employees of the employer or members of the association eligible to and applying for coverage in such group or class.

      4.  A statement that such contract is not in lieu of workers’ compensation insurance.

      5.  Such provisions as may be promulgated by the Commissioner from time to time.

      (Added to NRS by 1971, 1871)

      NRS 695B.220  Blanket service contracts: Issuance to college, school or school personnel; pupils not to be compelled to accept service.  Blanket hospital or blanket medical or dental service contracts may be issued to a college or school or to the head or principal thereof or to the governing board of any school district providing for services to pupils of such schools when such services are required as the result of accident to such pupils while they are required to be in or on buildings or other premises of the school or district during the time they are required to be therein or thereon by reason of their attendance upon a college or regular day school or any regular day school of a school district or while being transported to and from school or other place of instruction. No pupil shall be compelled to accept such service without the consent of a parent or guardian of the pupil.

      (Added to NRS by 1971, 1871)

      NRS 695B.225  Policies of group insurance: Order of benefits.  A policy of group insurance determines its order of benefits using the first of the following which applies:

      1.  A policy that does not coordinate with other policies is always the primary policy.

      2.  The benefits of the policy which covers a person as an employee, member or subscriber, other than a dependent, is the primary policy. The policy which covers the person as a dependent is the secondary policy.

      3.  When more than one policy covers the same child as a dependent of different parents who are not divorced or separated, the primary policy is the policy of the parent whose birthday falls earlier in the year. The secondary policy is the policy of the parent whose birthday falls later in the year. If both parents have the same birthday, the benefits of the policy which covered the parent the longer is the primary policy. The policy which covered the parent the shorter time is the secondary policy.

      4.  If more than one policy covers a person as a dependent child of divorced or separated parents, benefits for the child are determined in the following order:

      (a) First, the policy of the parent with custody of the child;

      (b) Second, the policy of the spouse of the parent with custody; and

      (c) Third, the policy of the parent without custody of the child,

Ê unless the specific terms of a court decree state that one parent is responsible for the health care expenses of the child, in which case, the policy of that parent is the primary policy. A parent responsible for the health care pursuant to a court decree shall notify the insurer of the terms of the decree.

      5.  The primary policy is the policy which covers a person as an employee who is neither laid off nor retired, or that employee’s dependent. The secondary policy is the policy which covers that person as a laid off or retired employee, or that employee’s dependent.

      6.  If none of the rules in subsections 1 to 5, inclusive, determines the order of benefits, the primary policy is the policy which covered an employee, member or subscriber longer. The secondary policy is the policy which covered that person the shorter time.

Ê When a policy is determined to be a secondary policy it acts to provide benefits in excess of those provided by the primary policy. The secondary policy may not reduce benefits based upon payments by the primary policy, except that this provision does not require duplication of benefits.

      (Added to NRS by 1989, 514)

      NRS 695B.230  Filing and approval of forms and schedules of premium rates.  If more than one class of risk is included:

      1.  A hospital or medical or dental service contract or evidence of coverage under a group or nongroup contract must not be issued or delivered in this state until a copy of the form of the contract is filed with the Commissioner and either:

      (a) Thirty days expires without notice from the Commissioner after the copy is filed; or

      (b) The Commissioner gives written approval before that time.

      2.  A schedule of premium rates to be paid by subscribers under either a group or nongroup contract must not be issued, delivered or used by any nonprofit hospital, medical or dental service corporation until that corporation files with the Commissioner a copy of the schedule together with any supplementary information required by the Commissioner and either:

      (a) Thirty days expires without notice from the Commissioner after the copy is filed; or

      (b) The Commissioner gives written approval before that time.

      (Added to NRS by 1971, 1872; A 1989, 517)

      NRS 695B.240  Provision of group service coverage before approval of forms.

      1.  A corporation subject to the provisions of this chapter is permitted to provide group hospital or group medical or dental service coverage prior to the approval of the form of the contract or certificate if all the conditions of subsection 2 of this section are met prior thereto and if thereafter it acts as required by subsection 3.

      2.  The conditions referred to in subsection 1 are that:

      (a) The group is one eligible for coverage pursuant to the provisions of this chapter.

