[Rev. 11/21/2013 1:12:47 PM--2013]

CHAPTER 689A - INDIVIDUAL HEALTH INSURANCE

GENERAL PROVISIONS

NRS 689A.010        Short title.

NRS 689A.020        Scope. [Effective through December 31, 2013.]

NRS 689A.020        Scope. [Effective January 1, 2014.]

NRS 689A.030        General requirements. [Effective through December 31, 2013.]

NRS 689A.030        General requirements. [Effective January 1, 2014.]

NRS 689A.035        Contracts between insurer and provider of health care: Prohibiting insurer from charging provider of health care fee for inclusion on list of providers given to insureds; form to obtain information on provider of health care; modification; providing schedule of fees.

REQUIRED PROVISIONS

NRS 689A.040        Contents of policy; substitution of provisions; captions; omission or modification of provisions. [Effective through December 31, 2013.]

NRS 689A.040        Contents of policy; substitution of provisions; captions; omission or modification of provisions. [Effective January 1, 2014.]

NRS 689A.0403      Procedure for arbitration of disputes concerning independent medical evaluations.

NRS 689A.04033    Coverage for treatment received as part of clinical trial or study.

NRS 689A.04036    Coverage for continued medical treatment.

NRS 689A.0404      Coverage for use of certain drugs for treatment of cancer.

NRS 689A.04042    Coverage for screening for colorectal cancer.

NRS 689A.04045    Coverage for prescription drug previously approved for medical condition of insured.

NRS 689A.0405      Coverage for cytologic screening test and mammograms for certain women.

NRS 689A.041        Coverage relating to mastectomy.

NRS 689A.0413      Coverage for certain gynecological or obstetrical services without authorization or referral from primary care physician.

NRS 689A.0415      Coverage for drug or device for contraception and for hormone replacement therapy in certain circumstances; prohibited actions by insurer; exceptions.

NRS 689A.0417      Coverage for health care services related to contraceptives and hormone replacement therapy in certain circumstances; prohibited actions by insurer; exceptions.

NRS 689A.042        Coverage relating to complications of pregnancy.

NRS 689A.0423      Coverage for treatment of certain inherited metabolic diseases.

NRS 689A.0425      Individual health benefit plan that includes coverage for maternity care and pediatric care: Requirement to allow minimum stay in hospital in connection with childbirth; prohibited acts.

NRS 689A.0427      Coverage for management and treatment of diabetes.

NRS 689A.043        Coverage of newly born and adopted children and children placed for adoption.

NRS 689A.0435      Coverage for autism spectrum disorders.

NRS 689A.044        Coverage for human papillomavirus vaccine. [Effective through December 31, 2013.]

NRS 689A.044        Coverage for human papillomavirus vaccine. [Effective January 1, 2014.]

NRS 689A.0445      Coverage for prostate cancer screening.

NRS 689A.0447      Coverage for orally administered chemotherapy.

NRS 689A.045        Termination of coverage on dependent child. [Effective through December 31, 2013.]

NRS 689A.0455      Coverage for treatment of conditions relating to severe mental illness. [Effective through December 31, 2013.]

NRS 689A.0455      Coverage for treatment of conditions relating to severe mental illness. [Effective January 1, 2014.]

NRS 689A.046        Benefits for treatment of abuse of alcohol or drugs.

NRS 689A.0465      Coverage of treatment of temporomandibular joint.

REIMBURSEMENT FOR CERTAIN MEDICALLY RELATED TREATMENT AND SERVICES

NRS 689A.0475      Acupuncture.

NRS 689A.048        Treatment by licensed psychologist.

NRS 689A.0483      Treatment by licensed marriage and family therapist or licensed clinical professional counselor.

NRS 689A.0485      Treatment by licensed associate in social work, social worker, independent social worker or clinical social worker.

NRS 689A.0487      Treatment by licensed podiatrist.

NRS 689A.049        Treatment by licensed chiropractor; restriction on policy limitations.

NRS 689A.0493      Treatment by licensed clinical alcohol and drug abuse counselor.

NRS 689A.0495      Services provided by certain registered nurses; restriction on policy limitations; exception.

NRS 689A.0497      Provider of medical transportation.

MISCELLANEOUS PROVISIONS

NRS 689A.050        Entire contract; changes.

NRS 689A.060        Time limit on certain defenses.

NRS 689A.070        Grace period.

NRS 689A.080        Reinstatement.

NRS 689A.090        Notice of claim.

NRS 689A.100        Claim forms: Required provision.

NRS 689A.105        Claim forms: Uniform billing, claims forms.

NRS 689A.110        Claim forms: Acceptance of uniform forms.

NRS 689A.120        Time of payment of claims.

NRS 689A.130        Payment of claims.

NRS 689A.135        Assignment of benefits to provider of health care.

NRS 689A.140        Physical examination and autopsy.

NRS 689A.150        Legal actions.

NRS 689A.160        Change of beneficiary.

NRS 689A.170        Right to examine and return policy.

NRS 689A.180        Optional provisions.

NRS 689A.190        Extended disability benefit.

NRS 689A.200        Change of occupation.

NRS 689A.210        Misstatement of age.

NRS 689A.220        Coordination of benefits: Same insurer.

NRS 689A.230        Coordination of benefits: All coverages. [Effective through December 31, 2013.]

NRS 689A.230        Coordination of benefits: All coverages. [Effective January 1, 2014.]

NRS 689A.240        Relation of earnings to insurance.

NRS 689A.250        Unpaid premiums.

NRS 689A.260        Conformity with state statutes.

NRS 689A.270        Illegal occupation.

NRS 689A.290        Renewability.

NRS 689A.300        Order of certain provisions.

NRS 689A.310        Ownership of policy by person other than insured.

NRS 689A.320        Requirements of other jurisdictions.

NRS 689A.330        Policies issued for delivery in another state.

NRS 689A.340        Limitation on provisions not subject to chapter; effect of violation.

NRS 689A.350        Age limit.

NRS 689A.370        Health insurance on franchise plan. [Effective through December 31, 2013.]

NRS 689A.380        Definitions of terms used in policies.

NRS 689A.390        Summary of coverage: Contents of disclosure; approval by Commissioner.

NRS 689A.400        Summary of coverage: Copy to be provided before policy issued; policy may not be offered unless summary approved by Commissioner.

NRS 689A.405        Coverage for prescription drugs: Provision of notice and information regarding use of formulary.

NRS 689A.410        Approval or denial of claims; payment of claims and interest; requests for additional information; award of costs and attorney’s fees; compliance with requirements.

NRS 689A.413        Insurer prohibited from denying coverage solely because person was victim of domestic violence.

NRS 689A.415        Insurer prohibited from denying coverage solely because insured was intoxicated or under influence of controlled substance; exceptions.

NRS 689A.417        Insurer prohibited from requiring or using information concerning genetic testing; exceptions.

NRS 689A.419        Offering policy of health insurance for purposes of establishing health savings account.

ELIGIBILITY FOR COVERAGE

NRS 689A.420        Definitions.

NRS 689A.430        Effect of eligibility for medical assistance under Medicaid; assignment of rights to state agency.

NRS 689A.440        Insurer prohibited from asserting certain grounds to deny enrollment of child of insured pursuant to order.

NRS 689A.450        Certain accommodations to be made when child is covered under policy of noncustodial parent.

NRS 689A.460        Insurer to authorize enrollment of child of parent who is required by order to provide medical coverage under certain circumstances; termination of coverage of child.

PORTABILITY AND ACCOUNTABILITY

General Provisions

NRS 689A.470        Definitions. [Effective through December 31, 2013.]

NRS 689A.470        Definitions. [Effective January 1, 2014.]

NRS 689A.475        “Affiliated” defined.

NRS 689A.480        “Basic health benefit plan” defined. [Effective through December 31, 2013.]

NRS 689A.485        “Bona fide association” defined.

NRS 689A.490        “Church plan” defined.

NRS 689A.495        “Control” defined.

NRS 689A.500        “Converted policy” defined. [Effective through December 31, 2013.]

NRS 689A.505        “Creditable coverage” defined.

NRS 689A.510        “Dependent” defined.

NRS 689A.515        “Eligible person” defined. [Effective through December 31, 2013.]

NRS 689A.520        “Established geographic service area” defined. [Effective through December 31, 2013.]

NRS 689A.523        “Exclusion for a preexisting condition” defined.

NRS 689A.525        “Geographic area” defined. [Effective through December 31, 2013.]

NRS 689A.525        “Geographic rating area” defined. [Effective January 1, 2014.]

NRS 689A.527        “Geographic service area” defined. [Effective January 1, 2014.]

NRS 689A.530        “Governmental plan” defined.

NRS 689A.535        “Group health plan” defined.

NRS 689A.540        “Health benefit plan” defined.

NRS 689A.545        “Health status-related factor” defined. [Effective through December 31, 2013.]

NRS 689A.550        “Individual carrier” defined.

NRS 689A.555        “Individual health benefit plan” defined.

NRS 689A.560        “Individual reinsuring carrier” defined. [Effective through December 31, 2013.]

NRS 689A.565        “Individual risk-assuming carrier” defined. [Effective through December 31, 2013.]

NRS 689A.570        “Plan for coverage of a bona fide association” defined.

NRS 689A.575        “Plan of operation” defined. [Effective through December 31, 2013.]

NRS 689A.580        “Plan sponsor” defined.

NRS 689A.585        “Preexisting condition” defined.

NRS 689A.590        “Producer” defined.

NRS 689A.595        “Program of Reinsurance” defined. [Effective through December 31, 2013.]

NRS 689A.600        “Provision for a restricted network” defined.

NRS 689A.605        “Standard health benefit plan” defined. [Effective through December 31, 2013.]

NRS 689A.610        Applicability; ceding arrangement prohibited in certain circumstances. [Effective through December 31, 2013.]

NRS 689A.615        Certain plan, fund or program to be treated as employee welfare benefit plan which is group health plan; partnership deemed employer of each partner.

NRS 689A.620        Certain person with break in coverage deemed eligible person. [Effective through December 31, 2013.]

 

Individual Carriers

NRS 689A.630        Requirement to renew coverage at option of individual; exceptions; discontinuation of form of product of health benefit plan; discontinuation of health benefit plan available through bona fide association. [Effective through December 31, 2013.]

NRS 689A.630        Requirement to renew coverage at option of individual; exceptions; discontinuation of form of product of health benefit plan; discontinuation of health benefit plan available through bona fide association. [Effective January 1, 2014.]

NRS 689A.635        Coverage offered through network plan not required to be offered to eligible person who does not reside or work in established geographic service area. [Effective through December 31, 2013.]

NRS 689A.635        Coverage offered through network plan not required to be offered to person who does not reside or work in geographic service area or geographic rating area. [Effective January 1, 2014.]

NRS 689A.637        Coverage offered through plan that provides for restricted network: Contracts with certain federally qualified health centers. [Effective through December 31, 2013.]

NRS 689A.637        Coverage offered through plan that provides for restricted network: Contracts with certain federally qualified health centers. [Effective January 1, 2014.]

NRS 689A.640        Each health benefit plan marketed in this State required to be offered to eligible persons. [Effective through December 31, 2013.]

NRS 689A.645        Coverage to eligible person who does not reside in established geographic service area not required; coverage within certain areas not required. [Effective through December 31, 2013.]

NRS 689A.650        Coverage to eligible persons not required under certain circumstances; notice to Commissioner of and prohibition on writing new business after election not to offer new coverage required. [Effective through December 31, 2013.]

NRS 689A.655        Requirement to file basic and standard health benefit plans with Commissioner; disapproval of plan. [Effective through December 31, 2013.]

NRS 689A.660        Prohibited acts concerning preexisting conditions and modification of health benefit plan. [Effective through December 31, 2013.]

NRS 689A.665        Certain health carriers not required to offer health benefit insurance coverage to individuals. [Effective through December 31, 2013.]

NRS 689A.670        Election to operate as individual risk-assuming carrier or individual reinsuring carrier: Notice to Commissioner; effective date; change in status. [Effective through December 31, 2013.]

NRS 689A.675        Election to act as individual risk-assuming carrier: Suspension by Commissioner; applicable statutes. [Effective through December 31, 2013.]

NRS 689A.680        Rates for individual health benefit plans to be developed based on rating characteristics: Prohibited characteristics; health status as rating factor. [Effective through December 31, 2013.]

NRS 689A.685        Amount of change in rate of single block of business; plan with provision for restricted network; involuntary transfer of individual or dependent prohibited; premiums adjusted for block of business. [Effective through December 31, 2013.]

NRS 689A.690        Information required to be disclosed as part of solicitation and sales materials; information required to be maintained at place of business; actuarial certification required to be filed with Commissioner. [Effective through December 31, 2013.]

NRS 689A.690        Information required to be disclosed as part of solicitation and sales materials; information required to be maintained at place of business. [Effective January 1, 2014.]

NRS 689A.695        Information and documents to be made available to Commissioner; proprietary information. [Effective through December 31, 2013.]

NRS 689A.695        Information and documents to be made available to Commissioner; proprietary information. [Effective January 1, 2014.]

NRS 689A.700        Regulations regarding rates. [Effective through December 31, 2013.]

NRS 689A.700        Regulations regarding rates. [Effective January 1, 2014.]

NRS 689A.705        Regulations concerning reissuance of health benefit plan.

NRS 689A.710        Prohibited acts; denial of application for coverage; regulations; violation may constitute unfair trade practice; applicability of section. [Effective through December 31, 2013.]

NRS 689A.710        Prohibited acts; denial of application for coverage; regulations; violation may constitute unfair trade practice; applicability of section. [Effective January 1, 2014.]

 

Individual Health Insurance Coverage

NRS 689A.715        Requirements for employee welfare benefit plan for providing benefits for employees of more than one employer.

NRS 689A.720        Written certification of coverage required for determining period of creditable coverage accumulated by person; provision of certificate to insured.

 

Bona Fide Associations

NRS 689A.725        Requirements for plan for coverage. [Effective through December 31, 2013.]

NRS 689A.725        Requirements for plan for coverage. [Effective January 1, 2014.]

NRS 689A.730        Producer may only sign up eligible persons if eligible persons are actively engaged in or related to association. [Effective through December 31, 2013.]

 

Miscellaneous Provisions

NRS 689A.740        Regulations.

SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS

NRS 689A.745        Approval; requirements; examination.

NRS 689A.750        Annual report; insurer to maintain records of complaints concerning something other than health care services.

NRS 689A.755        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 689A.010  Short title.  This chapter may be cited as the Uniform Health Policy Provision Law.

      (Added to NRS by 1971, 1751)

      NRS 689A.020  Scope. [Effective through December 31, 2013.]  Nothing in this chapter applies to or affects:

      1.  Any policy of liability or workers’ compensation insurance with or without supplementary expense coverage therein.

      2.  Any group or blanket policy.

      3.  Life insurance, endowment or annuity contracts, or contracts supplemental thereto which contain only such provisions relating to health insurance as to:

      (a) Provide additional benefits in case of death or dismemberment or loss of sight by accident or accidental means; or

      (b) Operate to safeguard such contracts against lapse, or to give a special surrender value or special benefit or an annuity if the insured or annuitant becomes totally and permanently disabled, as defined by the contract or supplemental contract.

      4.  Reinsurance, except as otherwise provided in NRS 689A.470 to 689A.740, inclusive, and 689C.610 to 689C.980, inclusive, relating to the program of reinsurance.

      (Added to NRS by 1971, 1751; A 1997, 2899)

      NRS 689A.020  Scope. [Effective January 1, 2014.]  Nothing in this chapter applies to or affects:

      1.  Any policy of liability or workers’ compensation insurance with or without supplementary expense coverage therein.

      2.  Any group or blanket policy.

      3.  Life insurance, endowment or annuity contracts, or contracts supplemental thereto which contain only such provisions relating to health insurance as to:

      (a) Provide additional benefits in case of death or dismemberment or loss of sight by accident or accidental means; or

      (b) Operate to safeguard such contracts against lapse, or to give a special surrender value or special benefit or an annuity if the insured or annuitant becomes totally and permanently disabled, as defined by the contract or supplemental contract.

      4.  Reinsurance, except as otherwise provided in NRS 689A.470 to 689A.740, inclusive, and 689C.610 to 689C.940, inclusive, relating to the program of reinsurance.

      (Added to NRS by 1971, 1751; A 1997, 2899; 2013, 3608, effective January 1, 2014)

      NRS 689A.030  General requirements. [Effective through December 31, 2013.]  A policy of health insurance must not be delivered or issued for delivery to any person in this State unless it otherwise complies with this Code, and complies with the following:

      1.  The entire money and other considerations for the policy must be expressed therein.

      2.  The time when the insurance takes effect and terminates must be expressed therein.

      3.  It must purport to insure only one person, except that a policy may insure, originally or by subsequent amendment, upon the application of an adult member of a family, who shall be deemed the policyholder, any two or more eligible members of that family, including the husband, wife, dependent children, from the time of birth, adoption or placement for the purpose of adoption as provided in NRS 689A.043, or any children under a specified age which must not exceed 19 years except as provided in NRS 689A.045, and any other person dependent upon the policyholder.

      4.  The style, arrangement and overall appearance of the policy must not give undue prominence to any portion of the text, and every printed portion of the text of the policy and of any endorsements or attached papers must be plainly printed in light-faced type of a style in general use, the size of which must be uniform and not less than 10 points with a lowercase unspaced alphabet length not less than 120 points. “Text” includes all printed matter except the name and address of the insurer, the name or the title of the policy, the brief description, if any, and captions and subcaptions.

      5.  The exceptions and reductions of indemnity must be set forth in the policy and, other than those contained in NRS 689A.050 to 689A.290, inclusive, must be printed, at the insurer’s option, with the benefit provision to which they apply or under an appropriate caption such as “Exceptions” or “Exceptions and Reductions,” except that if an exception or reduction specifically applies only to a particular benefit of the policy, a statement of that exception or reduction must be included with the benefit provision to which it applies.

      6.  Each such form, including riders and endorsements, must be identified by a number in the lower left-hand corner of the first page thereof.

      7.  The policy must not contain any provision purporting to make any portion of the charter, rules, constitution or bylaws of the insurer a part of the policy unless that portion is set forth in full in the policy, except in the case of the incorporation of or reference to a statement of rates or classification of risks, or short-rate table filed with the Commissioner.

      8.  The policy must provide benefits for expense arising from care at home or health supportive services if that care or service was prescribed by a physician and would have been covered by the policy if performed in a medical facility or facility for the dependent as defined in chapter 449 of NRS.

      9.  The policy must provide, at the option of the applicant, benefits for expenses incurred for the treatment of abuse of alcohol or drugs, unless the policy provides coverage only for a specified disease or provides for the payment of a specific amount of money if the insured is hospitalized or receiving health care in his or her home.

      10.  The policy must provide benefits for expense arising from hospice care.

      (Added to NRS by 1971, 1752; A 1973, 546; 1975, 446, 1108, 1848; 1979, 1176; 1983, 1933, 2035; 1985, 1568, 1772; 1989, 738, 1031)

      NRS 689A.030  General requirements. [Effective January 1, 2014.]  A policy of health insurance must not be delivered or issued for delivery to any person in this State unless it otherwise complies with this Code, and complies with the following:

      1.  The entire money and other considerations for the policy must be expressed therein.

      2.  The time when the insurance takes effect and terminates must be expressed therein.

      3.  It must purport to insure only one person, except that a policy may insure, originally or by subsequent amendment, upon the application of an adult member of a family, who shall be deemed the policyholder, any two or more eligible members of that family, including the husband, wife, domestic partner as defined in NRS 122A.030, dependent children, from the time of birth, adoption or placement for the purpose of adoption as provided in NRS 689A.043, or any child on or before the last day of the month in which the child attains 26 years of age, and any other person dependent upon the policyholder.