      (b) An executed memorandum has been or is concurrently delivered to the subscriber containing a provision that unless a group hospital or group medical or dental service certificate, the form of which has been approved by the Commissioner, which is issued under a group hospital or group medical or dental service contract the form of which has been approved by the Commissioner, and which embodies the coverage, has been issued and delivered to the subscriber within 90 days after the date on which the coverage is provided or agreed to be provided, the coverage provided pursuant to such memorandum terminates 120 days after such date. The memorandum shall contain a specification in either complete or summary form of:

             (1) The class or classes of employees eligible for coverage.

             (2) The benefits to be provided.

             (3) The exceptions and reductions to such benefits, if any.

      3.  A corporation subject to the provisions of this chapter providing coverage pursuant to this section shall:

      (a) Within 60 days after the date on which the coverage is provided or agreed to be provided, submit to the Commissioner for approval a form of a group hospital or group medical or dental service contract, and a form of a certificate of individual coverage, drafted to provide the coverage provided by such memorandum and to meet all requirements of law.

      (b) Make such revisions in the contract and certificate submitted as the Commissioner may lawfully require.

      (c) Terminate such coverage in accordance with the provisions of paragraph (b) of subsection 2 of this section if approval of such contract and certificate is not secured within the time specified therein.

      (Added to NRS by 1971, 1872)

      NRS 695B.250  Extensions of time; automatic approval.

      1.  Upon written request from the corporation subject to the provisions of this chapter filed within 50 days after the date on which the coverage is provided or agreed to be provided and upon proof satisfactory to the Commissioner that the corporation is acting with due diligence and that hardship will result unless an extension is granted, the Commissioner may extend the time set forth in paragraph (a) of subsection 3 of NRS 695B.240 for a period of not to exceed 30 days. Upon such extension, the corporation with the consent of the subscriber may amend the memorandum referred to in paragraph (b) of subsection 2 of NRS 695B.240 to extend the time within which the certificate must be issued and delivered to the subscriber to 30 days after the date to which the Commissioner has extended the time within which a form of contract and certificate must be submitted to the Commissioner for approval and to extend the date for termination of coverage to 30 days thereafter.

      2.  A contract and certificate submitted to the Commissioner with a letter from the corporation stating that coverage has been provided in accordance with this section shall be automatically approved unless the Commissioner disapproves the same within 30 days of the date of its submission to the Commissioner.

      (Added to NRS by 1971, 1873)

      NRS 695B.2505  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 corporation subject to the provisions of this chapter shall approve or deny a claim relating to a contract for dental, hospital or medical services within 30 days after the corporation receives the claim. If the claim is approved, the corporation 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 corporation 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 corporation 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 corporation shall notify the provider of dental, hospital or medical services of all the specific reasons for the delay in approving or denying the claim. The corporation shall approve or deny the claim within 30 days after receiving the additional information. If the claim is approved, the corporation shall pay the claim within 30 days after it receives the additional information. If the approved claim is not paid within that period, the corporation shall pay interest on the claim in the manner prescribed in subsection 1.

      3.  A corporation shall not request a claimant to resubmit information that the claimant has already provided to the corporation, unless the corporation 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 corporation 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 corporation.

      7.  The Commissioner may require a corporation to provide evidence which demonstrates that the corporation 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 corporation is not in substantial compliance with the requirements set forth in this section, the Commissioner may require the corporation to pay an administrative fine in an amount to be determined by the Commissioner. Upon a second or subsequent determination that a corporation 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 corporation.

      (Added to NRS by 1991, 1330; A 1999, 1650; 2001, 2733; 2003, 3364)

CONVERSION OF GROUP CONTRACTS TO INDIVIDUAL CONTRACTS

      NRS 695B.251  Group subscriber contracts to contain provision for conversion to individual contracts; exceptions. [Effective through December 31, 2013.]

      1.  Except as otherwise provided in the provisions of this section, NRS 689B.340 to 689B.590, inclusive, and chapter 689C of NRS relating to the portability and availability of health insurance, all group subscriber contracts delivered or issued for delivery in this state providing for hospital, surgical or major medical coverage, or any combination of these coverages, on a service basis or an expense-incurred basis, or both, must contain a provision that the employee or member is entitled to have issued to him or her a subscriber contract of health coverage when the employee or member is no longer covered by the group subscriber contract.

      2.  The requirement in subsection 1 does not apply to contracts providing benefits only for specific diseases or accidental injuries.

      3.  If an employee or member was a recipient of benefits under the coverage provided pursuant to NRS 695B.1944, the employee or member is not entitled to have issued to him or her by a replacement insurer a subscriber contract of health coverage unless the employee or member 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 695B.1944.

      (Added to NRS by 1979, 1087; A 1989, 1252; 1997, 2956)

      NRS 695B.251  Group subscriber contracts to contain provision for conversion to individual contracts; exceptions. [Effective January 1, 2014.]

      1.  Except as otherwise provided in the provisions of this section, NRS 689B.340 to 689B.580, inclusive, and chapter 689C of NRS relating to the portability and availability of health insurance, all group subscriber contracts delivered or issued for delivery in this state providing for hospital, surgical or major medical coverage, or any combination of these coverages, on a service basis or an expense-incurred basis, or both, must contain a provision that the employee or member is entitled to have issued to him or her a subscriber contract of health coverage when the employee or member is no longer covered by the group subscriber contract.

      2.  The requirement in subsection 1 does not apply to contracts providing benefits only for specific diseases or accidental injuries.

      3.  If an employee or member was a recipient of benefits under the coverage provided pursuant to NRS 695B.1944, the employee or member is not entitled to have issued to him or her by a replacement insurer a subscriber contract of health coverage unless the employee or member 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 695B.1944.

      (Added to NRS by 1979, 1087; A 1989, 1252; 1997, 2956; 2013, 3637, effective January 1, 2014)

      NRS 695B.252  Conversion privilege available to spouse and children; conditions.  Subject to the conditions set forth in NRS 695B.251 to 695B.259, inclusive, the conversion privilege must also be made available:

      1.  To the surviving spouse, if any, upon the death of the employee or member, with respect to the spouse and any child whose coverage under the group contract is terminated by reason of such death, or if there is no surviving spouse, to each surviving child whose coverage under the group contract terminates by reason of such death, or, if the group contract provides for continuation of dependents’ coverage following the employee’s or member’s death, at the end of the continued coverage;

      2.  To the spouse of the employee or member upon termination of coverage of the spouse while the employee or member remains covered under the group contract, if the spouse ceases to be a dependent as defined by the group contract, and to any child whose coverage under the group contract terminates at the same time; or

      3.  To a child solely with respect to himself or herself upon termination of his or her coverage because the child ceases to be a dependent as defined by the group contract, if a conversion privilege is not otherwise provided with respect to the termination.

      (Added to NRS by 1979, 1089)

      NRS 695B.253  Denial of converted contract because of overinsurance; notice concerning cancellation of other coverage.

      1.  The medical service corporation is not required to issue a converted contract to any person who:

      (a) Is covered for similar benefits by another hospital, surgical, medical or major medical expense insurance policy, a hospital or medical service subscriber contract, a medical practice or other prepayment plan, or by any other kind of plan or program;

      (b) Is eligible to be covered for similar benefits under any arrangement of coverage for individuals in a group, whether on an insured or uninsured basis; or

      (c) Has similar benefits provided for or available under the requirements of any state or federal law,

Ê if any benefits provided under the sources listed in this subsection, together with the benefits to be provided by the converted contract, would result in overinsurance according to the medical service corporation’s standards.

      2.  Before denying a converted contract to an applicant because the applicant has coverage as described in paragraph (a) of subsection 1, the medical service corporation shall notify the applicant that the converted contract will be issued only if the other coverage is cancelled.

      (Added to NRS by 1979, 1087)

      NRS 695B.254  Choice of types of contracts must be offered.

      1.  A person who is entitled to a converted contract must be given a choice of at least three types of contracts offering benefits on a service basis or an expense-incurred basis, or both.

      2.  The converted contract may include major medical or catastrophic benefits if they were provided under the group contract.

      3.  For those subscribers eligible for Medicare, the medical service corporation may provide for a supplement to Medicare as part of the conversion privilege.

      (Added to NRS by 1979, 1088)

      NRS 695B.255  Benefits exceeding those provided under group contract not required; exclusions and limitations.  A medical service corporation is not required to issue a converted contract which provides benefits in excess of those provided under the group contract from which conversion is made, and a converted contract may contain any exclusion or benefit limitation contained in the group contract.

      (Added to NRS by 1979, 1088)

      NRS 695B.2555  Benefits payable under converted contract may be reduced by amount payable under group contract.  A converted contract must not exclude a preexisting condition not excluded by the group contract, but a converted contract may provide that any hospital, surgical or medical benefits payable under it may be reduced by the amount of any benefits payable under the group contract after his or her termination. A converted contract may provide that during the first contract year the benefits payable under it, together with the benefits payable under the group contract, must not exceed those that would have been payable if the subscriber’s coverage under the group contract had remained in effect.