      4.  The style, arrangement and overall appearance of the policy must not give undue prominence to any portion of the text, and every printed portion of the text of the policy and of any endorsements or attached papers must be plainly printed in light-faced type of a style in general use, the size of which must be uniform and not less than 10 points with a lowercase unspaced alphabet length not less than 120 points. “Text” includes all printed matter except the name and address of the insurer, the name or the title of the policy, the brief description, if any, and captions and subcaptions.

      5.  The exceptions and reductions of indemnity must be set forth in the policy and, other than those contained in NRS 689A.050 to 689A.290, inclusive, must be printed, at the insurer’s option, with the benefit provision to which they apply or under an appropriate caption such as “Exceptions” or “Exceptions and Reductions,” except that if an exception or reduction specifically applies only to a particular benefit of the policy, a statement of that exception or reduction must be included with the benefit provision to which it applies.

      6.  Each such form, including riders and endorsements, must be identified by a number in the lower left-hand corner of the first page thereof.

      7.  The policy must not contain any provision purporting to make any portion of the charter, rules, constitution or bylaws of the insurer a part of the policy unless that portion is set forth in full in the policy, except in the case of the incorporation of or reference to a statement of rates or classification of risks, or short-rate table filed with the Commissioner.

      8.  The policy must provide benefits for expense arising from care at home or health supportive services if that care or service was prescribed by a physician and would have been covered by the policy if performed in a medical facility or facility for the dependent as defined in chapter 449 of NRS.

      9.  The policy must provide, at the option of the applicant, benefits for expenses incurred for the treatment of abuse of alcohol or drugs, unless the policy provides coverage only for a specified disease or provides for the payment of a specific amount of money if the insured is hospitalized or receiving health care in his or her home.

      10.  The policy must provide benefits for expense arising from hospice care.

      (Added to NRS by 1971, 1752; A 1973, 546; 1975, 446, 1108, 1848; 1979, 1176; 1983, 1933, 2035; 1985, 1568, 1772; 1989, 738, 1031; 2013, 3609, effective January 1, 2014)

      NRS 689A.035  Contracts between insurer and provider of health care: Prohibiting insurer from charging provider of health care fee for inclusion on list of providers given to insureds; form to obtain information on provider of health care; modification; providing schedule of fees.

      1.  An insurer shall not charge a provider of health care a fee to include the name of the provider on a list of providers of health care given by the insurer to its insureds.

      2.  An insurer shall not contract with a provider of health care to provide health care to an insured unless the insurer uses the form prescribed by the Commissioner pursuant to NRS 629.095 to obtain any information related to the credentials of the provider of health care.

      3.  A contract between an insurer and a provider of health care may be modified:

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

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

      4.  If an insurer contracts with a provider of health care to provide health care to an insured, the insurer shall:

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

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

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

      (Added to NRS by 1999, 1647; A 2001, 2729; 2003, 3355; 2011, 2532)

REQUIRED PROVISIONS

      NRS 689A.040  Contents of policy; substitution of provisions; captions; omission or modification of provisions. [Effective through December 31, 2013.]

      1.  Except as otherwise provided in subsections 2 and 3, each such policy delivered or issued for delivery to any person in this State must contain the provisions specified in NRS 689A.050 to 689A.170, inclusive, in the words in which the provisions appear, except that the insurer may, at its option, substitute for one or more of the provisions corresponding provisions of different wording approved by the Commissioner which are in each instance not less favorable in any respect to the insured or the beneficiary. Each such provision must be preceded individually by the applicable caption shown or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the Commissioner may approve.

      2.  Each policy delivered or issued for delivery in this State after November 1, 1973, must contain a provision, if applicable, setting forth the provisions of NRS 689A.045.

      3.  If any such provision is in whole or in part inapplicable to or inconsistent with the coverage provided by a particular form of policy, the insurer, with the approval of the Commissioner, may omit from the policy any inapplicable provision or part of a provision, and shall modify any inconsistent provision or part of a provision in such a manner as to make the provision as contained in the policy consistent with the coverage provided by the policy.

      (Added to NRS by 1971, 1753; A 1973, 547; 1985, 1059; 2007, 3237)

      NRS 689A.040  Contents of policy; substitution of provisions; captions; omission or modification of provisions. [Effective January 1, 2014.]

      1.  Except as otherwise provided in subsections 2 and 3, each such policy delivered or issued for delivery to any person in this State must contain the provisions specified in NRS 689A.050 to 689A.170, inclusive, in the words in which the provisions appear, except that the insurer may, at its option, substitute for one or more of the provisions corresponding provisions of different wording approved by the Commissioner which are in each instance not less favorable in any respect to the insured or the beneficiary. Each such provision must be preceded individually by the applicable caption shown or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the Commissioner may approve.

      2.  If any such provision is in whole or in part inapplicable to or inconsistent with the coverage provided by a particular form of policy, the insurer, with the approval of the Commissioner, may omit from the policy any inapplicable provision or part of a provision, and shall modify any inconsistent provision or part of a provision in such a manner as to make the provision as contained in the policy consistent with the coverage provided by the policy.

      (Added to NRS by 1971, 1753; A 1973, 547; 1985, 1059; 2007, 3237; 2013, 3610, effective January 1, 2014)

      NRS 689A.0403  Procedure for arbitration of disputes concerning independent medical evaluations.

      1.  Each policy of health insurance must include a procedure for binding arbitration to resolve disputes concerning independent medical evaluations pursuant to the rules of the American Arbitration Association.

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

      3.  The independent evaluation must include a physical examination of the patient, unless the patient is deceased, and a personal review of all X rays and reports prepared by the primary treating physician or chiropractor. A certified copy of all reports of findings must be sent to the primary treating physician or chiropractor and the insured person within 10 working days after the evaluation. If the insured person disagrees with the finding of the evaluation, the insured person must submit an appeal to the insurer pursuant to the procedure for binding arbitration set forth in the policy of insurance within 30 days after 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, 2114)

      NRS 689A.04033  Coverage for treatment received as part of clinical trial or study.

      1.  A policy of health insurance must provide coverage for medical treatment which a policyholder or subscriber 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 policyholder or subscriber has signed, before participating in the clinical trial or study, a statement of consent indicating that the policyholder or subscriber 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 policyholder or subscriber.

      (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 a policyholder or subscriber participating in a Phase I clinical trial or study.

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

      (e) Health care services required for the clinically appropriate monitoring of the policyholder or subscriber 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 policyholder or subscriber 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 689A.04036, the services provided pursuant to paragraphs (b), (c), (e) and (f) must be covered only if the services are provided by a provider with whom the insurer has contracted for such services. If the insurer has not contracted for the provision of such services, the insurer shall pay the provider the rate of reimbursement that is paid to other providers with whom the insurer has contracted for similar services and the provider shall accept that rate of reimbursement as payment in full.

      3.  Particular medical treatment described in subsection 2 and provided to a policyholder or subscriber 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 policyholder or subscriber.

      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 policyholder’s or subscriber’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 policyholder or subscriber during the clinical trial or study.

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

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

      5.  An insurer who delivers or issues for delivery a policy of 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 policyholder or subscriber, protocols for the clinical trial or study and any other materials related to the scope of the clinical trial or study relevant to the coverage of medical treatment pursuant to this section.

      6.  An insurer who delivers or issues for delivery a policy specified in subsection 1 shall:

      (a) Include in the disclosure required pursuant to NRS 689A.390 notice to each policyholder and subscriber 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.  An insurer who delivers or issues for delivery a policy specified in subsection 1 is immune from liability for:

      (a) Any injury to a policyholder or subscriber caused by:

             (1) Any medical treatment provided to the policyholder or subscriber 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 policyholder or subscriber 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 a policyholder’s or subscriber’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, 3519; A 2005, 2009)

      NRS 689A.04036  Coverage for continued medical treatment.

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

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

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

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

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

      (b) The provider of health care is entitled to receive reimbursement from the insurer for the medical treatment the provider of health care provides to the insured pursuant to this section, if the provider of health care agrees:

             (1) To provide medical treatment under the terms of the contract between the provider of health care and the insurer with regard to the insured, including, without limitation, the rates of payment for providing medical service, as those terms existed before the termination of the contract between the provider of health care and the insurer; and

             (2) Not to seek payment from the insured for any medical service provided by the provider of health care that the provider of health care could not have received from the insured were the provider of health care still under contract with the insurer.

      3.  The coverage required by subsection 2 must be provided until the later of:

      (a) The 120th day after the date the contract is terminated; or

      (b) If the medical condition is pregnancy, the 45th day after:

             (1) The date of delivery; or

             (2) If the pregnancy does not end in delivery, the date of the end of the pregnancy.

      4.  The requirements of this section do not apply to a provider of health care if:

      (a) The provider of health care was under contract with the insurer and the insurer terminated that contract because of the medical incompetence or professional misconduct of the provider of health care; and

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

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

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

      (Added to NRS by 2003, 3354)

      NRS 689A.0404  Coverage for use of certain drugs for treatment of cancer.  Except as otherwise provided in NRS 689A.04033:

      1.  No policy of health insurance that provides coverage for a drug approved by the Food and Drug Administration for use in the treatment of an illness, disease or other medical condition may be delivered or issued for delivery in this state unless the policy includes coverage for any other use of the drug for the treatment of cancer, if that use is:

      (a) Specified in the most recent edition of or supplement to:

             (1) The United States Pharmacopoeia Drug Information; or

             (2) The American Hospital Formulary Service Drug Information; or

      (b) Supported by at least two articles reporting the results of scientific studies that are published in scientific or medical journals, as defined in 21 C.F.R. § 99.3.

      2.  The coverage required pursuant to this section:

      (a) Includes coverage for any medical services necessary to administer the drug to the insured.

      (b) Does not include coverage for any:

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

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

      3.  A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 1999, has the legal effect of including the coverage required by this section, and any provision of the policy that conflicts with the provisions of this section is void.

      (Added to NRS by 1999, 759; A 2003, 3522)

      NRS 689A.04042  Coverage for screening for colorectal cancer.

      1.  A policy of health insurance that provides coverage for the treatment of colorectal cancer must provide coverage for colorectal cancer screening in accordance with:

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

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

      2.  A policy of 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, 1334)

      NRS 689A.04045  Coverage for prescription drug previously approved for medical condition of insured.

      1.  Except as otherwise provided in this section, a policy of health insurance which provides coverage for prescription drugs must not limit or exclude coverage for a drug if the drug:

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

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

      2.  The provisions of subsection 1 do not:

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

      (b) Prohibit:

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

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

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

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

      3.  Any provision of a policy subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 2001, which is in conflict with this section is void.

      (Added to NRS by 2001, 857; A 2003, 2298)

      NRS 689A.0405  Coverage for cytologic screening test and mammograms for certain women.

      1.  A policy of health insurance must provide coverage for benefits payable for expenses incurred for:

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

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

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

      2.  A policy of health insurance must not require an insured to obtain prior authorization for any service provided pursuant to subsection 1.

      3.  A policy subject to the provisions of this chapter which is delivered, issued for delivery or renewed on or after October 1, 1989, has the legal effect of including the coverage required by subsection 1, and any provision of the policy or the renewal which is in conflict with subsection 1 is void.

      (Added to NRS by 1989, 1888; A 1997, 1729)

      NRS 689A.041  Coverage relating to mastectomy.

      1.  A policy of health insurance which provides coverage for the surgical procedure known as a mastectomy must also provide commensurate coverage for:

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

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

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

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

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

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

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

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

Ê whichever is earlier.

      5.  A plan or issuer may not:

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

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

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

      7.  If reconstructive surgery is begun within 3 years after a mastectomy, the amount of the benefits for that surgery must equal the 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, 614; A 1989, 1889; 2001, 2218)

      NRS 689A.0413  Coverage for certain gynecological or obstetrical services without authorization or referral from primary care physician.

      1.  A policy of health insurance must include a provision authorizing a woman covered by the policy to obtain covered gynecological or obstetrical services without first receiving authorization or a referral from her primary care physician.

      2.  The provisions of this section do not authorize a woman covered by a policy of health insurance to designate an obstetrician or gynecologist as her primary care physician.

      3.  A policy subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 1999, has the legal effect of including the coverage required by this section, and any provision of the policy or the renewal which is in conflict with this section is void.

      4.  As used in this section, “primary care physician” has the meaning ascribed to it in NRS 695G.060.

      (Added to NRS by 1999, 1943)

      NRS 689A.0415  Coverage for drug or device for contraception and for hormone replacement therapy in certain circumstances; prohibited actions by insurer; exceptions.

      1.  Except as otherwise provided in subsection 5, an insurer that offers or issues a policy of health insurance which provides coverage for prescription drugs or devices shall include in the policy coverage for:

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

      (b) Any type of hormone replacement therapy,

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

      2.  An insurer that offers or issues a policy of health insurance that provides coverage for prescription drugs shall not:

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

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

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

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

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

      3.  Except as otherwise provided in subsection 5, a policy subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 1999, has the legal effect of including the coverage required by subsection 1, and any provision of the policy or the renewal which is in conflict with this section is void.

      4.  The provisions of this section do not:

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

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

      5.  An insurer which offers or issues a policy of health insurance and which is affiliated with a religious organization is not required to provide the coverage required by paragraph (a) of subsection 1 if the insurer objects on religious grounds. Such an insurer shall, before the issuance of a policy of health insurance and before the renewal of such a policy, provide to the prospective insured, written notice of the coverage that the insurer refuses to provide pursuant to this subsection.

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

      (Added to NRS by 1999, 1995)

      NRS 689A.0417  Coverage for 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 policy of health insurance which provides coverage for outpatient care shall include in the policy coverage for any health care service related to contraceptives or hormone replacement therapy.

      2.  An insurer that offers or issues a policy of health insurance that provides coverage for outpatient care shall not:

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

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

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

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

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

      3.  Except as otherwise provided in subsection 5, a policy subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 1999, has the legal effect of including the coverage required by subsection 1, and any provision of the policy or the renewal which is in conflict with this section is void.

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

      5.  An insurer which offers or issues such a policy of health insurance and which is affiliated with a religious organization is not required to provide the coverage for health care service related to contraceptives required by this section if the insurer objects on religious grounds. Such an insurer shall, before the issuance of a policy of health insurance and before the renewal of such a policy, provide to the prospective insured written notice of the coverage that the insurer refuses to provide pursuant to this subsection.

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

      (Added to NRS by 1999, 1996)

      NRS 689A.042  Coverage relating to complications of pregnancy.

      1.  No health insurance policy may be delivered or issued for delivery in this state if it contains any exclusion, reduction or other limitation of coverage relating to complications of pregnancy, unless the provision applies generally to all benefits payable under the policy.

      2.  As used in this section, the term “complications of pregnancy” includes any condition which requires hospital confinement for medical treatment and:

      (a) If the pregnancy is not terminated, is caused by an injury or sickness not directly related to the pregnancy or by acute nephritis, nephrosis, cardiac decompensation, missed abortion or similar medically diagnosed conditions; or

      (b) If the pregnancy is terminated, results in nonelective cesarean section, ectopic pregnancy or spontaneous termination.

      3.  A policy subject to the provisions of this chapter which is delivered or issued for delivery on or after July 1, 1977, has the legal effect of including the coverage required by this section, and any provision of the policy which is in conflict with this section is void.

      (Added to NRS by 1977, 415)

      NRS 689A.0423  Coverage for treatment of certain inherited metabolic diseases.

      1.  A policy of health insurance must provide coverage for:

      (a) Enteral formulas for use at home that are prescribed or ordered by a physician as medically necessary for the treatment of inherited metabolic diseases characterized by deficient metabolism, or malabsorption originating from congenital defects or defects arising shortly after birth, of amino acid, organic acid, carbohydrate or fat; and

      (b) At least $2,500 per year for special food products which are prescribed or ordered by a physician as medically necessary for the treatment of a person described in paragraph (a).

      2.  The coverage required by subsection 1 must be provided whether or not the condition existed when the policy was purchased.

      3.  A policy subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 1998, has the legal effect of including the coverage required by this section, and any provision of the policy or the renewal which is in conflict with this section is void.

      4.  As used in this section:

      (a) “Inherited metabolic disease” means a disease caused by an inherited abnormality of the body chemistry of a person.

      (b) “Special food product” means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be consumed under the direction of a physician for the dietary treatment of an inherited metabolic disease. The term does not include a food that is naturally low in protein.

      (Added to NRS by 1997, 1526)

      NRS 689A.0425  Individual health benefit plan that includes coverage for maternity care and pediatric care: Requirement to allow minimum stay in hospital in connection with childbirth; prohibited acts.

      1.  Except as otherwise provided in this subsection, an individual health benefit plan issued pursuant to this chapter that includes coverage for maternity care and pediatric care for newborn infants may not restrict benefits for any length of stay in a hospital in connection with childbirth for a mother or newborn infant covered by the plan to:

      (a) Less than 48 hours after a normal vaginal delivery; and

      (b) Less than 96 hours after a cesarean section.

Ê If a different length of stay is provided in the guidelines established by the American College of Obstetricians and Gynecologists, or its successor organization, and the American Academy of Pediatrics, or its successor organization, the individual health benefit plan may follow such guidelines in lieu of following the length of stay set forth above. The provisions of this subsection do not apply to any individual health benefit plan in any case in which the decision to discharge the mother or newborn infant before the expiration of the minimum length of stay set forth in this subsection is made by the attending physician of the mother or newborn infant.

      2.  Nothing in this section requires a mother to:

      (a) Deliver her baby in a hospital; or

      (b) Stay in a hospital for a fixed period following the birth of her child.

      3.  An individual health benefit plan that offers coverage for maternity care and pediatric care of newborn infants may not:

      (a) Deny a mother or her newborn infant coverage or continued coverage under the terms of the plan or coverage if the sole purpose of the denial of coverage or continued coverage is to avoid the requirements of this section;

      (b) Provide monetary payments or rebates to a mother to encourage her to accept less than the minimum protection available pursuant to this section;

      (c) Penalize, or otherwise reduce or limit, the reimbursement of an attending provider of health care because the attending provider of health care provided care to a mother or newborn infant in accordance with the provisions of this section;

      (d) Provide incentives of any kind to an attending physician to induce the attending physician to provide care to a mother or newborn infant in a manner that is inconsistent with the provisions of this section; or

      (e) Except as otherwise provided in subsection 4, restrict benefits for any portion of a hospital stay required pursuant to the provisions of this section in a manner that is less favorable than the benefits provided for any preceding portion of that stay.

      4.  Nothing in this section:

      (a) Prohibits an individual health benefit plan from imposing a deductible, coinsurance or other mechanism for sharing costs relating to benefits for hospital stays in connection with childbirth for a mother or newborn child covered by the plan, except that such coinsurance or other mechanism for sharing costs for any portion of a hospital stay required by this section may not be greater than the coinsurance or other mechanism for any preceding portion of that stay.

      (b) Prohibits an arrangement for payment between an individual health benefit plan and a provider of health care that uses capitation or other financial incentives, if the arrangement is designed to provide services efficiently and consistently in the best interest of the mother and her newborn infant.

      (c) Prevents an individual health benefit plan from negotiating with a provider of health care concerning the level and type of reimbursement to be provided in accordance with this section.

      (Added to NRS by 1997, 2898)

      NRS 689A.0427  Coverage for management and treatment of diabetes.

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

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

      (a) Shall include in the disclosure required pursuant to NRS 689A.390 notice to each policyholder and subscriber under the policy of the availability of the benefits required by this section.

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

      3.  A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 1998, has the legal effect of including the coverage required by this section, and any provision of the policy that conflicts with this section is void.

      4.  As used in this section:

      (a) “Coverage for the management and treatment of diabetes” includes coverage for medication, equipment, supplies and appliances that are medically necessary for the treatment of diabetes.

      (b) “Coverage for the self-management of diabetes” includes:

             (1) The training and education provided to an insured person after the insured 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 insured person and which requires modification of the insured 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, 742)

      NRS 689A.043  Coverage of newly born and adopted children and children placed for adoption.

      1.  All individual health insurance policies providing family coverage on an expense-incurred basis must as to family members’ coverage provide that the health benefits applicable for children are payable with respect to:

      (a) A newly born child of the insured from the moment of birth;

      (b) An adopted child from the date the adoption becomes effective, if the child was not placed in the home before adoption; and

      (c) A child placed with the insured for the purpose of adoption from the moment of placement as certified by the public or private agency making the placement. The coverage of such a child ceases if the adoption proceedings are terminated as certified by the public or private agency making the placement.

Ê The policies must provide the coverage specified in subsection 3 and must not exclude premature births.

      2.  The policy or contract may require that notification of:

      (a) The birth of a newly born child;

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

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

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

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

      (Added to NRS by 1975, 1109; A 1989, 739)

      NRS 689A.0435  Coverage for autism spectrum disorders.

      1.  A health benefit plan must provide an option of coverage for screening for and diagnosis of autism spectrum disorders and for treatment of autism spectrum disorders for persons covered by the policy under the age of 18 or, if enrolled in high school, until the person reaches the age of 22.

      2.  Optional coverage provided pursuant to this section must be subject to:

      (a) A maximum benefit of not less than $36,000 per year for applied behavior analysis treatment; and

      (b) Copayment, deductible and coinsurance provisions and any other general exclusions or limitations of a policy of health insurance to the same extent as other medical services or prescription drugs covered by the policy.

      3.  A health benefit plan that offers or issues a policy of health insurance which provides coverage for outpatient care shall not:

      (a) Require an insured to pay a higher deductible, copayment or coinsurance or require a longer waiting period for optional coverage for outpatient care related to autism spectrum disorders than is required for other outpatient care covered by the policy; or

      (b) Refuse to issue a policy of health insurance or cancel a policy of health insurance solely because the person applying for or covered by the policy uses or may use in the future any of the services listed in subsection 1.

      4.  Except as provided in subsections 1 and 2, an insurer who offers optional coverage pursuant to subsection 1 shall not limit the number of visits an insured may make to any person, entity or group for treatment of autism spectrum disorders.

      5.  Treatment of autism spectrum disorders must be identified in a treatment plan and may include medically necessary habilitative or rehabilitative care, prescription care, psychiatric care, psychological care, behavior therapy or therapeutic care that is:

      (a) Prescribed for a person diagnosed with an autism spectrum disorder by a licensed physician or licensed psychologist; and

      (b) Provided for a person diagnosed with an autism spectrum disorder by a licensed physician, licensed psychologist, licensed behavior analyst or other provider that is supervised by the licensed physician, psychologist or behavior analyst.

Ê An insurer may request a copy of and review a treatment plan created pursuant to this subsection.

      6.  Nothing in this section shall be construed as requiring an insurer to provide reimbursement to an early intervention agency or school for services delivered through early intervention or school services.

      7.  As used in this section:

      (a) “Applied behavior analysis” means the design, implementation and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including, without limitation, the use of direct observation, measurement and functional analysis of the relations between environment and behavior.

      (b) “Autism spectrum disorders” means a neurobiological medical condition including, without limitation, autistic disorder, Asperger’s Disorder and Pervasive Developmental Disorder Not Otherwise Specified.

      (c) “Behavioral therapy” means any interactive therapy derived from evidence-based research, including, without limitation, discrete trial training, early intensive behavioral intervention, intensive intervention programs, pivotal response training and verbal behavior provided by a licensed psychologist, licensed behavior analyst, licensed assistant behavior analyst or certified autism behavior interventionist.

      (d) “Certified autism behavior interventionist” means a person who is certified as an autism behavior interventionist by the Board of Psychological Examiners and who provides behavior therapy under the supervision of:

             (1) A licensed psychologist;

             (2) A licensed behavior analyst; or

             (3) A licensed assistant behavior analyst.

      (e) “Evidence-based research” means research that applies rigorous, systematic and objective procedures to obtain valid knowledge relevant to autism spectrum disorders.

      (f) “Habilitative or rehabilitative care” means counseling, guidance and professional services and treatment programs, including, without limitation, applied behavior analysis, that are necessary to develop, maintain and restore, to the maximum extent practicable, the functioning of a person.

      (g) “Licensed assistant behavior analyst” means a person who holds current certification or meets the standards to be certified as a board certified assistant behavior analyst issued by the Behavior Analyst Certification Board, Inc., or any successor in interest to that organization, who is licensed as an assistant behavior analyst by the Board of Psychological Examiners and who provides behavioral therapy under the supervision of a licensed behavior analyst or psychologist.

      (h) “Licensed behavior analyst” means a person who holds current certification or meets the standards to be certified as a board certified behavior analyst or a board certified assistant behavior analyst issued by the Behavior Analyst Certification Board, Inc., or any successor in interest to that organization, and who is licensed as a behavior analyst by the Board of Psychological Examiners.

      (i) “Prescription care” means medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need or effectiveness of the medications.

      (j) “Psychiatric care” means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.

      (k) “Psychological care” means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.

      (l) “Screening for autism spectrum disorders” means medically necessary assessments, evaluations or tests to screen and diagnose whether a person has an autism spectrum disorder.

      (m) “Therapeutic care” means services provided by licensed or certified speech pathologists, occupational therapists and physical therapists.

      (n) “Treatment plan” means a plan to treat an autism spectrum disorder that is prescribed by a licensed physician or licensed psychologist and may be developed pursuant to a comprehensive evaluation in coordination with a licensed behavior analyst.

      (Added to NRS by 2009, 1465)

      NRS689A.044  Coverage for human papillomavirus vaccine. [Effective through December 31, 2013.]

      1.  A policy of health insurance 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 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, 3236)

      NRS689A.044  Coverage for human papillomavirus vaccine. [Effective January 1, 2014.]

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

      2.  A policy of health insurance must not require an insured to obtain prior authorization for any service provided pursuant to subsection 1.

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

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

      (Added to NRS by 2007, 3236; A 2013, 3610, effective January 1, 2014)

      NRS689A.0445  Coverage for prostate cancer screening.

      1.  A policy of health insurance that provides coverage for the treatment of prostate cancer must provide coverage for prostate cancer screening in accordance with:

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

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

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

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

      (Added to NRS by 2007, 3236)

      NRS 689A.0447  Coverage for orally administered chemotherapy.

      1.  An insurer that offers or issues a policy of health insurance which provides coverage for the treatment of cancer through the use of chemotherapy shall not:

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

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

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

      2.  A policy subject to the provisions of this chapter which provides coverage for the treatment of cancer through the use of chemotherapy and that is delivered, issued for delivery or renewed on or after January 1, 2015, has the legal effect of providing that coverage subject to the requirements of this section, and any provision of the policy or renewal which is in conflict with this section is void.

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

      (Added to NRS by 2013, 1997; A 2013, 3657)

      NRS 689A.045  Termination of coverage on dependent child. [Effective through December 31, 2013.]

      1.  Any health insurance policy delivered or issued for delivery after November 1, 1973, which provides for the termination of coverage on a dependent child of a policyholder when such child attains a contractually specified limiting age shall also provide that such coverage shall not terminate when the dependent child reaches such age if such child is and continues to be:

      (a) Incapable of self-sustaining employment due to a physical handicap or an intellectual disability; and

      (b) Dependent on the policyholder for support and maintenance.

      2.  Proof of such child’s incapacity and dependency shall be furnished to the insurer by the policyholder within 31 days after such child attains the specified limiting age and as often as the insurer may thereafter require, but no more than once a year beginning 2 years after such child attains the specified limiting age.

      (Added to NRS by 1973, 546; A 2013, 699; R 2013, 3661, effective January 1, 2014)

      NRS 689A.0455  Coverage for treatment of conditions relating to severe mental illness. [Effective through December 31, 2013.]

      1.  Notwithstanding any provisions of this Title to the contrary, a policy of health insurance delivered or issued for delivery in this state pursuant to this chapter must provide coverage for the treatment of conditions relating to severe mental illness.

      2.  The coverage required by this section:

      (a) Must provide:

             (1) Benefits for at least 40 days of hospitalization as an inpatient per policy year and 40 visits for treatment as an outpatient per policy year, excluding visits for the management of medication; and

             (2) That two visits for partial or respite care, or a combination thereof, may be substituted for each 1 day of hospitalization not used by the insured. In no event is the policy required to provide coverage for more than 40 days of hospitalization as an inpatient per policy year.

      (b) Is not required to provide benefits for psychosocial rehabilitation or care received as a custodial inpatient.

      3.  Any deductibles and copayments required to be paid for the coverage required by this section must not be greater than 150 percent of the out-of-pocket expenses required to be paid for medical and surgical benefits provided pursuant to the policy of health insurance.

      4.  The provisions of this section do not apply to a policy of health insurance if, at the end of the policy year, the premiums charged for that policy, or a standard grouping of policies, increase by more than 2 percent as a result of providing the coverage required by this section and the insurer obtains an exemption from the Commissioner pursuant to subsection 5.

      5.  To obtain the exemption required by subsection 4, an insurer must submit to the Commissioner a written request therefor that is signed by an actuary and sets forth the reasons and actuarial assumptions upon which the request is based. To determine whether an exemption may be granted, the Commissioner shall subtract from the amount of premiums charged during the policy year the amount of premiums charged during the period immediately preceding the policy year and the amount of any increase in the premiums charged that is attributable to factors that are unrelated to providing the coverage required by this section. The Commissioner shall verify the information within 30 days after receiving the request. The request shall be deemed approved if the Commissioner does not deny the request within that time.

      6.  The provisions of this section do not:

      (a) Limit the provision of specialized services covered by Medicaid for persons with conditions relating to mental health or substance abuse.

      (b) Supersede any provision of federal law, any federal or state policy relating to Medicaid, or the terms and conditions imposed on any Medicaid waiver granted to this state with respect to the provisions of services to persons with conditions relating to mental health or substance abuse.

      7.  A policy of health insurance subject to the provisions of this chapter which is delivered, issued for delivery or renewed on or after January 1, 2000, 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, unless the policy is otherwise exempt from the provisions of this section pursuant to subsection 4.

      8.  As used in this section, “severe mental illness” means any of the following mental illnesses that are biologically based and for which diagnostic criteria are prescribed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, published by the American Psychiatric Association:

      (a) Schizophrenia.

      (b) Schizoaffective disorder.

      (c) Bipolar disorder.

      (d) Major depressive disorders.

      (e) Panic disorder.

      (f) Obsessive-compulsive disorder.

      (Added to NRS by 1999, 3100)

      NRS 689A.0455  Coverage for treatment of conditions relating to severe mental illness. [Effective January 1, 2014.]

      1.  A policy of health insurance delivered or issued for delivery in this state pursuant to this chapter must provide coverage for the treatment of conditions relating to severe mental illness.

      2.  As used in this section, “severe mental illness” means any of the following mental illnesses that are biologically based and for which diagnostic criteria are prescribed in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association:

      (a) Schizophrenia.

      (b) Schizoaffective disorder.

      (c) Bipolar disorder.

      (d) Major depressive disorders.

      (e) Panic disorder.

      (f) Obsessive-compulsive disorder.

      (Added to NRS by 1999, 3100; A 2013, 3610, effective January 1, 2014)

      NRS 689A.046  Benefits for treatment of abuse of alcohol or drugs.

      1.  The benefits provided by a policy for health insurance for treatment of the abuse of alcohol or drugs must consist of:

      (a) Treatment for withdrawal from the physiological effect of alcohol or drugs, with a minimum benefit of $1,500 per calendar year.

      (b) Treatment for a patient admitted to a facility, with a minimum benefit of $9,000 per calendar year.

      (c) Counseling for a person, group or family who is not admitted to a facility, with a minimum benefit of $2,500 per calendar year.

      2.  These benefits must be paid in the same manner as benefits for any other illness covered by a similar policy are paid.

      3.  The insured person is entitled to these benefits if treatment is received in any:

      (a) Facility for the treatment of abuse of alcohol or drugs which is certified by the Division of Public and Behavioral Health of the Department of Health and Human Services.

      (b) Hospital or other medical facility or facility for the dependent which is licensed by the Division of Public and Behavioral Health of the Department of Health and Human Services, accredited by the Joint Commission on Accreditation of Healthcare Organizations and provides a program for the treatment of abuse of alcohol or drugs as part of its accredited activities.

      (Added to NRS by 1979, 1176; A 1983, 2036; 1985, 1569, 1773; 1993, 1918; 1997, 1301; 1999, 1888; 2001, 438)

      NRS 689A.0465  Coverage of treatment of temporomandibular joint.

      1.  Except as otherwise provided in this section, no policy of health insurance may be delivered or issued for delivery in this state if it contains an exclusion of coverage of treatment of the temporomandibular joint whether by specific language in the policy or by a claims settlement practice. A policy may exclude coverage of those methods of treatment which are recognized as dental procedures, including, but not limited to, the extraction of teeth and the application of orthodontic devices and splints.

      2.  The insurer may limit its liability on the treatment of the temporomandibular joint to:

      (a) No more than 50 percent of the usual and customary charges for such treatment actually received by an insured, but in no case more than 50 percent of the maximum benefits provided by the policy for such treatment; and

      (b) Treatment which is medically necessary.

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

      (Added to NRS by 1989, 2137)

REIMBURSEMENT FOR CERTAIN MEDICALLY RELATED TREATMENT AND SERVICES

      NRS 689A.0475  Acupuncture.  If any policy of health insurance provides coverage for acupuncture performed by a physician, the insured is entitled to reimbursement for acupuncture performed by a person who is licensed pursuant to chapter 634A of NRS.

      (Added to NRS by 1991, 1133)

      NRS 689A.048  Treatment by licensed psychologist.  If any policy of health insurance provides coverage for treatment of an illness which is within the authorized scope of the practice of a qualified psychologist, the insured is entitled to reimbursement for treatments by a psychologist who is licensed pursuant to chapter 641 of NRS.

      (Added to NRS by 1979, 367; A 1989, 1553)

      NRS 689A.0483  Treatment by licensed marriage and family therapist or licensed clinical professional counselor.  If any policy of health insurance provides coverage for treatment of an illness which is within the authorized scope of practice of a licensed marriage and family therapist or licensed clinical professional counselor, the insured is entitled to reimbursement for treatment by a marriage and family therapist or clinical professional counselor who is licensed pursuant to chapter 641A of NRS.

      (Added to NRS by 1987, 2133; A 2007, 3093)

      NRS 689A.0485  Treatment by licensed associate in social work, social worker, independent social worker or clinical social worker.  If any policy of health insurance provides coverage for treatment of an illness which is within the authorized scope of the practice of a licensed associate in social work, social worker, independent social worker or clinical social worker, the insured is entitled to reimbursement for treatment by an associate in social work, social worker, independent social worker or clinical social worker who is licensed pursuant to chapter 641B of NRS.

      (Added to NRS by 1987, 1123)

      NRS689A.0487  Treatment by licensed podiatrist.

      1.  If any policy of health insurance provides coverage for treatment of an illness which is within the authorized scope of practice of a qualified podiatrist, the insured is entitled to reimbursement for treatments by a podiatrist who is licensed pursuant to chapter 635 of NRS.

      2.  The terms of the policy must not limit:

      (a) Coverage for treatments by a podiatrist to a number less than for treatments by other physicians.

      (b) Reimbursement for treatments by a podiatrist to an amount less than that reimbursed for similar treatments by other physicians.

      (Added to NRS by 2007, 1046)

      NRS 689A.049  Treatment by licensed chiropractor; restriction on policy limitations.

      1.  If any policy of health insurance provides coverage for treatment of an illness which is within the authorized scope of practice of a qualified chiropractor, the insured is entitled to reimbursement for treatments by a chiropractor who is licensed pursuant to chapter 634 of NRS.

      2.  The terms of the policy must not limit:

      (a) Coverage for treatments by a chiropractor to a number less than for treatments by other physicians.

      (b) Reimbursement for treatments by a chiropractor to an amount less than that reimbursed for similar treatments by other physicians.

      (Added to NRS by 1981, 930; A 1983, 327)

      NRS689A.0493  Treatment by licensed clinical alcohol and drug abuse counselor.  If any policy of health insurance provides coverage for treatment of an illness which is within the authorized scope of practice of a licensed clinical alcohol and drug abuse counselor, the insured is entitled to reimbursement for treatment by a clinical alcohol and drug abuse counselor who is licensed pursuant to chapter 641C of NRS.

      (Added to NRS by 2007, 3093)

      NRS 689A.0495  Services provided by certain registered nurses; restriction on policy limitations; exception.

      1.  If any policy of health insurance provides coverage for services which are within the authorized scope of practice of a registered nurse who is authorized pursuant to chapter 632 of NRS to perform additional acts in an emergency or under other special conditions as prescribed by the State Board of Nursing, and which are reimbursed when provided by another provider of health care, the insured is entitled to reimbursement for services provided by such a registered nurse.

      2.  The terms of the policy must not limit:

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

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

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

      (Added to NRS by 1985, 1446)

      NRS 689A.0497  Provider of medical transportation.

      1.  Except as otherwise provided in subsection 3, every policy of health insurance amended, delivered or issued for delivery in this State after October 1, 1989, that provides coverage for medical transportation, must contain a provision for the direct reimbursement of a provider of medical transportation for covered services if that provider does not receive reimbursement from any other source.

      2.  The insured or the provider may submit the claim for reimbursement. The provider shall not demand payment from the insured until after that reimbursement has been granted or denied.

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

      (Added to NRS by 1989, 1273)

MISCELLANEOUS PROVISIONS

      NRS 689A.050  Entire contract; changes.  There shall be a provision as follows:

 

       Entire Contract; Changes: This policy, including the endorsements and the attached papers, if any, constitutes the entire contract of insurance. No change in this policy shall be valid until approved by an executive officer of the insurer and unless such approval is endorsed hereon or attached hereto. No agent has authority to change this policy or to waive any of its provisions.

 

      (Added to NRS by 1971, 1753)

      NRS 689A.060  Time limit on certain defenses.  There shall be a provision as follows:

 

      Time Limit on Certain Defenses:

       1.  After 3 years from the date of issue of this policy no misstatements, except fraudulent misstatements, made by the applicant in the application for such policy shall be used to void the policy or to deny a claim for loss incurred or disability (as defined in the policy) commencing after the expiration of such 3-year period.

 

The foregoing policy provision shall not be so construed as to affect any legal requirement for avoidance of a policy or denial of a claim during such initial 3-year period, nor to limit the application of NRS 689A.200 to 689A.230, inclusive, in the event of misstatement with respect to age or occupation or other insurance. A policy which the insured has the right to continue in force subject to its terms by the timely payment of the premium until at least age 50 or, in the case of a policy issued after age 44, for at least 5 years from its date of issue, may contain in lieu of the foregoing the following provision (from which the clause in parentheses may be omitted at the insurer’s option): “Incontestable: After this policy has been in force for a period of three years during the lifetime of the insured (excluding any period during which the insured is disabled), it shall become incontestable as to the statements contained in the application.”