      (Added to NRS by 1979, 1088)

      NRS 695B.256  Issuance and effective date of converted contract; premiums; persons covered.  The medical service corporation shall:

      1.  Issue the converted contract without evidence of insurability;

      2.  Base the premium on the converted policies for the first 12 months, and subsequent renewals, upon the medical service corporation’s table of premium rates applicable to the age and class of risk of each person to be covered under the contract and to the type and amount of coverage provided. The frequency of premium payments must be the same as is customarily required by the medical service corporation for the contract form and plan selected except that premium payments must not be required more often than quarterly;

      3.  Provide that the effective date of the converted contract is 12:01 a.m. on the day after the termination of coverage under the group contract; and

      4.  Provide that the converted contract covers the employee or member and dependents of the employee or member who were covered by the group contract on the date of his or her termination. At the option of the insurer, a separate converted contract may be issued to cover any dependent.

      (Added to NRS by 1979, 1087)

      NRS 695B.2565  Renewal of converted contract: Request for information on sources of other benefits; grounds for refusal to renew; notice concerning cancellation of other coverage.

      1.  A converted contract issued under NRS 695B.251 may include a provision permitting the medical service corporation to request from the applicant, in advance of any premium due date, information as to whether the applicant is covered for similar benefits under any of the sources listed in NRS 695B.253.

      2.  The medical service corporation may not refuse to renew the contract or the coverage of any person unless:

      (a) Benefits provided under the sources listed in subsection 1 of NRS 695B.253, together with the benefits provided by the converted contract would result in overinsurance according to the medical service corporation’s standards;

      (b) The holder of the converted contract has refused to provide requested information as to such sources; or

      (c) Fraud was committed in applying for any benefits under the converted contract.

      3.  Before refusing to renew a converted contract because of overinsurance, the medical service corporation shall notify the subscriber that the converted contract will be renewed only if the other coverage is cancelled.

      (Added to NRS by 1979, 1088)

      NRS 695B.257  Notice of conversion privilege.  A notification of the conversion privilege must be included in each certificate of coverage. A written notice of the existence of the conversion privilege must also be given to the employee or member at least 15 days before the expiration of the 31 days permitted a person to make a written application for the converted contract. If written notice of the right to convert is not given as required under this section, an additional period must be allowed the person to apply for the converted contract. The additional period expires 15 days after written notice of the conversion privilege has been given, or 60 days after the expiration of the 31-day period, whichever is earlier.

      (Added to NRS by 1979, 1089)

      NRS 695B.2575  Converted contract delivered outside Nevada: Form.  A converted contract which is to be delivered outside this state must be in such form as would be deliverable in the other jurisdiction as a converted contract if the group contract had been issued in that jurisdiction.

      (Added to NRS by 1979, 1089)

      NRS 695B.258  Extension of coverage under existing group contract.  The medical service corporation may elect to extend coverage of a subscriber under the existing group contract for a period not to exceed 6 months following the day of the person’s eligibility for a converted contract if the conversion privilege is offered upon termination of the extended coverage under the group contract.

      (Added to NRS by 1979, 1089)

      NRS 695B.2585  Group coverage may be provided in lieu of converted individual contract.  The medical service corporation may elect to provide group coverage in lieu of the issuance of a converted individual contract.

      (Added to NRS by 1979, 1089)

      NRS 695B.259  Medical service corporation may continue identical coverage in lieu of converting contract. [Effective through December 31, 2013.]  The medical service corporation may continue coverage identical to that provided under the group contract instead of issuing a converted contract. Coverage may be offered by amending the group certificate or by issuing an individual contract and, except as otherwise provided in NRS 689B.245 to 689B.249, inclusive, must otherwise comply with every requirement of NRS 695B.251 to 695B.259, inclusive.

      (Added to NRS by 1979, 1089; A 1987, 2235)

      NRS 695B.259  Medical service corporation may continue identical coverage in lieu of converting contract. [Effective January 1, 2014.]  The medical service corporation may continue coverage identical to that provided under the group contract instead of issuing a converted contract. Coverage may be offered by amending the group certificate or by issuing an individual contract and must otherwise comply with every requirement of NRS 695B.251 to 695B.259, inclusive.