 

       2.  No claim for loss incurred or disability (as defined in the policy) commencing after 3 years from the date of issue of this policy shall be reduced or denied on the ground that a disease or physical condition not excluded from coverage by name or specific description effective on the date of loss had existed prior to the effective date of coverage of this policy.

 

      (Added to NRS by 1971, 1753)

      NRS 689A.070  Grace period.  There shall be a provision as follows:

 

       Grace Period: A grace period of ..... (insert a number not less than “7” for weekly premium policies, “10” for monthly premium policies and “31” for all other policies) days will be granted for the payment of each premium falling due after the first premium, during which grace period the policy shall continue in force.

 

A policy in which the insurer reserves the right to refuse any renewal shall have, at the beginning of the above provision:

 

       Unless not less than 30 days prior to the premium due date the company has delivered to the insured or has mailed to the last address of the insured as shown by the records of the insurer written notice of its intention not to renew this policy beyond the period for which the premium has been accepted.

 

      (Added to NRS by 1971, 1754)

      NRS 689A.080  Reinstatement.

      1.  There shall be a provision as follows:

 

       Reinstatement: If any renewal premium be not paid within the time granted the insured for payment, a subsequent acceptance of premium by the insurer or by any agent duly authorized by the insurer to accept such premium, without requiring in connection therewith an application for reinstatement, shall reinstate the policy; provided, however, that if the insurer or such agent requires an application for reinstatement and issues a conditional receipt for the premium tendered, the policy will be reinstated upon approval of such application by the insurer or, lacking such approval, upon the 45th day following the date of such conditional receipt unless the insurer has previously notified the insured in writing of its disapproval of such application. The reinstated policy shall cover only loss resulting from such accidental injury as may be sustained after the date of reinstatement and loss due to such sickness as may begin more than 10 days after such date. In all other respects the insured and insurer shall have the same rights thereunder as they had under the policy immediately before the due date of the defaulted premium, subject to any provisions endorsed herein or attached hereto in connection with the reinstatement. Any premium accepted in connection with a reinstatement shall be applied to a period for which premium has not been previously paid, but not to any period more than 60 days prior to the date of reinstatement.

 

      2.  The last sentence of subsection 1 may be omitted from any policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums:

      (a) Until at least age 50; or

      (b) In the case of a policy issued after age 44, for at least 5 years from its date of issue.

      3.  Pursuant to the last sentence in subsection 1, the insurer shall apply the premium accepted in such manner as to place the policy currently in force, exclusive of any applicable grace period, but not in any event to any period more than 60 days prior to the date of reinstatement.

      (Added to NRS by 1971, 1754)

      NRS 689A.090  Notice of claim.

      1.  There shall be a provision as follows:

 

       Notice of Claim: Written notice of claim must be given to the insurer within 20 days after the occurrence or commencement of any loss covered by the policy, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the insured or the beneficiary to the insurer at ................ (insert the location of such office as the insurer may designate for the purpose), or to any authorized agent of the insurer, with information sufficient to identify the insured, shall be deemed notice to the insurer.

 

      2.  In a policy providing a loss-of-time benefit which may be payable for at least 2 years, an insurer may at its option insert the following between the first and second sentence of subsection 1:

 

       Subject to the qualifications set forth below, if the insured suffers loss of time on account of disability for which indemnity may be payable for at least 2 years, the insured shall, at least once in every 6 months after having given notice of the claim, give to the insurer notice of continuance of said disability, except in the event of legal incapacity. The period of 6 months following any filing of proof by the insured or any payment by the insurer on account of such claim or any denial of liability in whole or in part by the insurer shall be excluded in applying this provision. Delay in the giving of such notice shall not impair the insured’s right to any indemnity which would otherwise have accrued during the period of 6 months preceding the date on which such notice is actually given.

 

      (Added to NRS by 1971, 1755)

      NRS 689A.100  Claim forms: Required provision.  There shall be a provision as follows:

 

       Claim Forms: The insurer, upon receipt of a notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within 15 days after the giving of such notice the claimant shall be deemed to have complied with the requirements of this policy as to proof of loss upon submitting, within the time fixed in the policy for filing proofs of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made.

 

      (Added to NRS by 1971, 1756)

      NRS 689A.105  Claim forms: Uniform billing, claims forms.  Every insurer under a health insurance contract and every state agency for its records shall accept from:

      1.  A hospital the Uniform Billing and Claims Forms established by the American Hospital Association in lieu of its individual billing and claims forms.

      2.  An individual who is licensed to practice one of the health professions regulated by Title 54 of NRS such uniform health insurance claims forms as the Commissioner shall prescribe, except in those cases where the Commissioner has excused uniform reporting.

      (Added to NRS by 1975, 897)

      NRS 689A.110  Claim forms: Acceptance of uniform forms.  There shall be a provision as follows:

 

       Proofs of Loss: Written proof of loss must be furnished to the insurer at its office in case of claim for loss for which this policy provides any periodic payment contingent upon continuing loss within 90 days after the termination of the period for which the insurer is liable and in case of claim for any other loss within 90 days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than 1 year from the time proof is otherwise required.

 

      (Added to NRS by 1971, 1756)

      NRS 689A.120  Time of payment of claims.  There shall be a provision as follows:

 

       Time of Payment of Claims: Indemnities payable under this policy for any loss, other than loss for which this policy provides any periodic payment, will be paid immediately upon receipt of due written proof of such loss. Subject to due written proof of loss, all accrued indemnities for loss for which this policy provides periodic payment will be paid ................ (insert period for payment which must not be less frequently than monthly) and any balance remaining unpaid upon the termination of liability will be paid immediately upon receipt of due written proof.

 

      (Added to NRS by 1971, 1756)

      NRS 689A.130  Payment of claims.

      1.  There shall be a provision as follows:

 

       Payment of Claims: Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of payment. If no such designation or provision is then effective, such indemnity shall be payable to the estate of the insured. Any other accrued indemnities unpaid at the insured’s death may, at the option of the insurer, be paid either to such beneficiary or to such estate. All other indemnities will be payable to the insured.

 

      2.  The following provisions, or either of them, may be included with the provision in subsection 1 at the option of the insurer:

 

       If any indemnity of this policy shall be payable to the estate of the insured, or to an insured or beneficiary who is a minor or otherwise not competent to give a valid release, the insurer may pay such indemnity, up to an amount not exceeding $..... (insert an amount which shall not exceed $1,000), to any relative by blood or connection by marriage of the insured or beneficiary who is deemed by the insurer to be equitably entitled thereto. Any payment made by the insurer in good faith pursuant to this provision shall fully discharge the insurer to the extent of such payment.

       Subject to any written direction of the insured in the application or otherwise all or a portion of any indemnities provided by this policy on account of hospital, nursing, medical or surgical services may, at the insurer’s option and unless the insured requests otherwise in writing not later than the time of filing proofs of such loss, be paid directly to the hospital or person rendering such services; but it is not required that the service be rendered by a particular hospital or person.

 

      (Added to NRS by 1971, 1756)

      NRS 689A.135  Assignment of benefits to provider of health care.

      1.  A person insured under a policy of health insurance may assign his or her right to benefits to the provider of health care who provided the services covered by the policy. The insurer shall pay all or the part of the benefits assigned by the insured to the person designated by the insured. A payment made pursuant to this subsection discharges the insurer’s obligation to pay those benefits.

      2.  If the insured makes an assignment under this section, but the insurer after receiving a copy of the assignment pays the benefits to the insured, the insurer shall also pay those benefits to the provider of health care who received the assignment as soon as the insurer receives notice of the incorrect payment.

      3.  For the purpose of this section, “provider of health care” has the meaning ascribed to it in NRS 629.031.

      (Added to NRS by 1983, 879)

      NRS 689A.140  Physical examination and autopsy.  There shall be a provision as follows:

 

       Physical Examinations and Autopsy: The insurer at its own expense shall have the right and opportunity to examine the person of the insured when and as often as it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death where it is not forbidden by law.

 

      (Added to NRS by 1971, 1757)

      NRS 689A.150  Legal actions.  There shall be a provision as follows:

 

       Legal Actions: No action at law or in equity shall be brought to recover on this policy prior to the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of this policy. No such action shall be brought after the expiration of 3 years after the time written proof of loss is required to be furnished.

 

      (Added to NRS by 1971, 1757)

      NRS 689A.160  Change of beneficiary.

      1.  There shall be a provision as follows:

 

       Change of Beneficiary: Unless the insured makes an irrevocable designation of beneficiary, the right to change of beneficiary is reserved to the insured and the consent of the beneficiary or beneficiaries shall not be requisite to surrender or assignment of this policy or to any change of beneficiary or beneficiaries, or to any other changes in this policy.

 

      2.  The first clause of the provision set forth in subsection 1, relating to the irrevocable designation of beneficiary, may be omitted at the insurer’s option.

      (Added to NRS by 1971, 1757)

      NRS 689A.170  Right to examine and return policy.

      1.  Except as to nonrenewable accident policies and individual credit health insurance policies, every individual health insurance policy shall contain a provision therein or in a separate rider attached thereto when delivered, stating in substance that the person to whom the policy is issued shall be permitted to return the policy within 10 days of its delivery to such person and to have a refund of the premium paid if after examination of the policy the purchaser is not satisfied with it for any reason. The provision shall be set forth in the policy under an appropriate caption, and if not so printed on the face page of the policy adequate notice of the provision shall be printed or stamped conspicuously on the face page.

      2.  The policy may be so returned to the insurer at its home or branch office or to the agent through whom it was applied for, and thereupon shall be void as from the beginning and as if the policy had not been issued.

      (Added to NRS by 1971, 1758)

      NRS 689A.180  Optional provisions.  Except as otherwise provided in NRS 689A.040, no such policy delivered or issued for delivery to any person in this State may contain provisions respecting the matters set forth in NRS 689A.190 to 689A.270, inclusive, unless the provisions are in the words in which the provisions appear in the applicable section, except that the insurer may, at its option, use in lieu of any such provision a corresponding provision of different wording approved by the Commissioner which is not less favorable in any respect to the insured or the beneficiary. Any such provision contained in the policy must be preceded individually by the appropriate caption or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the Commissioner may approve.

      (Added to NRS by 1971, 1758; A 1985, 1060; 2005, 2343)

An insurer refused to pay a beneficiary death benefits under a policy of insurance when the insured died from an accidental overdose of medication prescribed by her physician on the ground that the policy contained a provision denying coverage for any loss resulting from the influence of drugs unless “taken as prescribed by a physician.” However, former NRS 689A.280 authorizes an insurer to deny coverage on that ground unless the narcotic is “administered on the advice of a physician.” Additionally, NRS 689A.180 allows the use of language that is different from that contained in former NRS 689A.280 if it is not less favorable to the insured or the beneficiary. The court concluded that “taken as prescribed by a physician” was a stricter standard than “administered on the advice of a physician” and was, therefore, less advantageous to the insured and the beneficiary. As a result of that finding, the court amended the language contained in former NRS 689A.280 into the policy pursuant to NRS 689A.340, which provides that, if the language in a policy conflicts with any provision of NRS ch. 689A, the provisions of the chapter apply, and determined that under the statutory language, the plaintiff was entitled to recover the benefits provided under the policy. Hummel v. Continental Cas. Ins. Co., 254 F.Supp.2d 1183 (D. Nev. 2003)

      NRS 689A.190  Extended disability benefit.  Any health insurance policy may contain a provision for payment not exceeding $500 as an extended disability benefit upon the insured’s death from any cause, which benefit shall not be construed as life insurance.

      (Added to NRS by 1971, 1758)

      NRS 689A.200  Change of occupation.  There may be a provision as follows:

 

       Change of Occupation: If the insured be injured or contracts sickness after having changed his or her occupation to one classified by the insurer as more hazardous than that stated in this policy or while doing for compensation anything pertaining to an occupation so classified, the insurer will pay only such portion of the indemnities provided in this policy as the premium paid would have purchased at the rates and within the limits fixed by the insurer for such more hazardous occupation. If the insured changes his or her occupation to one classified by the insurer as less hazardous than that stated in this policy, the insurer, upon receipt of proof of such change of occupation, will reduce the premium rate accordingly, and will return the excess pro rata unearned premium from the date of change of occupation or from the policy anniversary date immediately preceding receipt of such proof, whichever is the more recent. In applying this provision, the classification of occupational risk and the premium rates shall be such as have been last filed by the insurer prior to the occurrence of the loss for which the insurer is liable or prior to date of proof of change in occupation with the state official having supervision of insurance in the state where the insured resided at the time this policy was issued; but if such filing was not required, then the classification of occupational risk and the premium rates shall be those last made effective by the insurer in such state prior to the occurrence of the loss or prior to the date of proof of change in occupation.

 

      (Added to NRS by 1971, 1758)

      NRS 689A.210  Misstatement of age.  There may be a provision as follows:

 

       Misstatement of Age: If the age of the insured has been misstated, all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age.

 

      (Added to NRS by 1971, 1759)

      NRS 689A.220  Coordination of benefits: Same insurer.  There may be a provision as follows:

 

       If an accident or sickness or accident and sickness policy or policies previously issued by the insurer to the insured be in force concurrently herewith, making the aggregate indemnity for ................ (insert type of coverage or coverages) in excess of $..... (insert maximum limit of indemnity or indemnities), the excess shall be void and all premiums paid for such excess shall be returned to the insured or to the estate of the insured.

 

Or, in lieu thereof:

 

       Insurance effective at any one time on the insured under this policy and like policy or policies in this insurer is limited to the one policy elected by the insured or the beneficiary or estate of the insured, as the case may be, and the insurer will return all premiums paid for all other such policies.

 

      (Added to NRS by 1971, 1759)

      NRS 689A.230  Coordination of benefits: All coverages. [Effective through December 31, 2013.]

      1.  There may be a provision as follows:

 

       Coordination of Benefits: If, with respect to a person covered under this policy, benefits for allowable expense incurred during a claim determination period under this policy, together with benefits for allowable expense during such period under all other valid coverage (without giving effect to this provision or to any “coordination of benefits provision” applying to such other valid coverage), exceed the total of such person’s allowable expense during such period, this insurer shall be liable only for such proportionate amount of the benefits for allowable expense under this policy during such period as (a) the total allowable expense during such period bears to (b) the total amount of benefits payable during such period for such expense under this policy and all other valid coverage (without giving effect to this provision or to any “coordination of benefits provision” applying to such other valid coverage) less in both (a) and (b) any amount of benefits for allowable expense payable under other valid coverage which does not contain a “coordination of benefits provision.” In no event shall this provision operate to increase the amount of benefits for allowable expense payable under this policy with respect to a person covered under this policy above the amount which would have been paid in the absence of this provision. This insurer may pay benefits to any insurer providing other valid coverage in the event of overpayment by such insurer. Any such payment shall discharge the liability of this insurer as fully as if the payment had been made directly to the insured or the assignee or beneficiary of the insured. If this insurer pays benefits to the insured or the assignee or beneficiary of the insured, in excess of the amount which would have been payable if the existence of other valid coverage had been disclosed, this insurer shall have a right of action against the insured or the assignee or beneficiary of the insured to recover the amount which would not have been paid had there been a disclosure of the existence of the other valid coverage. The amount of other valid coverage which is on a provision of service basis shall be computed as the amount the services rendered would have cost in the absence of such coverage.

       For the purposes of this provision:

       (1) “Allowable expense” means 100 percent of any necessary, reasonable and customary item of expense which is covered, in whole or in part, as a hospital, surgical, medical or major medical expense under this policy or under any other valid coverage.

       (2) “Claim determination period” with respect to any covered person means the initial period of ..... (insert period of not less than 30 days) and each successive period of a like number of days, during which allowable expense covered under this policy is incurred on account of such person. The first such period begins on the date when the first such expense is incurred, and successive periods shall begin when such expense is incurred after expiration of a prior period.

 

or, in lieu thereof:

 

       (2) “Claim determination period” with respect to any covered person means each ..... (insert calendar or policy period of not less than a month) during which allowable expense covered under this policy is incurred on account of such person.

       (3) “Coordination of benefits provision” means this provision and any other provision which may reduce an insurer’s liability because of the existence of benefits under other valid coverage.

 

      2.  The foregoing policy provisions may be inserted in all policies providing hospital, surgical, medical or major medical benefits for which the application includes a question as to other coverages subject to this provision. If the policy provision stated in subsection 1 is included in a policy which also contains the policy provision stated in NRS 689A.240, there shall be added to the caption of the provision stated in subsection 1 of the phrase “expense-incurred benefits.” The insurer may make this provision applicable to either or both:

      (a) Other valid coverage with other insurers; and

      (b) Other valid coverage with the same insurer.

Ê The insurer shall include in this provision a definition of “other valid coverage” approved as to form by the Commissioner. Such term may include hospital, surgical, medical or major medical benefits provided by individual or family-type coverage, government programs or workers’ compensation. Such term shall not include any group insurance, automobile medical payments or third-party liability coverage. The insurer shall not include a subrogation clause in the policy. The insurer may require, as part of the proof of claim, the information necessary to administer this provision.

      3.  If by application of any of the foregoing provisions the insurer effects a material reduction of benefits otherwise payable under the policy, the insurer shall refund to the insured any premium unearned on the policy by reason of such reduction of coverage during the policy year current and that next preceding at the time the loss commenced, subject to the insurer’s right to provide in the policy that no such reduction of benefits or refund will be made unless the unearned premium to be so refunded amounts to $5 or such larger sum as the insurer may so specify.

      (Added to NRS by 1971, 1760)

      NRS 689A.230  Coordination of benefits: All coverages. [Effective January 1, 2014.]

      1.  There may be a provision as follows:

 

       Coordination of Benefits: If, with respect to a person covered under this policy, benefits for allowable expense incurred during a claim determination period under this policy, together with benefits for allowable expense during such period under all other valid coverage (without giving effect to this provision or to any “coordination of benefits provision” applying to such other valid coverage), exceed the total of such person’s allowable expense during such period, this insurer shall be liable only for such proportionate amount of the benefits for allowable expense under this policy during such period as (a) the total allowable expense during such period bears to (b) the total amount of benefits payable during such period for such expense under this policy and all other valid coverage (without giving effect to this provision or to any “coordination of benefits provision” applying to such other valid coverage) less in both (a) and (b) any amount of benefits for allowable expense payable under other valid coverage which does not contain a “coordination of benefits provision.” In no event shall this provision operate to increase the amount of benefits for allowable expense payable under this policy with respect to a person covered under this policy above the amount which would have been paid in the absence of this provision. This insurer may pay benefits to any insurer providing other valid coverage in the event of overpayment by such insurer. Any such payment shall discharge the liability of this insurer as fully as if the payment had been made directly to the insured or the assignee or beneficiary of the insured. If this insurer pays benefits to the insured or the assignee or beneficiary of the insured, in excess of the amount which would have been payable if the existence of other valid coverage had been disclosed, this insurer shall have a right of action against the insured or the assignee or beneficiary of the insured to recover the amount which would not have been paid had there been a disclosure of the existence of the other valid coverage. The amount of other valid coverage which is on a provision of service basis shall be computed as the amount the services rendered would have cost in the absence of such coverage.

       For the purposes of this provision:

       (1) “Allowable expense” means 100 percent of any necessary, reasonable and customary item of expense which is covered, in whole or in part, as a hospital, surgical, medical or major medical expense under this policy or under any other valid coverage.

       (2) “Claim determination period” with respect to any covered person means the initial period of ..... (insert period of not less than 30 days) and each successive period of a like number of days, during which allowable expense covered under this policy is incurred on account of such person. The first such period begins on the date when the first such expense is incurred, and successive periods shall begin when such expense is incurred after expiration of a prior period.

 

or, in lieu thereof:

 

       (2) “Claim determination period” with respect to any covered person means each ..... (insert calendar or policy period of not less than a month) during which allowable expense covered under this policy is incurred on account of such person.

       (3) “Coordination of benefits provision” means this provision and any other provision which may reduce an insurer’s liability because of the existence of benefits under other valid coverage.

 

      2.  The foregoing policy provisions may be inserted in all policies providing hospital, surgical, medical or major medical benefits for which the application includes a question as to other coverages subject to this provision. If the policy provision stated in subsection 1 is included in a policy which also contains the policy provision stated in NRS 689A.240, there shall be added to the caption of the provision stated in subsection 1 of the phrase “expense-incurred benefits.” The insurer may make this provision applicable to either or both:

      (a) Other valid coverage with other insurers; and

      (b) Other valid coverage with the same insurer.

Ê The insurer shall include in this provision a definition of “other valid coverage” approved as to form by the Commissioner. Such term may include hospital, surgical, medical or major medical benefits provided by individual or family-type coverage, government programs or workers’ compensation. Such term shall not include any automobile medical payments or third-party liability coverage. The insurer shall not include a subrogation clause in the policy. The insurer may require, as part of the proof of claim, the information necessary to administer this provision.

      3.  If by application of any of the foregoing provisions the insurer effects a material reduction of benefits otherwise payable under the policy, the insurer shall refund to the insured any premium unearned on the policy by reason of such reduction of coverage during the policy year current and that next preceding at the time the loss commenced, subject to the insurer’s right to provide in the policy that no such reduction of benefits or refund will be made unless the unearned premium to be so refunded amounts to $5 or such larger sum as the insurer may so specify.

      (Added to NRS by 1971, 1760; A 2013, 3612, effective January 1, 2014)

      NRS 689A.240  Relation of earnings to insurance.

      1.  There may be a provision as follows:

 

       Relation of Earnings to Insurance: After the loss-of-time benefit of this policy has been payable for 90 days, such benefit will be adjusted, as provided below, if the total amount of unadjusted loss-of-time benefits provided in all valid loss-of-time coverage upon the insured should exceed ..... percent of the insured’s earned income; provided, however, that if the information contained in the application discloses that the total amount of loss-of-time benefits under this policy and under all other valid loss-of-time coverage expected to be effective upon the insured in accordance with the application for this policy exceeded ..... percent of the insured’s earned income at the time of such application, such higher percentage will be used in place of ..... percent. Such adjusted loss-of-time benefit under this policy for any month shall be only such proportion of the loss-of-time benefit otherwise payable under this policy as (a) the product of the insured’s earned income and ..... percent (or, if higher the alternative percentage described at the end of the first sentence of this provision) bears to (b) the total amount of loss-of-time benefits payable for such month under this policy and all other valid loss-of-time coverage on the insured (without giving effect to the “overinsurance provision” in this or any other coverage) less in both (a) and (b) any amount of loss-of-time benefits payable under other valid loss-of-time coverage which does not contain an “overinsurance provision.” In making such computation, all benefits and earnings shall be converted to a consistent (insert “weekly” if the loss-of-time benefit of this policy is payable weekly, “monthly” if such benefit is payable monthly, etc.) basis. If the numerator of the foregoing ratio is zero or is negative, no benefit shall be payable under this policy. In no event shall this provision (1) operate to reduce the total combined amount of loss-of-time benefits for such month payable under this policy and all other valid loss-of-time coverage below the lesser of $300 and the total combined amount of loss-of-time benefits determined without giving effect to any “coordination of benefits provision,” nor (2) operate to increase the amount of benefits payable under this policy above the amount which would have been paid in the absence of this provision, nor (3) take into account or operate to reduce any benefit other than the loss-of-time benefit.

       For purposes of this provision:

       (A) “Earned income,” except where otherwise specified, means the greater of the monthly earnings of the insured at the time disability commences and the average monthly earnings of the insured for a period of 2 years immediately preceding the commencement of such disability, and shall not include any investment income or any other income not derived from the insured’s vocational activities.

       (B) “Coordination of benefits provision” includes this provision and any other provision with respect to any loss-of-time coverage which may have the effect of reducing an insurer’s liability if the total amount of loss-of-time benefits under all coverage exceeds a stated relationship to the insured’s earnings.

 

      2.  If the policy provision stated in subsection 1 is included in a policy which also contains the policy provision stated in NRS 689A.230, there shall be added to the caption of the provision stated in subsection 1 the phrase “loss-of-time benefits.”

      3.  The foregoing provision may be included only in a policy which provides a loss-of-time benefit which may be payable for at least 52 weeks, which is issued on the basis of selective underwriting of each individual application, and for which the application includes a question designed to elicit information necessary either to determine the ratio of the total loss-of-time benefits of the insured to the insured’s earned income or to determine that such ratio does not exceed the percentage of earnings, not less than 60 percent selected by the insurer and inserted in lieu of the blank factor above. The insurer may require, as part of the proof of claim, the information necessary to administer this provision. If the application indicates that other loss-of-time coverage is to be discontinued, the amount of such other coverage shall be excluded in computing the alternative percentage in the first sentence of the overinsurance provision. The policy shall include a definition of “valid loss-of-time coverage,” approved as to form by the Commissioner, which definition shall not include group insurance, benefits provided by union welfare plans, employer or employee benefit plans, workers’ compensation or employer’s liability statute or third-party liability. The insurer shall not include a subrogation clause in the policy.

      4.  If by application of any of the foregoing provisions the insurer effects a material reduction of benefits otherwise payable under the policy, the insurer shall refund to the insured any premium unearned on the policy by reason of such reduction of coverage during the policy year current and that next preceding at the time the loss commenced, subject to the insurer’s right to provide in the policy that no such reduction of benefits or refund will be made unless the unearned premium to be so refunded amounts to $5 or such larger sum as the insurer may so specify.

      (Added to NRS by 1971, 1761)

      NRS 689A.250  Unpaid premiums.  There may be a provision as follows:

 

       Unpaid Premium: Upon the payment of a claim under this policy, any premium then due and unpaid or covered by any note or written order may be deducted therefrom.

 

      (Added to NRS by 1971, 1763)

      NRS 689A.260  Conformity with state statutes.  There may be a provision as follows:

 

       Conformity with State Statutes: Any provision of this policy which, on its effective date is in conflict with the statutes of the state in which the insured resides on such date is hereby amended to conform to the minimum requirements of such statutes.

 

      (Added to NRS by 1971, 1763)

      NRS 689A.270  Illegal occupation.  There may be a provision as follows:

 

       Illegal Occupation: The insurer shall not be liable for any loss to which a contributing cause was the insured’s commission of or attempt to commit a felony or to which a contributing cause was the insured’s being engaged in an illegal occupation.

 

      (Added to NRS by 1971, 1763)

      NRS 689A.290  Renewability.  Health insurance policies, other than accident insurance only policies, in which the insurer reserves the right to refuse renewal on an individual basis, shall provide in substance in a provision thereof or in an endorsement thereon or rider attached thereto that subject to the right to terminate the policy upon nonpayment of premium when due, such right to refuse renewal may not be exercised so as to take effect before the renewal date occurring on, or after and nearest, each policy anniversary (or in the case of lapse and reinstatement, at the renewal date occurring on, or after and nearest, each anniversary of the last reinstatement), and that any refusal of renewal shall be without prejudice to any claim originating while the policy is in force. (The parenthetic reference to lapse and reinstatement may be omitted at the insurer’s option.)

      (Added to NRS by 1971, 1764)

      NRS 689A.300  Order of certain provisions.  The provisions which are the subject of NRS 689A.050 to 689A.290, inclusive, or any corresponding provisions which are used in lieu thereof in accordance with such sections shall be printed in the consecutive order of the provisions in such sections or, at the option of the insurer, any such provision may appear as a unit in any part of the policy, with other provisions to which it may be logically related, provided that the resulting policy shall not be in whole or in part unintelligible, uncertain, ambiguous, abstruse or likely to mislead a person to whom the policy is offered, delivered or issued.

      (Added to NRS by 1971, 1764)

      NRS 689A.310  Ownership of policy by person other than insured.  The word “insured,” as used in this chapter, shall not be construed as preventing a person other than the insured with a proper insurable interest from making application for and owning a policy covering the insured or from being entitled under such a policy to any indemnities, benefits and rights provided therein.

      (Added to NRS by 1971, 1764)

      NRS 689A.320  Requirements of other jurisdictions.

      1.  Any policy of a foreign or alien insurer, when delivered or issued for delivery to any person in this state, may contain any provision which is not less favorable to the insured or the beneficiary than the provisions of this chapter and which is prescribed or required by the law of the state or country under which the insurer is organized.

      2.  Any policy of a domestic insurer may, when issued for delivery in any other state or country, contain any provision permitted or required by the laws of such other state or country.

      (Added to NRS by 1971, 1764)

      NRS 689A.330  Policies issued for delivery in another state.  If any policy is issued by a domestic insurer for delivery to a person residing in another state, and if the insurance commissioner or corresponding public officer of that other state has informed the Commissioner that the policy is not subject to approval or disapproval by that officer, the Commissioner may by ruling require that the policy meet the standards set forth in NRS 689A.030 to 689A.320, inclusive.

      (Added to NRS by 1971, 1765; A 1985, 1447; 1989, 1273; 1997, 743; 1999, 760, 1997; 2003, 1334, 3355, 3522; 2007, 3237; 2009, 1467; 2013, 1998)

      NRS 689A.340  Limitation on provisions not subject to chapter; effect of violation.

      1.  No policy provision which is not subject to this chapter shall make a policy, or any portion thereof, less favorable in any respect to the insured or the beneficiary than the provisions thereof which are subject to this chapter.

      2.  A policy delivered or issued for delivery to any person in this state in violation of this chapter shall be held valid but shall be construed as provided in this chapter. When any provision in a policy subject to this chapter is in conflict with any provision of this chapter, the rights, duties and obligations of the insurer, the insured and the beneficiary shall be governed by the provisions of this chapter.

      (Added to NRS by 1971, 1765)

      NRS 689A.350  Age limit.  If any such policy contains a provision establishing, as an age limit or otherwise, a date after which the coverage provided by the policy will not be effective, and if such date falls within a period for which a premium is accepted by the insurer or if the insurer accepts a premium after such date, the coverage provided by the policy will continue in force subject to any right of termination until the end of the period for which the premium has been accepted. If the age of the insured has been misstated and if, according to the correct age of the insured, the coverage provided by the policy would not have become effective, or would have ceased prior to the acceptance of such premium or premiums, then the liability of the insurer shall be limited to the refund of all premiums paid for the period not covered by the policy.

      (Added to NRS by 1971, 1765)

      NRS 689A.370  Health insurance on franchise plan. [Effective through December 31, 2013.]

      1.  Health insurance on a franchise plan is hereby declared to be that form of health insurance issued to:

      (a) Three or more employees of any corporation, copartnership or individual employer or any governmental corporation, agency or department thereof; or

      (b) Ten or more members, employees or employees of members of any trade or professional association or of a labor union or of any other association having had an active existence for at least 2 years where such association or union has a constitution or bylaws and is formed in good faith for purposes other than that of obtaining insurance,

Ê where such persons with or without their dependents, are issued the same form of an individual policy varying only as to amounts and kinds of coverage applied for by such persons under an arrangement whereby the premiums on such policies may be paid to the insurer periodically by the employer, with or without payroll deductions, or by the insured, or the association or union for its members, or by some designated person acting on behalf of such employer or association or union. The term “employees” as used in this section shall be deemed to include the officers, managers and employees and retired employees of the employer and the individual proprietor or partners if the employer is an individual proprietor or partnership.

      2.  Each policy issued under this section shall provide that the coverage shall terminate when the insured individual no longer qualifies for such policy under this section; but the policy may provide that it may be continued in force or be replaced with another policy if the premium, benefits and other relevant factors of the continued or replacement policy are the same as those of a similar individual policy not issued under or pursuant to this section.

      (Added to NRS by 1971, 1765; R 2013, 3661, effective January 1, 2014)

      NRS 689A.380  Definitions of terms used in policies.  As used in any policy of health insurance delivered, issued for delivery or used in this state, unless otherwise provided in the policy or in an endorsement thereon or in a rider attached thereto:

      1.  “Accidental death” means death by accident exclusively and independently of all other causes.

      2.  “Confinement to house” or “house confinement” includes the activities of a convalescent not able to be gainfully employed.

      3.  “Medical or surgical services” includes also services within the scope of his or her license rendered by any person while duly licensed by the State of Nevada under any of the following chapters of NRS: 631 (dentistry); 633 (osteopathic medicine); 634 (chiropractic); 634A (Oriental medicine); 635 (podiatry); or 636 (optometry). No policy of health insurance may provide that the insured does not have the option of selecting any licensee provided for in this subsection to perform any medical or surgical services covered by a policy of insurance if the service is within the scope of his or her license.

      4.  “Total disability” means inability to perform the duties of any gainful occupation for which the insured is reasonably fitted by training, experience and accomplishment.

      (Added to NRS by 1971, 1766; A 1971, 1953; 1975, 240; 1977, 966)

      NRS 689A.390  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 policy of health insurance offered by the insurer. The disclosure must include:

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

      (b) Any other information,

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

      2.  The disclosure must be written in language which is easily understood and must include a statement that the disclosure is a summary of the policy only, and that the policy 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, 1248)

      NRS 689A.400  Summary of coverage: Copy to be provided before policy issued; policy may not be offered unless summary approved by Commissioner.  An insurer shall provide each person to whom it offers a policy of health insurance with a copy of the disclosure approved for that policy pursuant to NRS 689A.390 before the policy is issued. An insurer shall not offer a policy of health insurance unless the disclosure for that policy has been approved by the Commissioner.

      (Added to NRS by 1989, 1249)

      NRS 689A.405  Coverage for prescription drugs: Provision of notice and information regarding use of formulary.

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

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

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

      (c) If a formulary is used, include:

             (1) An explanation of:

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

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

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

      2.  If an insurer offers or issues a policy of health insurance which provides coverage for prescription drugs and a formulary is used, the insurer shall:

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

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

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

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

      (Added to NRS by 2001, 856)

      NRS 689A.410  Approval or denial of claims; payment of claims and interest; requests for additional information; award of costs and attorney’s fees; compliance with requirements.

      1.  Except as otherwise provided in subsection 2, an insurer shall approve or deny a claim relating to a policy of health insurance within 30 days after the insurer receives the claim. If the claim is approved, the insurer shall pay the claim within 30 days after it is approved. Except as otherwise provided in this section, if the approved claim is not paid within that period, the insurer shall pay interest on the claim at a rate of interest equal to the prime rate at the largest bank in Nevada, as ascertained by the Commissioner of Financial Institutions, on January 1 or July 1, as the case may be, immediately preceding the date on which the payment was due, plus 6 percent. The interest must be calculated from 30 days after the date on which the claim is approved until the date on which the claim is paid.

      2.  If the insurer requires additional information to determine whether to approve or deny the claim, it shall notify the claimant of its request for the additional information within 20 days after it receives the claim. The insurer shall notify the provider of health care of all the specific reasons for the delay in approving or denying the claim. The insurer shall approve or deny the claim within 30 days after receiving the additional information. If the claim is approved, the insurer shall pay the claim within 30 days after it receives the additional information. If the approved claim is not paid within that period, the insurer shall pay interest on the claim in the manner prescribed in subsection 1.

      3.  An insurer shall not request a claimant to resubmit information that the claimant has already provided to the insurer, unless the insurer provides a legitimate reason for the request and the purpose of the request is not to delay the payment of the claim, harass the claimant or discourage the filing of claims.

      4.  An insurer shall not pay only part of a claim that has been approved and is fully payable.

      5.  A court shall award costs and reasonable attorney’s fees to the prevailing party in an action brought pursuant to this section.

      6.  The payment of interest provided for in this section for the late payment of an approved claim may be waived only if the payment was delayed because of an act of God or another cause beyond the control of the insurer.

      7.  The Commissioner may require an insurer to provide evidence which demonstrates that the insurer has substantially complied with the requirements set forth in this section, including, without limitation, payment within 30 days of at least 95 percent of approved claims or at least 90 percent of the total dollar amount for approved claims.

      8.  If the Commissioner determines that an insurer is not in substantial compliance with the requirements set forth in this section, the Commissioner may require the insurer to pay an administrative fine in an amount to be determined by the Commissioner. Upon a second or subsequent determination that an insurer is not in substantial compliance with the requirements set forth in this section, the Commissioner may suspend or revoke the certificate of authority of the insurer.

      (Added to NRS by 1991, 1328; A 1999, 1647; 2001, 2729; 2003, 3355)

      NRS 689A.413  Insurer prohibited from denying coverage solely because person was victim of domestic violence.  An insurer shall not deny a claim, refuse to issue a policy of health insurance or cancel a policy of health insurance solely because the claim involves an act that constitutes domestic violence pursuant to NRS 33.018, or because the person applying for or covered by the health insurance policy was the victim of such an act of domestic violence, regardless of whether the insured or applicant contributed to any loss or injury.

      (Added to NRS by 1997, 1095)

      NRS 689A.415  Insurer prohibited from denying coverage solely because insured was intoxicated or under influence of controlled substance; exceptions.

      1.  Except as otherwise provided in subsection 2, an insurer shall not:

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

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

      (c) Refuse to issue a policy of health insurance to an eligible applicant solely because the applicant has made a claim involving an injury sustained by the applicant as a consequence of being intoxicated or under the influence of a controlled substance.

      2.  The provisions of subsection 1 do not prohibit an insurer from enforcing a provision included in a policy of health insurance pursuant to NRS 689A.270 to:

      (a) Deny a claim which involves an injury to which a contributing cause was the insured’s commission of or attempt to commit a felony;

      (b) Cancel a policy of health insurance solely because of such a claim; or

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

      3.  The provisions of this section do not apply to an insurer under a policy of health insurance that provides coverage for long-term care or disability income.

      (Added to NRS by 2005, 2343; A 2007, 84)

      NRS 689A.417  Insurer prohibited from requiring or using information concerning genetic testing; exceptions.

      1.  Except as otherwise provided in subsection 2, an insurer who 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 an insurer who 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, 1459)

      NRS 689A.419  Offering policy of health insurance for purposes of establishing health savings account.  An insurer may, subject to regulation by the Commissioner, offer a policy of health insurance that has a high deductible and is in compliance with 26 U.S.C. § 223 for the purposes of establishing a health savings account.

      (Added to NRS by 2005, 2136)

ELIGIBILITY FOR COVERAGE

      NRS 689A.420  Definitions.  As used in NRS 689A.420 to 689A.460, inclusive, unless the context otherwise requires:

      1.  “Medicaid” means a program established in any state pursuant to Title XIX of the Social Security Act (42 U.S.C. §§ 1396 et seq.) to provide assistance for part or all of the cost of medical care rendered on behalf of indigent persons.

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

      (Added to NRS by 1995, 2427)

      NRS 689A.430  Effect of eligibility for medical assistance under Medicaid; assignment of rights to state agency.

      1.  An insurer shall not, when considering eligibility for coverage or making payments under a policy of health insurance, consider the availability of, or eligibility of a person for, medical assistance under Medicaid.