      (Added to NRS by 1979, 1089; A 1987, 2235; 2013, 3638, effective January 1, 2014)

MISCELLANEOUS PROVISIONS

      NRS 695B.260  Suspension or revocation of permission to provide coverage before approval of forms.  The Commissioner may suspend or revoke the permission granted by NRS 695B.240 if, after notice and hearing, the Commissioner finds that the corporation has:

      1.  Misrepresented the conditional nature of the coverage.

      2.  Neglected or refused either to cancel or otherwise terminate such coverage within the time required by such section.

      3.  Delivered any such memorandum which did not comply with such section.

      4.  Shown a lack of diligence in making revisions in the contract or certificate necessary to obtain its approval by the Commissioner.

      5.  Failed so often in so many important respects in drafting any such contract or certificate to conform to the applicable requirements of the insurance laws that a conclusion of lack of good faith or competency in drafting is reasonably justified.

      6.  Circulated announcements of coverage to individual subscribers which failed to advise them of the conditional nature of the coverage.

      7.  In any other manner so negligently or carelessly handled the effecting of group hospital or group medical or dental service coverage under NRS 695B.240 or the administration thereof that the subscriber or the persons covered by the contract or certificate have been misled or exposed to the danger of loss.

      (Added to NRS by 1971, 1873)

      NRS 695B.270  Disapproval of forms; issuance unlawful.  If the Commissioner notifies the corporation, in writing, that the filed form does not comply with the requirements of law, specifying the reasons for his or her opinion, it is unlawful for the corporation thereafter to issue any contract in such form.

      (Added to NRS by 1971, 1874)

      NRS 695B.280  Regulations; limitations.  The Commissioner may adopt such reasonable regulations, not inconsistent with the provisions of this chapter, relating to the substance, form and issuance of any contract covering the furnishing of hospital or medical or dental services and required to be approved by the Commissioner as are necessary or desirable. The regulations may not prohibit the use in any such contract or agreement of:

      1.  The word “subscriber” as a designation of the obligee.

      2.  The phrase “a family member” as a designation for the members of the family of the obligee.

      3.  The word “contract” or “agreement” as a designation for the undertakings of the hospital or medical or dental service corporation.

      4.  The phrases “furnishing of service” or “payment of benefits” as a designation for the commitments of the hospital or medical or dental service corporation.

      5.  The phrase “the service” as a designation for the corporate obligor in any such contract or agreement.

      (Added to NRS by 1971, 1874; A 1981, 107)

      NRS 695B.285  Use of Uniform Billing and Claims Forms authorized.  Every nonprofit hospital or medical or dental service corporation may utilize the Uniform Billing and Claims Forms established by the American Hospital Association.

      (Added to NRS by 1975, 897)

      NRS 695B.290  Agent’s license required.  Any agent of a nonprofit hospital or medical or dental service corporation who acts as such in the solicitation, negotiation, procurement or making of a hospital service or medical or dental care contract shall be qualified, examined and licensed in the same manner and pay the same fees as provided for health insurance agents in NRS 680B.010 (fee schedule), chapter 683A of NRS and, in addition to any other fee or charge, all applicable fees required pursuant to NRS 680C.110.

      (Added to NRS by 1971, 1874; A 2009, 1817)

      NRS 695B.300  Contracts with agencies or political subdivisions of United States or State of Nevada; acceptance of money; subcontracts.  Any nonprofit hospital or medical or dental service corporation organized and created under the provisions of this chapter and engaged in the operation of a hospital or medical or dental service plan may contract, without regard to the limitations in respect to contracts imposed by this chapter, with any agency, instrumentality or political subdivision of the United States of America or of the State of Nevada for the furnishing of hospital or medical or dental service and care and, in aid or furtherance of such contract, may accept, receive and administer, in trust, funds directly or indirectly made available by such agency, instrumentality or political subdivision. Any such nonprofit hospital or medical or dental service corporation may subcontract with any organization which has contracted with any agency, instrumentality or political subdivision of the United States of America or of the State of Nevada for the furnishing of medical, dental and hospital services, by which subcontract such hospital or medical or dental service corporation undertakes to furnish the hospital or medical or dental services required by the basic contract.

      (Added to NRS by 1971, 1874)

      NRS 695B.310  Corporation subject to same fees, licenses and supervision as domestic mutual insurer.  Any nonprofit hospital or medical or dental service corporation subject to the provisions of this chapter shall be subject to the same taxes, licenses, fees and, to the extent not regulated by the provisions of this chapter, the same supervision as a mutual insurer organized under the laws of the State of Nevada.