      2.  To the extent that payment has been made by Medicaid for health care, an insurer, self-insured plan, group health plan as defined in section 607(1) of the Employee Retirement Income Security Act of 1974, 29 U.S.C.A. § 1167(1), service benefit plan or other organization that has issued a policy of health insurance:

      (a) Shall treat Medicaid as having a valid and enforceable assignment of an insured’s benefits regardless of any exclusion of Medicaid or the absence of a written assignment; and

      (b) May, as otherwise allowed by the policy, evidence of coverage or contract and applicable law or regulation concerning subrogation, seek to enforce any right of a recipient of Medicaid to reimbursement against any other liable party if:

             (1) It is so authorized pursuant to a contract with Medicaid for managed care; or

             (2) It has reimbursed Medicaid in full for the health care provided by Medicaid to its insured.

      3.  If a state agency is assigned any rights of a person who is:

      (a) Eligible for medical assistance under Medicaid; and

      (b) Covered by a policy of health insurance,

Ê the insurer that issued the policy shall not impose any requirements upon the state agency except requirements it imposes upon the agents or assignees of other persons covered by the policy.

      4.  If a state agency is assigned any rights of an insured who is eligible for medical assistance under Medicaid, an insurer shall:

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

             (1) Any period during which the insured or the insured’s spouse or dependent may be or may have been covered by the insurer; and

             (2) The nature of the coverage that is or was provided by the insurer, including, without limitation, the name and address of the insured and the identifying number of the policy, evidence of coverage or 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, 2427; A 2007, 2402)

      NRS 689A.440  Insurer prohibited from asserting certain grounds to deny enrollment of child of insured pursuant to order.  An insurer shall not deny the enrollment of a child pursuant to an order for medical coverage, under a policy of health insurance pursuant to which a parent of the child is insured, on the ground that the child:

      1.  Was born out of wedlock;

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

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

      (Added to NRS by 1995, 2427)

      NRS 689A.450  Certain accommodations to be made when child is covered under policy of noncustodial parent.  If a child has coverage under a policy of health insurance pursuant to which a noncustodial parent of the child is insured, the insurer issuing that policy shall:

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

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

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

      (Added to NRS by 1995, 2428)

      NRS 689A.460  Insurer 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 under a policy of health insurance for a child and the parent is eligible for coverage of members of the family of the parent under a policy of health insurance, the insurer that issued the policy:

      1.  Shall, if the child is otherwise eligible for that coverage, allow the parent to enroll the child in that coverage without regard to any restrictions upon periods for enrollment.

      2.  Shall, if:

      (a) The child is otherwise eligible for that coverage; and

      (b) The parent is enrolled in that coverage but fails to apply for enrollment of the child,

Ê enroll the child in that coverage upon application by the other parent of the child, or by an agency of this or another state responsible for the administration of Medicaid or a state program for the enforcement of child support established pursuant to 42 U.S.C. §§ 651 et seq., without regard to any restrictions upon periods for enrollment.

      3.  Shall not terminate the enrollment of the child in that coverage or otherwise eliminate that coverage of the child unless the insurer has written proof that:

      (a) The order for medical coverage is no longer in effect; or

      (b) The child is or will be enrolled in comparable coverage through another insurer on or before the effective date of the termination of enrollment or elimination of coverage.

      (Added to NRS by 1995, 2428)

PORTABILITY AND ACCOUNTABILITY

General Provisions

      NRS 689A.470  Definitions. [Effective through December 31, 2013.]  As used in NRS 689A.470 to 689A.740, inclusive, unless the context otherwise requires, the words and terms defined in NRS 689A.475 to 689A.605, inclusive, have the meanings ascribed to them in those sections.

      (Added to NRS by 1997, 2883; A 2001, 1922; 2005, 2136)

      NRS 689A.470  Definitions. [Effective January 1, 2014.]  As used in NRS 689A.470 to 689A.740, inclusive, unless the context otherwise requires, the words and terms defined in NRS 689A.475 to 689A.600, inclusive, have the meanings ascribed to them in those sections.

      (Added to NRS by 1997, 2883; A 2001, 1922; 2005, 2136; 2013, 3613, effective January 1, 2014)

      NRS 689A.475  “Affiliated” defined.  “Affiliated” means any entity or person who directly, or indirectly through one or more intermediaries, controls or is controlled by or is under common control with a specified entity or person.

      (Added to NRS by 1997, 2883)

      NRS 689A.480  “Basic health benefit plan” defined. [Effective through December 31, 2013.]  “Basic health benefit plan” means the basic health benefit plan developed pursuant to NRS 689C.610 to 689C.980, inclusive.

      (Added to NRS by 1997, 2883; R 2013, 3661, effective January 1, 2014)

      NRS 689A.485  “Bona fide association” defined.  “Bona fide association” means, with respect to health insurance coverage offered in this state, an association that:

      1.  Has been actively in existence for at least 5 years;

      2.  Has been formed and maintained in good faith for purposes other than obtaining insurance;

      3.  Does not condition membership in the association on any health status-related factor relating to an individual, including an employee of an employer or a dependent of an employee;

      4.  Makes health insurance coverage offered through the association available to all of its members regardless of any health status-related factors of the members or other individuals who are eligible for such health insurance coverage through a member of the association;

      5.  Does not make health insurance coverage offered through the association available other than in connection with a member of the association; and

      6.  Meets such additional requirements as may be imposed by specific statute.

      (Added to NRS by 1997, 2883)

      NRS 689A.490  “Church plan” defined.  “Church plan” has the meaning ascribed to it in section 3(33) of the Employee Retirement Income Security Act of 1974, as that section existed on July 16, 1997.

      (Added to NRS by 1997, 2884)

      NRS 689A.495  “Control” defined.  “Control” has the meaning ascribed to it in NRS 692C.050.

      (Added to NRS by 1997, 2884)

      NRS 689A.500  “Converted policy” defined. [Effective through December 31, 2013.]  “Converted policy” means a basic or standard health benefit plan issued in accordance with NRS 689B.120 to 689B.210, inclusive, and 689B.590.

      (Added to NRS by 1997, 2884; A 2001, 2219; R 2013, 3661, effective January 1, 2014)

      NRS 689A.505  “Creditable coverage” defined.  “Creditable coverage” means, with respect to a person, health benefits or coverage provided pursuant to:

      1.  A group health plan;

      2.  A health benefit plan;

      3.  Part A or Part B of Title XVIII of the Social Security Act, 42 U.S.C. §§ 1395c et seq., also known as Medicare;

      4.  Title XIX of the Social Security Act, 42 U.S.C. §§ 1396 et seq., also known as Medicaid, other than coverage consisting solely of benefits under section 1928 of that Title, 42 U.S.C. § 1396s;

      5.  The Civilian Health and Medical Program of Uniformed Services, CHAMPUS, 10 U.S.C. §§ 1071 et seq.;

      6.  A medical care program of the Indian Health Service or of a tribal organization;

      7.  A state health benefit risk pool;

      8.  A health plan offered pursuant to the Federal Employees Health Benefits Program, FEHBP, 5 U.S.C. §§ 8901 et seq.;

      9.  A public health plan as defined in 45 C.F.R. § 146.113, authorized by the Public Health Service Act, 42 U.S.C. § 300gg(c)(1)(I);

      10.  A health benefit plan under section 5(e) of the Peace Corps Act, 22 U.S.C. § 2504(e);

      11.  The Children’s Health Insurance Program established pursuant to 42 U.S.C. §§ 1397aa to 1397jj, inclusive;

      12.  A short-term health insurance policy; or

      13.  A blanket student accident and health insurance policy.

      (Added to NRS by 1997, 2884; A 1999, 2239, 2802)

      NRS 689A.510  “Dependent” defined.  “Dependent” has the meaning ascribed to it in NRS 689C.055.

      (Added to NRS by 1997, 2884)

      NRS 689A.515  “Eligible person” defined. [Effective through December 31, 2013.]  “Eligible person” means:

      1.  A person:

      (a) Who, as of the date on which the person seeks coverage pursuant to this chapter, has an aggregate period of creditable coverage that is 18 months or more;

      (b) Whose most recent prior creditable coverage, other than coverage under a short-term health insurance policy, was under a group health plan, governmental plan, church plan or health insurance coverage offered in connection with any such plan;

      (c) Who is not eligible for coverage under a group health plan, Part A or Part B of Title XVIII of the Social Security Act, 42 U.S.C. §§ 1395c et seq., also known as Medicare, a state plan pursuant to Title XIX of the Social Security Act, 42 U.S.C. §§ 1396 et seq., also known as Medicaid, or any successor program, and who does not have any other health insurance coverage;

      (d) Whose most recent health insurance coverage within the period of aggregate creditable coverage was not terminated because of a failure to pay premiums or fraud;

      (e) Who has exhausted his or her continuation of coverage under the Consolidation Omnibus Budget Reconciliation Act of 1985, Public Law 99-272, or under a similar state program, if any; and

      (f) Who has not had a break of more than 63 consecutive days in his or her creditable coverage.

      2.  A person whose most recent prior creditable coverage was under a basic or standard health benefit plan and was not renewed by a carrier who discontinued offering and renewing individual health benefit plans in this state pursuant to NRS 689A.630.

      3.  Notwithstanding the provisions of paragraph (a) of subsection 1, a newborn child or a child placed for adoption, if the child was enrolled timely and would have otherwise met the requirements of an eligible person as set forth in subsection 1.

      (Added to NRS by 1997, 2884; A 1999, 2803; R 2013, 3661, effective January 1, 2014)

      NRS 689A.520  “Established geographic service area” defined. [Effective through December 31, 2013.]  “Established geographic service area” means a geographic area, as approved by the Commissioner and based on the certificate of authority of the carrier to transact insurance in this state, within which the carrier is authorized to provide coverage.

      (Added to NRS by 1997, 2885)

      NRS 689A.523  “Exclusion for a preexisting condition” defined.  “Exclusion for a preexisting condition” means:

      1.  Any limitation or exclusion of benefits relating to a condition that was present before the date coverage was first provided, regardless of whether any medical advice, diagnosis, care or treatment was recommended or received before that date; or

      2.  Any exclusion applicable to an individual based on any information relating to the status of an individual’s health that was obtained before the date coverage was first provided, including, without limitation, any identification of a condition resulting from:

      (a) A preenrollment questionnaire or physical examination provided to the individual; or

      (b) A review of any medical records relating to the period of preenrollment.

      (Added to NRS by 2005, 2136)

      NRS 689A.525  “Geographic area” defined. [Effective through December 31, 2013.]  “Geographic area” means an area established by the Commissioner for use in adjusting the rates for a health benefit plan.

      (Added to NRS by 1997, 2885)

      NRS 689A.525  “Geographic rating area” defined. [Effective January 1, 2014.]  “Geographic rating area” means an area established by the Commissioner for use in adjusting the rates for a health benefit plan.

      (Added to NRS by 1997, 2885; A 2013, 3613, effective January 1, 2014)

      NRS 689A.527  “Geographic service area” defined. [Effective January 1, 2014.]  “Geographic service area” means a geographic area, as approved by the Commissioner, within which the carrier is authorized to provide coverage.

      (Added to NRS by 1997, 2885; A 2013, 3613, effective January 1, 2014)—(Substituted in revision for NRS 689A.520)

      NRS 689A.530  “Governmental plan” defined.  “Governmental plan” has the meaning ascribed to it in section 3(32) of the Employee Retirement Income Security Act of 1974, as that section existed on July 16, 1997, and any health plan of the Federal Government.

      (Added to NRS by 1997, 2885)

      NRS 689A.535  “Group health plan” defined.

      1.  “Group health plan” means an employee welfare benefit plan, as defined in section 3(1) of the Employee Retirement Income Security Act of 1974, as that section existed on July 16, 1997, to the extent that the plan provides medical care to employees or their dependents as defined under the terms of the plan directly, or through insurance, reimbursement or otherwise.

      2.  The term does not include:

      (a) Coverage that is only for accident or disability income insurance, or any combination thereof;

      (b) Coverage issued as a supplement to liability insurance;

      (c) Liability insurance, including general liability insurance and automobile liability insurance;

      (d) Workers’ compensation or similar insurance;

      (e) Coverage for medical payments under a policy of automobile insurance;

      (f) Credit insurance;

      (g) Coverage for on-site medical clinics; and

      (h) Other similar insurance coverage specified in federal regulations adopted pursuant to Public Law 104-191 under which benefits for medical care are secondary or incidental to other insurance benefits.

      3.  The term does not include the following benefits if the benefits are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of a health benefit plan:

      (a) Limited-scope dental or vision benefits;

      (b) Benefits for long-term care, nursing home care, home health care or community-based care, or any combination thereof; and

      (c) Such other similar benefits as are specified in federal regulations adopted pursuant to Public Law 104-191.

      4.  The term does not include the following benefits if the benefits are provided under a separate policy, certificate or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and such benefits are paid for a claim without regard to whether benefits are provided for such a claim under any group health plan maintained by the same plan sponsor:

      (a) Coverage that is only for a specified disease or illness; and

      (b) Hospital indemnity or other fixed indemnity insurance.

      5.  The term does not include any of the following, if offered as a separate policy, certificate or contract of insurance:

      (a) Medicare supplemental health insurance as defined in section 1882(g)(1) of the Social Security Act, as that section existed on July 16, 1997;

      (b) Coverage supplemental to the coverage provided pursuant to chapter 55 of Title 10, United States Code (Civilian Health and Medical Program of Uniformed Services (CHAMPUS)); and

      (c) Similar supplemental coverage provided under a group health plan.

      (Added to NRS by 1997, 2885)

      NRS 689A.540  “Health benefit plan” defined.

      1.  “Health benefit plan” means a policy, contract, certificate or agreement offered by a carrier to provide for, deliver payment for, arrange for the payment of, pay for or reimburse any of the costs of health care services. Except as otherwise provided in this section, the term includes catastrophic health insurance policies and a policy that pays on a cost-incurred basis.

      2.  The term does not include:

      (a) Coverage that is only for accident or disability income insurance, or any combination thereof;

      (b) Coverage issued as a supplement to liability insurance;

      (c) Liability insurance, including general liability insurance and automobile liability insurance;

      (d) Workers’ compensation or similar insurance;

      (e) Coverage for medical payments under a policy of automobile insurance;

      (f) Credit insurance;

      (g) Coverage for on-site medical clinics;

      (h) Other similar insurance coverage specified in federal regulations issued pursuant to Public Law 104-191 under which benefits for medical care are secondary or incidental to other insurance benefits;

      (i) Coverage under a short-term health insurance policy; and

      (j) Coverage under a blanket student accident and health insurance policy.

      3.  The term does not include the following benefits if the benefits are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of a health benefit plan:

      (a) Limited-scope dental or vision benefits;

      (b) Benefits for long-term care, nursing home care, home health care or community-based care, or any combination thereof; and

      (c) Such other similar benefits as are specified in any federal regulations adopted pursuant to the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191.

      4.  The term does not include the following benefits if the benefits are provided under a separate policy, certificate or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and the benefits are paid for a claim without regard to whether benefits are provided for such a claim under any group health plan maintained by the same plan sponsor:

      (a) Coverage that is only for a specified disease or illness; and

      (b) Hospital indemnity or other fixed indemnity insurance.

      5.  The term does not include any of the following, if offered as a separate policy, certificate or contract of insurance:

      (a) Medicare supplemental health insurance as defined in section 1882(g)(1) of the Social Security Act, 42 U.S.C. § 1395ss, as that section existed on July 16, 1997;

      (b) Coverage supplemental to the coverage provided pursuant to the Civilian Health and Medical Program of Uniformed Services, CHAMPUS, 10 U.S.C. §§ 1071 et seq.; and

      (c) Similar supplemental coverage provided under a group health plan.

      (Added to NRS by 1997, 2886; A 1999, 2803)

      NRS 689A.545  “Health status-related factor” defined. [Effective through December 31, 2013.]  “Health status-related factor” means, with regard to a person who is or seeks to be insured:

      1.  Health status;

      2.  Any medical conditions, including physical or mental illness, or both;

      3.  Claims experience;

      4.  Receipt of health care;

      5.  Medical history;

      6.  Genetic information;

      7.  Evidence of insurability, including conditions arising out of acts of domestic violence; and

      8.  Disability.

      (Added to NRS by 1997, 2887; R 2013, 3661, effective January 1, 2014)

      NRS 689A.550  “Individual carrier” defined.  “Individual carrier” means any entity subject to the provisions of this title and the regulations adopted pursuant thereto, that contracts or offers to contract to provide for, deliver payment for, arrange for payment of, pay for, or reimburse any cost of health care services, including a sickness and accident health service corporation, and any other entity providing a plan of health insurance, health benefits or health services to individuals and their dependents in this state.

      (Added to NRS by 1997, 2887)

      NRS 689A.555  “Individual health benefit plan” defined.  “Individual health benefit plan” means:

      1.  A health benefit plan for individuals and their dependents, other than a converted policy or a plan for coverage of a bona fide association; and

      2.  A certificate issued to an individual that evidences coverage under a policy or contract issued to a trust or an association or to any other similar group of persons, other than a plan for coverage of a bona fide association, regardless of the situs of delivery of the policy or contract, if the individual pays the premium and is not being covered under the policy or contract pursuant to any provision for the continuation of benefits applicable under federal or state law.

      (Added to NRS by 1997, 2887)

      NRS 689A.560  “Individual reinsuring carrier” defined. [Effective through December 31, 2013.]  “Individual reinsuring carrier” means an individual carrier that is eligible to reinsure eligible persons in the Program of Reinsurance established pursuant to NRS 689C.610 to 689C.980, inclusive.

      (Added to NRS by 1997, 2887; R 2013, 3661, effective January 1, 2014)

      NRS 689A.565  “Individual risk-assuming carrier” defined. [Effective through December 31, 2013.]  “Individual risk-assuming carrier” means an individual carrier that has elected to act as a risk-assuming carrier.

      (Added to NRS by 1997, 2888; R 2013, 3661, effective January 1, 2014)

      NRS 689A.570  “Plan for coverage of a bona fide association” defined.  “Plan for coverage of a bona fide association” means a health benefit plan for the members, and their dependents, of a bona fide association in this state regardless of the situs of delivery of the policy or contract, if the health benefit plan conforms with NRS 689A.725.

      (Added to NRS by 1997, 2888)

      NRS 689A.575  “Plan of operation” defined. [Effective through December 31, 2013.]  “Plan of operation” means the plan of operation of the Program of Reinsurance established pursuant to NRS 689C.610 to 689C.980, inclusive.

      (Added to NRS by 1997, 2888; R 2013, 3661, effective January 1, 2014)

      NRS 689A.580  “Plan sponsor” defined.  “Plan sponsor” has the meaning ascribed to it in section 3(16)(B) of the Employee Retirement Security Act of 1974, as that section existed on July 16, 1997.

      (Added to NRS by 1997, 2888)

      NRS 689A.585  “Preexisting condition” defined.  “Preexisting condition” means a condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received during the 6 months preceding the effective date of the new coverage. The term does not include genetic information in the absence of a diagnosis of the condition related to such information.

      (Added to NRS by 1997, 2888)

      NRS 689A.590  “Producer” defined.  “Producer” means an agent or broker licensed pursuant to this Title.

      (Added to NRS by 1997, 2888)

      NRS 689A.595  “Program of Reinsurance” defined. [Effective through December 31, 2013.]  “Program of Reinsurance” means the Program of Reinsurance for Small Employers and Eligible Persons established pursuant to NRS 689C.740.

      (Added to NRS by 1997, 2888; R 2013, 3661, effective January 1, 2014)

      NRS 689A.600  “Provision for a restricted network” defined.  “Provision for a restricted network” means any provision of a health benefit plan that conditions the payment of benefits, in whole or in part, on the use of a provider of health care that has entered into a contractual arrangement with an individual carrier to provide health care services to individuals covered by the plan.

      (Added to NRS by 1997, 2888)

      NRS 689A.605  “Standard health benefit plan” defined. [Effective through December 31, 2013.]  “Standard health benefit plan” means a standard health benefit plan developed pursuant to NRS 689C.610 to 689C.980, inclusive.

      (Added to NRS by 1997, 2888; R 2013, 3661, effective January 1, 2014)

      NRS 689A.610  Applicability; ceding arrangement prohibited in certain circumstances. [Effective through December 31, 2013.]

      1.  NRS 689A.470 to 689A.740, inclusive, apply to:

      (a) Any health benefit plan that must be made available to eligible persons; and

      (b) Any certificate issued to a trust or an association or other similar groupings of persons for coverage of eligible persons,

Ê regardless of the location of delivery of the policy or certificate, if the eligible person pays the premium and is not otherwise covered under the policy or contract pursuant to any federal or state law relating to the continuation of benefits.

      2.  For the purposes of NRS 689A.470 to 689A.740, inclusive, and except as otherwise provided in subsection 3, two or more individual carriers which are affiliated companies or which are eligible to file a consolidated tax return shall be deemed to be one individual carrier, and any restriction or limitation imposed by NRS 689A.470 to 689A.740, inclusive, applies as if all health benefit plans delivered or issued for delivery to eligible persons in this State by the affiliated individual carriers were issued by one individual carrier.

      3.  An affiliated individual carrier that is a health maintenance organization having a certificate of authority issued pursuant to the provisions of chapter 695C of NRS may be considered a separate individual carrier for the purposes of NRS 689A.470 to 689A.740, inclusive.

      4.  Unless otherwise authorized by the Commissioner, an individual carrier shall not enter into any ceding arrangement with respect to a health benefit plan delivered or issued for delivery to any eligible person in this State if the ceding arrangement would result in the ceding individual carrier retaining less than 30 percent of the insurance obligations or risks for that health benefit plan.

      (Added to NRS by 1997, 2888; R 2013, 3661, effective January 1, 2014)

      NRS 689A.615  Certain plan, fund or program to be treated as employee welfare benefit plan which is group health plan; partnership deemed employer of each partner.  For the purposes of NRS 689A.470 to 689A.740, inclusive:

      1.  Any plan, fund or program which would not be, but for section 2721(e) of the Public Health Service Act, as amended by Public Law 104-191, as that section existed on July 16, 1997, an employee welfare benefit plan and which is established or maintained by a partnership to the extent that the plan, fund or program provides medical care to current or former partners in the partnership or to their dependents, as defined under the terms of the plan, fund or program, directly or through insurance, reimbursement or otherwise, must be treated, subject to subsection 2, as an employee welfare benefit plan which is a group health plan.

      2.  In the case of a group health plan, a partnership shall be deemed to be the employer of each partner.

      (Added to NRS by 1997, 2889)

      NRS 689A.620  Certain person with break in coverage deemed eligible person. [Effective through December 31, 2013.]  A person who meets the requirements to be an eligible person as set forth in NRS 689A.515, except that the person had a break in creditable coverage of more than 63 days, shall be deemed to be an eligible person and is eligible to obtain health insurance coverage pursuant to this chapter as an eligible person if the person seeks that coverage between January 1, 1998, and January 31, 1998, inclusive.

      (Added to NRS by 1997, 2889; R 2013, 3661, effective January 1, 2014)

Individual Carriers

      NRS 689A.630  Requirement to renew coverage at option of individual; exceptions; discontinuation of form of product of health benefit plan; discontinuation of health benefit plan available through bona fide association. [Effective through December 31, 2013.]

      1.  Except as otherwise provided in this section, coverage under an individual health benefit plan must be renewed by the individual carrier that issued the plan, at the option of the individual, unless:

      (a) The individual has failed to pay premiums or contributions in accordance with the terms of the health benefit plan or the individual carrier has not received timely premium payments.

      (b) The individual has performed an act or a practice that constitutes fraud or has made an intentional misrepresentation of material fact under the terms of the coverage.

      (c) The individual carrier decides to discontinue offering and renewing all health benefit plans delivered or issued for delivery in this state. If the individual carrier decides to discontinue offering and renewing such plans, the individual carrier shall:

             (1) Provide notice of its intention to the Commissioner and the chief regulatory officer for insurance in each state in which the individual carrier is licensed to transact insurance at least 60 days before the date on which notice of cancellation or nonrenewal is delivered or mailed to the persons covered by the insurance to be discontinued pursuant to subparagraph (2).

             (2) Provide notice of its intention to all persons covered by the discontinued insurance and to the Commissioner and the chief regulatory officer for insurance in each state in which such a person is known to reside. The notice must be made at least 180 days before the nonrenewal of any health benefit plan by the individual carrier.

             (3) Discontinue all health insurance issued or delivered for issuance for individuals in this state and not renew coverage under any health benefit plan issued to such individuals.

      (d) The Commissioner finds that the continuation of the coverage in this state by the individual carrier would not be in the best interests of the policyholders or certificate holders of the individual carrier or would impair the ability of the individual carrier to meet its contractual obligations. If the Commissioner makes such a finding, the Commissioner shall assist the persons covered by the discontinued insurance in this state in finding replacement coverage.

      2.  An individual carrier may discontinue the issuance and renewal of a form of a product of a health benefit plan if the Commissioner finds that the form of the product offered by the individual carrier is obsolete and is being replaced with comparable coverage. A form of a product of a health benefit plan may be discontinued by the individual carrier pursuant to this subsection only if:

      (a) The individual carrier notifies the Commissioner and the chief regulatory officer for insurance in each state in which it is licensed of its decision pursuant to this subsection to discontinue the issuance and renewal of the form of the product at least 60 days before the individual carrier notifies the persons covered by the discontinued insurance pursuant to paragraph (b).

      (b) The individual carrier notifies each person covered by the discontinued insurance, the Commissioner and the chief regulatory officer for insurance in each state in which a person covered by the discontinued insurance is known to reside of the decision of the individual carrier to discontinue offering the form of the product. The notice must be made to persons covered by the discontinued insurance at least 180 days before the date on which the individual carrier will discontinue offering the form of the product.

      (c) The individual carrier offers to each person covered by the discontinued insurance the option to purchase any other health benefit plan currently offered by the individual carrier to individuals in this state.

      (d) In exercising the option to discontinue the form of the product and in offering the option to purchase other coverage pursuant to paragraph (c), the individual carrier acts uniformly without regard to the claim experience of the persons covered by the discontinued insurance or any health status-related factor relating to those persons or beneficiaries covered by the discontinued form of the product or any persons or beneficiaries who may become eligible for such coverage.

      3.  An individual carrier may discontinue the issuance and renewal of a health benefit plan that is made available to individuals pursuant to this chapter only through a bona fide association if:

      (a) The membership of the individual in the association was the basis for the provision of coverage;

      (b) The membership of the individual in the association ceases; and

      (c) The coverage is terminated pursuant to this subsection uniformly without regard to any health status-related factor relating to the covered individual.

      4.  An individual carrier that elects not to renew a health benefit plan pursuant to paragraph (c) of subsection 1 shall not write new business for individuals pursuant to this chapter for 5 years after the date on which notice is provided to the Commissioner pursuant to subparagraph (2) of paragraph (c) of subsection 1.

      5.  If an individual carrier does business in only one established geographic service area of this state, the provisions of this section apply only to the operations of the individual carrier in that service area.

      (Added to NRS by 1997, 2890)

      NRS 689A.630  Requirement to renew coverage at option of individual; exceptions; discontinuation of form of product of health benefit plan; discontinuation of health benefit plan available through bona fide association. [Effective January 1, 2014.]

      1.  Except as otherwise provided in this section, coverage under an individual health benefit plan must be renewed by the individual carrier that issued the plan, at the option of the individual, unless:

      (a) The individual has failed to pay premiums or contributions in accordance with the terms of the health benefit plan or the individual carrier has not received timely premium payments.

      (b) The individual has performed an act or a practice that constitutes fraud or has made an intentional misrepresentation of material fact under the terms of the coverage.

      (c) The individual carrier decides to discontinue offering and renewing all health benefit plans delivered or issued for delivery in this state. If the individual carrier decides to discontinue offering and renewing such plans, the individual carrier shall:

             (1) Provide notice of its intention to the Commissioner and the chief regulatory officer for insurance in each state in which the individual carrier is licensed to transact insurance at least 60 days before the date on which notice of cancellation or nonrenewal is delivered or mailed to the persons covered by the insurance to be discontinued pursuant to subparagraph (2).

             (2) Provide notice of its intention to all persons covered by the discontinued insurance and to the Commissioner and the chief regulatory officer for insurance in each state in which such a person is known to reside. The notice must be made at least 180 days before the nonrenewal of any health benefit plan by the individual carrier.

             (3) Discontinue all health insurance issued or delivered for issuance for individuals in this state and not renew coverage under any health benefit plan issued to such individuals.

      (d) The Commissioner finds that the continuation of the coverage in this state by the individual carrier would not be in the best interests of the policyholders or certificate holders of the individual carrier or would impair the ability of the individual carrier to meet its contractual obligations. If the Commissioner makes such a finding, the Commissioner shall assist the persons covered by the discontinued insurance in this state in finding replacement coverage.

      2.  An individual carrier may discontinue the issuance and renewal of a form of a product of a health benefit plan if the Commissioner finds that the form of the product offered by the individual carrier is obsolete and is being replaced with comparable coverage. A form of a product of a health benefit plan may be discontinued by the individual carrier pursuant to this subsection only if:

      (a) The individual carrier notifies the Commissioner and the chief regulatory officer for insurance in each state in which it is licensed of its decision pursuant to this subsection to discontinue the issuance and renewal of the form of the product at least 60 days before the individual carrier notifies the persons covered by the discontinued insurance pursuant to paragraph (b).

      (b) The individual carrier notifies each person covered by the discontinued insurance, the Commissioner and the chief regulatory officer for insurance in each state in which a person covered by the discontinued insurance is known to reside of the decision of the individual carrier to discontinue offering the form of the product. The notice must be made to persons covered by the discontinued insurance at least 180 days before the date on which the individual carrier will discontinue offering the form of the product.

      (c) The individual carrier offers to each person covered by the discontinued insurance the option to purchase any other health benefit plan currently offered by the individual carrier to individuals in this state.

      (d) In exercising the option to discontinue the form of the product and in offering the option to purchase other coverage pursuant to paragraph (c), the individual carrier acts uniformly without regard to the claim experience of the persons covered by the discontinued insurance or any health status-related factor relating to those persons or beneficiaries covered by the discontinued form of the product or any persons or beneficiaries who may become eligible for such coverage.

      3.  An individual carrier may discontinue the issuance and renewal of a health benefit plan that is made available to individuals pursuant to this chapter only through a bona fide association if:

      (a) The membership of the individual in the association was the basis for the provision of coverage;

      (b) The membership of the individual in the association ceases; and

      (c) The coverage is terminated pursuant to this subsection uniformly without regard to any health status-related factor relating to the covered individual.

      4.  An individual carrier that elects not to renew a health benefit plan pursuant to paragraph (c) of subsection 1 shall not write new business for individuals pursuant to this chapter for 5 years after the date on which notice is provided to the Commissioner pursuant to subparagraph (2) of paragraph (c) of subsection 1.

      5.  If an individual carrier does business in only one geographic service area of this state, the provisions of this section apply only to the operations of the individual carrier in that service area.

      (Added to NRS by 1997, 2890; A 2013, 3614, effective January 1, 2014)

      NRS 689A.635  Coverage offered through network plan not required to be offered to eligible person who does not reside or work in established geographic service area. [Effective through December 31, 2013.]

      1.  An individual carrier that offers coverage through a network plan is not required pursuant to NRS 689A.630 to offer coverage to or accept an application from an eligible person if the eligible person does not reside or work in the established geographic service area or in a geographic area for which the individual carrier is authorized to transact insurance, provided that the coverage is refused or terminated uniformly without regard to any health status-related factor of any eligible person.

      2.  As used in this section, “network plan” means a health benefit plan offered by a health carrier under which the financing and delivery of medical care is provided, in whole or in part, through a defined set of providers under contract with the carrier. The term does not include an arrangement for the financing of premiums.

      (Added to NRS by 1997, 2892)

      NRS 689A.635  Coverage offered through network plan not required to be offered to person who does not reside or work in geographic service area or geographic rating area. [Effective January 1, 2014.]

      1.  An individual carrier that offers coverage through a network plan is not required pursuant to NRS 689A.630 to offer coverage to or accept an application from a person if the person does not reside or work in the geographic service area or in a geographic rating area, provided that the coverage is refused or terminated uniformly without regard to any health status-related factor of any eligible person.

      2.  As used in this section, “network plan” means a health benefit plan offered by a health carrier under which the financing and delivery of medical care is provided, in whole or in part, through a defined set of providers under contract with the carrier. The term does not include an arrangement for the financing of premiums.

      (Added to NRS by 1997, 2892; A 2013, 3615, effective January 1, 2014)

      NRS 689A.637  Coverage offered through plan that provides for restricted network: Contracts with certain federally qualified health centers. [Effective through December 31, 2013.]

      1.  An individual carrier that offers a health benefit plan that includes a provision for a restricted network shall use its best efforts to contract with at least one health center in each established geographic service area to provide health care services to persons covered by the plan if the health center:

      (a) Meets all conditions imposed by the carrier on similarly situated providers of health care with which the carrier contracts, including, without limitation:

             (1) Certification for participation in the Medicaid or Medicare program; and

             (2) Requirements relating to the appropriate credentials for providers of health care; and

      (b) Agrees to reasonable reimbursement rates that are generally consistent with those offered by the carrier to similarly situated providers of health care with which the carrier contracts.

      2.  As used in this section, “health center” has the meaning ascribed to it in 42 U.S.C. § 254b.

      (Added to NRS by 2001, 1922)

      NRS 689A.637  Coverage offered through plan that provides for restricted network: Contracts with certain federally qualified health centers. [Effective January 1, 2014.]

      1.  An individual carrier that offers a health benefit plan that includes a provision for a restricted network shall use its best efforts to contract with at least one health center in each geographic service area to provide health care services to persons covered by the plan if the health center:

      (a) Meets all conditions imposed by the carrier on similarly situated providers of health care with which the carrier contracts, including, without limitation:

             (1) Certification for participation in the Medicaid or Medicare program; and

             (2) Requirements relating to the appropriate credentials for providers of health care; and

      (b) Agrees to reasonable reimbursement rates that are generally consistent with those offered by the carrier to similarly situated providers of health care with which the carrier contracts.

      2.  As used in this section, “health center” has the meaning ascribed to it in 42 U.S.C. § 254b.

      (Added to NRS by 2001, 1922; A 2013, 3615, effective January 1, 2014)

      NRS 689A.640  Each health benefit plan marketed in this State required to be offered to eligible persons. [Effective through December 31, 2013.]

      1.  As a condition of transacting insurance in this State with individuals, an individual carrier must actively market to eligible persons each health benefit plan that is actively marketed in this State by the individual carrier to any individual in this State. The health insurance plans marketed pursuant to this section by an individual carrier must include, without limitation, a basic health benefit plan and a standard health benefit plan.

      2.  An individual carrier shall issue to an eligible person any basic or standard individual health benefit plan that it markets in accordance with subsection 1 if the eligible person applies for the plan and agrees to make the required premium payments and satisfy the other reasonable provisions of the health benefit plan that are not inconsistent with NRS 689A.470 to 689A.740, inclusive.

      (Added to NRS by 1997, 2892; R 2013, 3661, effective January 1, 2014)

      NRS 689A.645  Coverage to eligible person who does not reside in established geographic service area not required; coverage within certain areas not required. [Effective through December 31, 2013.]  An individual carrier is not required pursuant to NRS 689A.640 to offer coverage to or accept an application for coverage:

      1.  From an eligible person if the eligible person does not reside in the established geographic service area of the individual carrier.

      2.  Within an area where the individual carrier reasonably anticipates, and demonstrates to the satisfaction of the Commissioner, that the individual carrier does not have the capacity within its established geographic service area to deliver adequate service to additional eligible persons because of its obligations to existing policyholders. If an individual carrier is authorized by the Commissioner not to offer coverage pursuant to this subsection, the individual carrier shall not thereafter offer coverage in the applicable area to additional eligible persons until the individual carrier demonstrates to the satisfaction of the Commissioner that it has regained the capacity to deliver adequate service to additional eligible persons in that service area.

      (Added to NRS by 1997, 2893; R 2013, 3661, effective January 1, 2014)

      NRS 689A.650  Coverage to eligible persons not required under certain circumstances; notice to Commissioner of and prohibition on writing new business after election not to offer new coverage required. [Effective through December 31, 2013.]

      1.  An individual carrier is not required to provide coverage to eligible persons pursuant to NRS 689A.640:

      (a) During any period in which the Commissioner determines that requiring the individual carrier to provide such coverage would place the individual carrier in a financially impaired condition.

      (b) If the individual carrier elects not to offer any new coverage to any persons in this State. An individual carrier that elects not to offer new coverage in accordance with this paragraph may maintain its existing policies issued to persons in this State, subject to the requirements of NRS 689A.630.

      2.  An individual carrier that elects not to offer new coverage pursuant to paragraph (b) of subsection 1 shall notify the Commissioner forthwith of that election and shall not thereafter write any new business to individuals in this State for 5 years after the date of the notification.

      (Added to NRS by 1997, 2893; A 1999, 2805; R 2013, 3661, effective January 1, 2014)

      NRS 689A.655  Requirement to file basic and standard health benefit plans with Commissioner; disapproval of plan. [Effective through December 31, 2013.]

      1.  Each individual carrier shall file with the Commissioner within 90 days after the date on which a basic health benefit plan and a standard health benefit plan are approved pursuant to NRS 689C.770, or for a new individual carrier within 90 days after the date it enters the individual market in this State, in a format and manner prescribed by the Commissioner, the basic health benefit plans and the standard health benefit plans to be offered by the individual carrier. A health benefit plan filed pursuant to this section may not be offered by an individual carrier until the earlier of:

      (a) The date of approval by the Commissioner; or

      (b) Thirty days after the date on which the plans are filed, unless the Commissioner disapproves the use of the plans before the 30-day period expires.

      2.  The Commissioner may, at any time, after providing notice and an opportunity for a hearing, disapprove the continued use of a basic or standard health benefit plan by the individual carrier on the ground that the plan does not meet the requirements of NRS 689A.470 to 689A.740, inclusive, and 689C.610 to 689C.980, inclusive.

      (Added to NRS by 1997, 2892; R 2013, 3661, effective January 1, 2014)

      NRS 689A.660  Prohibited acts concerning preexisting conditions and modification of health benefit plan. [Effective through December 31, 2013.]  An individual carrier shall not:

      1.  Impose on an eligible person who is covered under a basic or standard health benefit plan any exclusion because of a preexisting condition.

      2.  Modify a health benefit plan, with respect to an eligible person, through riders, endorsements or otherwise, to restrict or exclude services otherwise covered by the plan.

      (Added to NRS by 1997, 2893; A 1999, 2805; R 2013, 3661, effective January 1, 2014)

      NRS 689A.665  Certain health carriers not required to offer health benefit insurance coverage to individuals. [Effective through December 31, 2013.]  Nothing in NRS 689A.640 to 689A.660, inclusive, requires a health carrier that offers a health benefit plan only in connection with a group health plan or through a bona fide association, or both, to offer such health benefit insurance coverage to individuals.

      (Added to NRS by 1997, 2893; R 2013, 3661, effective January 1, 2014)

      NRS 689A.670  Election to operate as individual risk-assuming carrier or individual reinsuring carrier: Notice to Commissioner; effective date; change in status. [Effective through December 31, 2013.]