      (Added to NRS by 1971, 1875)

      NRS 695B.315  Insurer to provide certain information regarding renewal of insurance policy upon request; fee.

      1.  If a policyholder requests information for the renewal of the policy of the policyholder, an insurer shall provide to the policyholder information regarding claims paid on behalf of the policyholder. The information must be provided within 30 working days after the insurer receives a written request from the policyholder. The insurer may charge the policyholder a reasonable fee for the information.

      2.  The Commissioner may adopt regulations to carry out the provisions of subsection 1.

      (Added to NRS by 1993, 2400)

      NRS 695B.316  Corporation prohibited from denying coverage solely because person was victim of domestic violence.  A corporation shall not deny a claim, refuse to issue a contract for hospital, medical or dental services or cancel a contract for hospital, medical or dental services 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 contract 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 695B.3165  Corporation prohibited from denying coverage solely because insured was intoxicated or under the influence of controlled substance; exceptions.

      1.  Except as otherwise provided in subsection 2, a medical services corporation that issues contracts for hospital, medical or dental services shall not:

      (a) Deny a claim under such a contract solely because the claim involves an injury sustained by an insured as a consequence of being intoxicated or under the influence of a controlled substance.

      (b) Cancel such a contract solely because an insured has made a claim involving an injury sustained by the insured as a consequence of being intoxicated or under the influence of a controlled substance.

      (c) Refuse to issue such a contract 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 medical services corporation from enforcing a provision included in a contract for hospital, medical or dental services 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 such a contract solely because of such a claim; or

      (c) Refuse to issue such a contract to an eligible applicant solely because of such a claim.

      3.  The provisions of this section do not apply to a medical services corporation under a contract for hospital, medical or dental services that provides coverage for long-term or disability income.

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

      NRS 695B.317  Corporation that provides health insurance prohibited from requiring or using information concerning genetic testing; exceptions.

      1.  Except as otherwise provided in subsection 2, a corporation that provides health insurance shall not:

      (a) Require an insured person or any member of the family of the insured person to take a genetic test;

      (b) Require an insured person to disclose whether the insured person or any member of the family of the insured person has taken a genetic test or any genetic information of the insured person or a member of the family of the insured person; or

      (c) Determine the rates or any other aspect of the coverage or benefits for health care provided to an insured person based on:

             (1) Whether the insured person or any member of the family of the insured person has taken a genetic test; or

             (2) Any genetic information of the insured person or any member of the family of the insured person.

      2.  The provisions of this section do not apply to a corporation that issues a policy of health insurance that provides coverage for long-term care or disability income.

      3.  As used in this section:

      (a) “Genetic information” means any information that is obtained from a genetic test.

      (b) “Genetic test” means a test, including a laboratory test that uses deoxyribonucleic acid extracted from the cells of a person or a diagnostic test, to determine the presence of abnormalities or deficiencies, including carrier status, that:

             (1) Are linked to physical or mental disorders or impairments; or

             (2) Indicate a susceptibility to illness, disease, impairment or any other disorder, whether physical or mental.

      (Added to NRS by 1997, 1461)

      NRS 695B.318  Corporations are subject to certain provisions concerning portability and availability of health insurance. [Effective through December 31, 2013.]

      1.  Nonprofit hospital, medical or dental service corporations are subject to the provisions of NRS 689B.340 to 689B.590, 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.590, inclusive, and chapter 689C of NRS, the provisions of NRS 689B.340 to 689B.590, 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:

      (a) “Carrier” must be replaced by “corporation.”

      (b) “Group health plan” must be replaced by “group contract for hospital, medical or dental services.”

      (Added to NRS by 1997, 2954; A 2001, 1924)

      NRS 695B.318  Corporations are subject to certain provisions concerning portability and availability of health insurance. [Effective January 1, 2014.]

      1.  Nonprofit hospital, medical or dental service corporations are 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:

      (a) “Carrier” must be replaced by “corporation.”

      (b) “Group health plan” must be replaced by “group contract for hospital, medical or dental services.”