      1.  Within 30 days after the date on which a plan of operation is approved by the Commissioner pursuant to NRS 689C.770, or for a new carrier within 30 days after the date on which it enters the individual market in this state, an individual carrier shall elect to operate as either an individual risk-assuming carrier or an individual reinsuring carrier and shall notify the Commissioner of its election.

      2.  The initial election of an individual carrier to act as an individual risk-assuming or reinsuring carrier is effective on the individual carrier for 2 years after the date on which it notifies the Commissioner pursuant to subsection 1. After the initial 2-year period, such an election is effective for 5 years. The Commissioner may allow an individual carrier to modify its election at any time for good cause shown. The Commissioner may waive or modify the period during which the election of a carrier to operate as an individual risk-assuming or reinsuring carrier is effective.

      3.  An individual carrier may apply to the Commissioner, in a manner prescribed by the Commissioner by regulation, to change its status as an individual risk-assuming or reinsuring carrier.

      4.  An individual reinsuring carrier that elects or is subsequently authorized by the Commissioner to operate as a risk-assuming carrier:

      (a) Shall not continue to reinsure any individual health benefit plan with the Program of Reinsurance.

      (b) Shall pay a prorated assessment based upon business issued as an individual reinsuring carrier for any portion of the year that the business was reinsured.

      (Added to NRS by 1997, 2893; R 2013, 3661, effective January 1, 2014)

      NRS 689A.675  Election to act as individual risk-assuming carrier: Suspension by Commissioner; applicable statutes. [Effective through December 31, 2013.]

      1.  The Commissioner may suspend the election of an individual carrier to act as an individual risk-assuming carrier, if the Commissioner finds that:

      (a) The financial condition of the individual carrier no longer supports the assumption of risk from issuing coverage to eligible persons in compliance with NRS 689A.640 to 689A.660, inclusive, without the protection afforded by the Program of Reinsurance;

      (b) The individual carrier has failed to market its health benefit plans fairly to all eligible persons in this state or in its established geographic service area, as applicable; or

      (c) The individual carrier has failed to provide coverage to eligible persons as required pursuant to NRS 689A.640 to 689A.660, inclusive.

      2.  An individual carrier that elects to become an individual risk-assuming carrier is subject to:

      (a) The provisions of NRS 689A.640 to 689A.660, inclusive, relating to the availability of coverage; and

      (b) The provisions of NRS 689A.680 to 689A.700, inclusive, relating to premium rates.

      (Added to NRS by 1997, 2894; R 2013, 3661, effective January 1, 2014)

      NRS 689A.680  Rates for individual health benefit plans to be developed based on rating characteristics: Prohibited characteristics; health status as rating factor. [Effective through December 31, 2013.]

      1.  An individual carrier shall develop its rates for its individual health benefit plans pursuant to NRS 689A.470 to 689A.740, inclusive, based on rating characteristics. After any adjustments for rating characteristics and design of benefits, the rate for any block of business for an individual health benefit plan written on or after January 1, 2000, must not exceed the rate for any other block of business for an individual health benefit plan offered by the individual carrier by more than 50 percent. The rate for a block of business is equal to the average rate charged to all the insureds in the block of business. In determining whether the rate of a block of business complies with the provisions of this subsection, any differences in rating factors between blocks of business must be considered.

      2.  In determining the rating factors to establish premium rates for a health benefit plan, an individual carrier shall not use characteristics other than age, sex, occupation, geographic area, composition of the family of the individual and health status.

      3.  If an individual carrier uses health status as a rating factor in establishing premium rates, the highest factor associated with any classification for health status may not exceed the lowest factor by more than 75 percent.

      4.  For the purposes of this section, rating characteristics must not include durational or tier rating, or adverse changes in health status or claim experience after the policy is issued.

      5.  As used in this section, “characteristics” means demographic or other information concerning individuals that is considered by a carrier in the determination of premium rates for individuals.

      (Added to NRS by 1997, 2894; A 1999, 2805; R 2013, 3661, effective January 1, 2014)

      NRS 689A.685  Amount of change in rate of single block of business; plan with provision for restricted network; involuntary transfer of individual or dependent prohibited; premiums adjusted for block of business. [Effective through December 31, 2013.]

      1.  The amount of change in the rate of a single block of business of an individual carrier in any 12-month period because of claims experience or health status-related factors of that block of business, after adjustment for allowed rating characteristics and design of benefits, must not exceed the amount of any similar change in the rate of any other block of business of that individual carrier during the same period by more than 15 percent.

      2.  For the purposes of NRS 689A.470 to 689A.740, inclusive, a health benefit plan that contains a provision for a restricted network must not be considered to be a similar design of benefits when compared to a health benefit plan that does not contain such a provision if the restriction of benefits to the network providers results in substantial differences in the cost of claims.

      3.  An individual carrier shall not transfer an individual or his or her dependent covered by an individual health benefit plan issued by the individual carrier involuntarily into or out of a block of business.

      4.  If an individual carrier adjusts its premiums for a block of business to a level that is higher than permitted by requirements relating to the ratio of losses, as set forth in this Title and the regulations adopted pursuant thereto, to comply with this section and NRS 689A.680, the individual carrier shall make such adjustments on its entire individual health benefit plan business as needed to meet those requirements.

      (Added to NRS by 1997, 2895; R 2013, 3661, effective January 1, 2014)

      NRS 689A.690  Information required to be disclosed as part of solicitation and sales materials; information required to be maintained at place of business; actuarial certification required to be filed with Commissioner. [Effective through December 31, 2013.]

      1.  As part of its solicitation and sales materials for an individual health benefit plan, an individual carrier shall disclose, to the extent reasonable:

      (a) The extent to which premium rates for an individual and the dependent of the individual are established or adjusted based upon rating characteristics;

      (b) The right of the individual carrier to change premium rates and the factors, other than claims experience, that may affect changes in premium rates;

      (c) Any provisions in the individual health benefit plan relating to the renewability of the plan; and

      (d) Any provisions in the individual health benefit plan relating to an exclusion for a preexisting condition.

      2.  For the purposes of this section, an individual carrier shall maintain at its principal place of business a complete and detailed description of its rating practices and underwriting practices, including information and documentation that demonstrate that its rating methods and practices are based upon commonly accepted actuarial assumptions and are in accordance with sound actuarial principles.

      3.  On or before March 1 of each year, an individual carrier shall file with the Commissioner an actuarial certification that the individual carrier is in compliance with NRS 689A.680 to 689A.700, inclusive, and that the rating methods of the individual carrier are actuarially sound. The certification must be in such a form and must contain such information as specified by the Commissioner. A copy of the certification must be retained by the individual carrier at its principal place of business.

      4.  As used in this section, “actuarial certification” means a written statement signed by a member of the American Academy of Actuaries or any other person acceptable to the Commissioner that an individual carrier is in compliance with the provisions of NRS 689A.680 to 689A.700, inclusive, based upon an examination conducted by the person which included a review of the appropriate records and the actuarial assumptions and methods used by the individual carrier in establishing premium rates for applicable health benefit plans.

      (Added to NRS by 1997, 2895)

      NRS 689A.690  Information required to be disclosed as part of solicitation and sales materials; information required to be maintained at place of business. [Effective January 1, 2014.]

      1.  As part of its solicitation and sales materials for an individual health benefit plan, an individual carrier shall disclose, to the extent reasonable:

      (a) The extent to which premium rates for an individual and the dependent of the individual are established or adjusted based upon rating characteristics;

      (b) The right of the individual carrier to change premium rates and the factors, other than claims experience, that may affect changes in premium rates; and

      (c) Any provisions in the individual health benefit plan relating to the renewability of the plan.

      2.  For the purposes of this section, an individual carrier shall maintain at its principal place of business a complete and detailed description of its rating practices and underwriting practices, including information and documentation that demonstrate that its rating methods and practices are based upon commonly accepted actuarial assumptions and are in accordance with sound actuarial principles.

      (Added to NRS by 1997, 2895; A 2013, 3616, effective January 1, 2014)

      NRS 689A.695  Information and documents to be made available to Commissioner; proprietary information. [Effective through December 31, 2013.]  An individual carrier shall make the information and documents described in NRS 689A.680 to 689A.700, inclusive, available to the Commissioner upon request. Except in cases of violations of the provisions of this chapter, the information, other than the premium rates charged by the individual carrier, is proprietary, constitutes a trade secret and is not subject to disclosure by the Commissioner to persons outside of the Division except as agreed to by the individual carrier or as ordered by a court of competent jurisdiction.

      (Added to NRS by 1997, 2896)

      NRS 689A.695  Information and documents to be made available to Commissioner; proprietary information. [Effective January 1, 2014.]  An individual carrier shall make the information and documents described in NRS 689A.690, 689A.695 and 689A.700 available to the Commissioner upon request. Except in cases of violations of the provisions of this chapter, the information, other than the premium rates charged by the individual carrier, is proprietary, constitutes a trade secret and is not subject to disclosure by the Commissioner to persons outside of the Division except as agreed to by the individual carrier or as ordered by a court of competent jurisdiction.

      (Added to NRS by 1997, 2896; A 2013, 3616, effective January 1, 2014)

      NRS 689A.700  Regulations regarding rates. [Effective through December 31, 2013.]  The Commissioner may adopt regulations to carry out the provisions of NRS 689A.680 to 689A.700, inclusive, and to ensure that the practices used by individual carriers relating to the establishment of rates are consistent with the purposes of NRS 689A.470 to 689A.740, inclusive, including, but not limited to, determining the manner in which geographic areas are designated by all individual carriers.

      (Added to NRS by 1997, 2895)

      NRS 689A.700  Regulations regarding rates. [Effective January 1, 2014.]  The Commissioner may adopt regulations to carry out the provisions of NRS 689A.690, 689A.695 and 689A.700 and to ensure that the practices used by individual carriers relating to the establishment of rates are consistent with the purposes of NRS 689A.470 to 689A.740, inclusive.

      (Added to NRS by 1997, 2895; A 2013, 3617, effective January 1, 2014)

      NRS 689A.705  Regulations concerning reissuance of health benefit plan.  The Commissioner may adopt regulations to require an individual carrier, as a condition of transacting business with individuals in this state after July 16, 1997, to reissue a health benefit plan to any individual whose health benefit plan has been terminated or not renewed by the individual carrier after July 1, 1997. The Commissioner may prescribe such terms for the reissue of coverage as the Commissioner finds are reasonable and necessary to provide continuity of coverage to individuals.

      (Added to NRS by 1997, 2897)

      NRS 689A.710  Prohibited acts; denial of application for coverage; regulations; violation may constitute unfair trade practice; applicability of section. [Effective through December 31, 2013.]

      1.  Except as otherwise provided in this section, an individual carrier or a producer shall not, directly or indirectly:

      (a) Encourage or direct an eligible person to refrain from filing an application for coverage with an individual carrier because of the health status, claims experience, industry, occupation or geographic location of the eligible person.

      (b) Encourage or direct an eligible person to seek coverage from another carrier because of the health status, claims experience, industry, occupation or geographic location of the eligible person.

      2.  The provisions of subsection 1 do not apply to information provided to an eligible person by an individual carrier or a producer relating to the established geographic service area or a provision for a restricted network of the individual carrier.

      3.  Except as otherwise provided in this subsection, an individual carrier shall not, directly or indirectly, enter into any contract, agreement or arrangement with a producer if the contract, agreement or arrangement provides for or results in a variation to the compensation paid to a producer for the sale of a health benefit plan because of the health status, claims experience, industry, occupation or geographic location of the individual at the time that the health benefit plan is issued to or renewed by the individual. The provisions of this subsection do not apply to any arrangement for compensation that provides payment to a producer on the basis of a percentage of premiums, except that the percentage may not vary because of the health status, claims experience, industry, occupation or geographic area of the individual.

      4.  An individual carrier shall not terminate, fail to renew, or limit its contract or agreement of representation with a producer for any reason related to the health status, claims experience, industry, occupation or geographic location of an individual at the time that the health benefit plan is issued to or renewed by the individual placed by the producer with the individual carrier.

      5.  A denial by an individual carrier of an application for coverage from an eligible person must be in writing and must state the reason for the denial.

      6.  The Commissioner may adopt regulations that set forth additional standards to provide for the fair marketing and broad availability of health benefit plans to eligible persons in this state.

      7.  A violation of any provision of this section by an individual carrier may constitute an unfair trade practice for the purposes of chapter 686A of NRS.

      8.  The provisions of this section apply to a third-party administrator if the third-party administrator enters into a contract, agreement or other arrangement with an individual carrier to provide administrative, marketing or other services related to the offering of a health benefit plan to eligible persons in this state.

      9.  Nothing in this section interferes with the right and responsibility of a broker to advise and represent the best interests of an eligible person who is seeking health insurance coverage from an individual carrier.

      (Added to NRS by 1997, 2896)

      NRS 689A.710  Prohibited acts; denial of application for coverage; regulations; violation may constitute unfair trade practice; applicability of section. [Effective January 1, 2014.]

      1.  Except as otherwise provided in this section, an individual carrier or a producer shall not, directly or indirectly:

      (a) Encourage or direct an individual or family to refrain from filing an application for coverage with an individual carrier because of the health status, claims experience, industry, occupation or geographic location of the individual or family.

      (b) Encourage or direct an individual or family to seek coverage from another carrier because of the health status, claims experience, industry, occupation or geographic location of the individual or family.

      2.  The provisions of subsection 1 do not apply to information provided to an individual or family by an individual carrier or a producer relating to the geographic service area or a provision for a restricted network of the individual carrier.

      3.  An individual carrier shall not, directly or indirectly, enter into any contract, agreement or arrangement with a producer if the contract, agreement or arrangement provides for or results in a variation to the compensation paid to a producer for the sale of a health benefit plan because of the health status, claims experience, industry, occupation or geographic location of the individual at the time that the health benefit plan is issued to or renewed by the individual.

      4.  An individual carrier shall not terminate, fail to renew, or limit its contract or agreement of representation with a producer for any reason related to the health status, claims experience, industry, occupation or geographic location of an individual at the time that the health benefit plan is issued to or renewed by the individual placed by the producer with the individual carrier.

      5.  A denial by an individual carrier of an application for coverage from an individual or family must be in writing and must state the reason for the denial.

      6.  The Commissioner may adopt regulations that set forth additional standards to provide for the fair marketing and broad availability of health benefit plans to individuals or families in this state.

      7.  A violation of any provision of this section by an individual carrier may constitute an unfair trade practice for the purposes of chapter 686A of NRS.

      8.  The provisions of this section apply to a third-party administrator if the third-party administrator enters into a contract, agreement or other arrangement with an individual carrier to provide administrative, marketing or other services related to the offering of a health benefit plan to individuals or families in this state.

      9.  Nothing in this section interferes with the right and responsibility of a producer to advise and represent the best interests of an individual or family who is seeking health insurance coverage from an individual carrier.

      (Added to NRS by 1997, 2896; A 2013, 3617, effective January 1, 2014)

Individual Health Insurance Coverage

      NRS 689A.715  Requirements for employee welfare benefit plan for providing benefits for employees of more than one employer.

      1.  An employee welfare benefit plan for providing benefits for employees of more than one employer under which individual health insurance coverage is provided must comply with the provisions of NRS 679B.139 and 689A.470 to 689A.740, inclusive, and the regulations adopted by the Commissioner pursuant thereto.

      2.  As used in this section, the term “employee welfare benefit plan for providing benefits for employees of more than one employer” is intended to be equivalent to the term “employee welfare benefit plan which is a multiple employer welfare arrangement” as used in federal statutes and regulations.

      (Added to NRS by 1997, 2890)

      NRS 689A.720  Written certification of coverage required for determining period of creditable coverage accumulated by person; provision of certificate to insured.

      1.  To determine the period of creditable coverage of a person, a health insurance issuer offering individual health insurance coverage shall provide written certification of coverage on a form prescribed by the Commissioner to the person that certifies:

      (a) The period of creditable coverage of the person under the individual health insurance coverage; and

      (b) The date that a substantially completed application was received by the health insurance issuer from the person for individual health insurance coverage.

      2.  The certification of coverage must be provided to the insured:

      (a) At the time that the insured ceases to be covered under the individual health insurance coverage or otherwise becomes covered under any provision of the Consolidated Omnibus Budget Reconciliation Act of 1985, as that act existed on July 16, 1997, relating to the continuation of coverage;

      (b) If the insured becomes covered under such a provision, at the time that the insured ceases to be covered by that provision; and

      (c) Upon the request of the insured, if the request is made not later than 24 months after the date on which the insured ceased to be covered as described in paragraphs (a) and (b).

      (Added to NRS by 1997, 2897)

Bona Fide Associations

      NRS 689A.725  Requirements for plan for coverage. [Effective through December 31, 2013.]  For the purposes of NRS 689A.470 to 689A.740, inclusive, a plan for coverage of a bona fide association must:

      1.  Conform with NRS 689A.680 to 689A.700, inclusive, concerning rates.

      2.  Provide for the renewability of coverage for members of the bona fide association, and their dependents, if such coverage meets the criteria set forth in NRS 689A.630.

      3.  Provide for the availability of coverage for members of the bona fide association, and their dependents, if such coverage conforms with NRS 689A.640, except that the bona fide association is not required to offer basic and standard health benefit plan coverage to its members or their dependents.

      4.  Conform with subsection 1 of NRS 689A.660, relating to preexisting conditions.

      (Added to NRS by 1997, 2889)

      NRS 689A.725  Requirements for plan for coverage. [Effective January 1, 2014.]  For the purposes of NRS 689A.470 to 689A.740, inclusive, a plan for coverage of a bona fide association must:

      1.  Conform with NRS 689A.690, 689A.695 and 689A.700 concerning rates.

      2.  Provide for the renewability of coverage for members of the bona fide association, and their dependents, if such coverage meets the criteria set forth in NRS 689A.630.

      (Added to NRS by 1997, 2889; A 2013, 3618, effective January 1, 2014)

      NRS 689A.730  Producer may only sign up eligible persons if eligible persons are actively engaged in or related to association. [Effective through December 31, 2013.]  For the purposes of providing coverage under a health benefit plan pursuant to the provisions of NRS 689A.470 to 689A.740, inclusive, a producer may only market association memberships to eligible persons, accept applications for such membership, or sign up such members in a bona fide association if the eligible persons being marketed are actively engaged in, or directly related to, the bona fide association.

      (Added to NRS by 1997, 2889; R 2013, 3661, effective January 1, 2014)

Miscellaneous Provisions

      NRS 689A.740  Regulations.  The Commissioner shall adopt regulations as necessary to carry out the provisions of NRS 689A.470 to 689A.740, inclusive.

      (Added to NRS by 1997, 2896)

SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS

      NRS 689A.745  Approval; requirements; examination.

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

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

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

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

      (Added to NRS by 1997, 307; A 2003, 774; 2011, 3381)

      NRS 689A.750  Annual report; insurer to maintain records of complaints concerning something other than health care services.

      1.  Each insurer that issues a policy of health insurance in this State shall submit to the Commissioner and the State Board of Health an annual report regarding its system for resolving complaints established pursuant to subsection 1 of NRS 689A.745 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, 308; A 2003, 774)

      NRS 689A.755  Written notice to insured explaining right to file complaint; notice to insured required when insurer denies coverage of health care service.

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

      (a) At the time the insured receives his or her 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 an insured, including, without limitation, denying a claim relating to a policy of health insurance pursuant to NRS 689A.410, it shall notify the insured in writing within 10 working days after it denies coverage of the health care service of:

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

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

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

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

      (Added to NRS by 1997, 308; A 1999, 3082)