      (Added to NRS by 1997, 2954; A 2001, 1924; 2013, 3638, effective January 1, 2014)

      NRS 695B.319  Offering policy of health insurance for purposes of establishing health savings account.  A corporation 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 695B.320  Applicability of other provisions. [Effective through December 31, 2013.]  Nonprofit hospital and medical or dental service corporations are subject to the provisions of this chapter, and to the provisions of chapters 679A and 679B of NRS, NRS 686A.010 to 686A.315, inclusive, 687B.010 to 687B.040, inclusive, 687B.070 to 687B.140, inclusive, 687B.150, 687B.160, 687B.180, 687B.200 to 687B.255, inclusive, 687B.270, 687B.310 to 687B.380, inclusive, 687B.410, 687B.420, 687B.430, and chapters 692C and 696B of NRS, to the extent applicable and not in conflict with the express provisions of this chapter.

      (Added to NRS by 1971, 1875; A 1995, 988, 1631, 1636; 1997, 2957, 3036; 1999, 631)

      NRS 695B.320  Applicability of other provisions. [Effective January 1, 2014.]  Nonprofit hospital and medical or dental service corporations are subject to the provisions of this chapter, and to the provisions of chapters 679A and 679B of NRS, NRS 686A.010 to 686A.315, inclusive, 687B.010 to 687B.040, inclusive, 687B.070 to 687B.140, inclusive, 687B.150, 687B.160, 687B.180, 687B.200 to 687B.255, inclusive, 687B.270, 687B.310 to 687B.380, inclusive, 687B.410, 687B.420, 687B.430, 687B.500 and chapters 692C and 696B of NRS, to the extent applicable and not in conflict with the express provisions of this chapter.

      (Added to NRS by 1971, 1875; A 1995, 988, 1631, 1636; 1997, 2957, 3036; 1999, 631; 2013, 3638, effective January 1, 2014)

ELIGIBILITY FOR COVERAGE

      NRS 695B.330  Definitions.  As used in NRS 695B.330 to 695B.370, inclusive, unless the context otherwise requires:

      1.  “Contract” means a contract for hospital, medical or dental services issued pursuant to this chapter.

      2.  “Corporation” means a corporation organized pursuant to this chapter.

      3.  “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.

      4.  “Order for medical coverage” means an order of a court or administrative tribunal to provide coverage under a contract to a child pursuant to the provisions of 42 U.S.C. § 1396g-1.

      (Added to NRS by 1995, 2433)

      NRS 695B.340  Effect of eligibility for medical assistance under Medicaid; assignment of rights to state agency.

      1.  A corporation shall not, when considering eligibility for coverage or making payments under a contract, consider the availability of, or any eligibility of a person for, medical assistance under Medicaid.

      2.  To the extent that payment has been made by Medicaid for health care, a corporation:

      (a) Shall treat Medicaid as having a valid and enforceable assignment of benefits of a subscriber or policyholder or claimant under the subscriber or policyholder regardless of any exclusion of Medicaid or the absence of a written assignment; and

      (b) May, as otherwise allowed by the policy, evidence of coverage or contract and applicable law or regulation concerning subrogation, seek to enforce any rights of a recipient of Medicaid 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 subscriber or policyholder.

      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 contract,

Ê the corporation that issued the contract 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 contract.

      4.  If a state agency is assigned any rights of a subscriber or policyholder who is eligible for medical assistance under Medicaid, a corporation shall:

      (a) Upon request of the state agency, provide to the state agency information regarding the subscriber or policyholder to determine:

             (1) Any period during which the subscriber or policyholder, the spouse or a dependent of the subscriber or policyholder may be or may have been covered by a contract; and

             (2) The nature of the coverage that is or was provided by the corporation, including, without limitation, the name and address of the subscriber or policyholder and the identifying number of the contract;

      (b) Respond to any inquiry by the state agency regarding a claim for payment for the provision of any medical item or service not later than 3 years after the date of the provision of the medical item or service; and

      (c) Agree not to deny a claim submitted by the state agency solely on the basis of the date of submission of the claim, the type or format of the claim form or failure to present proper documentation at the point of sale that is the basis for the claim if:

             (1) The claim is submitted by the state agency not later than 3 years after the date of the provision of the medical item or service; and

             (2) Any action by the state agency to enforce its rights with respect to such claim is commenced not later than 6 years after the submission of the claim.

      (Added to NRS by 1995, 2433; A 2007, 2405)

      NRS 695B.350  Corporation prohibited from asserting certain grounds to deny enrollment of child of insured pursuant to order.  A corporation shall not deny the enrollment of a child pursuant to an order for medical coverage under a contract pursuant to which a parent of the child is insured, on the ground that the child:

      1.  Was born out of wedlock;

      2.  Has not been claimed as a dependent on the parent’s federal income tax return; or

      3.  Does not reside with the parent or within the corporation’s geographic area of service.

      (Added to NRS by 1995, 2433)

      NRS 695B.360  Certain accommodations to be made when child is covered under policy of noncustodial parent.  If a child has coverage under a contract pursuant to which a noncustodial parent of the child is insured, the corporation issuing that contract shall:

      1.  Provide to the custodial parent such information as necessary for the child to obtain any benefits under that coverage.

      2.  Allow the custodial parent or, with the approval of the custodial parent, a provider of health care to submit claims for covered services without the approval of the noncustodial parent.

      3.  Make payments on claims submitted pursuant to subsection 2 directly to the custodial parent, the provider of health care or an agency of this or another state responsible for the administration of Medicaid.

      (Added to NRS by 1995, 2433)

      NRS 695B.370  Corporation 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 family coverage under a contract, the corporation that issued the contract:

      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 corporation 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, 2434)

SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS

      NRS 695B.380  Approval; requirements; examination.

      1.  Except as otherwise provided in subsection 4, each insurer that issues a contract for hospital or medical services in this State shall establish a system for resolving any complaints of an insured concerning health care services covered under the policy. The system must be approved by the Commissioner in consultation with the State Board of Health.

      2.  A system for resolving complaints established pursuant to subsection 1 must include an initial investigation, a review of the complaint by a review board and a procedure for appealing a determination regarding the complaint. The majority of the members on a review board must be insureds who receive health care services pursuant to a contract for hospital or medical services issued by the insurer.

      3.  The Commissioner or the State Board of Health may examine the system for resolving complaints established pursuant to subsection 1 at such times as either deems necessary or appropriate.

      4.  Each insurer that issues a contract specified in subsection 1 shall, if the contract provides, delivers, arranges for, pays for or reimburses any cost of health care services through managed care, provide a system for resolving any complaints of an insured concerning those health care services that complies with the provisions of NRS 695G.200 to 695G.310, inclusive.

      (Added to NRS by 1997, 310; A 2003, 776; 2011, 3395)

      NRS 695B.390  Annual report; insurer to maintain records of complaints concerning something other than health care services.

      1.  Each insurer that issues a contract for hospital or medical services in this State shall submit to the Commissioner and the State Board of Health an annual report regarding its system for resolving complaints established pursuant to subsection 1 of NRS 695B.380 on a form prescribed by the Commissioner in consultation with the State Board of Health which includes, without limitation:

      (a) A description of the procedures used for resolving any complaints of an insured;

      (b) The total number of complaints and appeals handled through the system for resolving complaints since the last report and a compilation of the causes underlying the complaints filed;

      (c) The current status of each complaint and appeal filed; and

      (d) The average amount of time that was needed to resolve a complaint and an appeal, if any.

      2.  Each insurer shall maintain records of complaints filed with it which concern something other than health care services and shall submit to the Commissioner a report summarizing such complaints at such times and in such format as the Commissioner may require.

      (Added to NRS by 1997, 310; A 2003, 776)

      NRS 695B.400  Written notice to insured explaining right to file complaint; notice to insured required when insurer denies coverage of health care service.

      1.  Following approval by the Commissioner, each insurer that issues a contract for hospital or medical services in this State shall provide written notice to an insured, in clear and comprehensible language that is understandable to an ordinary layperson, explaining the right of the insured to file a written complaint. Such notice must be provided to an insured:

      (a) At the time the insured receives a certificate of coverage or evidence of coverage;

      (b) Any time that the insurer denies coverage of a health care service or limits coverage of a health care service to an insured; and

      (c) Any other time deemed necessary by the Commissioner.

      2.  Any time that an insurer denies coverage of a health care service to a beneficiary or subscriber, including, without limitation, denying a claim relating to a contract for dental, hospital or medical services pursuant to NRS 695B.2505, it shall notify the beneficiary or subscriber in writing within 10 working days after it denies coverage of the health care service of:

      (a) The reason for denying coverage of the service;

      (b) The criteria by which the insurer determines whether to authorize or deny coverage of the health care service; and

      (c) The right of the beneficiary or subscriber to file a written complaint and the procedure for filing such a complaint.

      3.  A written notice which is approved by the Commissioner shall be deemed to be in clear and comprehensible language that is understandable to an ordinary layperson.

      (Added to NRS by 1997, 310; A 1999, 3093)