[Rev. 11/21/2013 1:13:31 PM--2013]

CHAPTER 689B - GROUP AND BLANKET HEALTH INSURANCE

GENERAL PROVISIONS

NRS 689B.010        Short title; scope.

NRS 689B.015        Contracts between insurer and provider of health care: Prohibiting insurer from charging provider of health care fee for inclusion on list of providers given to insureds; form to obtain information on provider of health care; modification; schedule of fees.

GROUP POLICIES

General Provisions

NRS 689B.020        “Group health insurance” defined; eligible groups and benefits.

NRS 689B.026        Delivery of policy to group formed to purchase health insurance prohibited; exception.

NRS 689B.0265      Policy to guaranteed association.

NRS 689B.027        Summary of coverage: Contents of disclosure; approval by Commissioner; copy to be made available to employer or producer acting on behalf of employer.

NRS 689B.028        Summary of coverage: Copy to be provided before policy issued; policy may not be offered unless summary approved by Commissioner.

NRS 689B.0283      Coverage for prescription drugs: Provision of notice and information regarding use of formulary.

NRS 689B.0285      System for resolving complaints: Approval; requirements; examination.

NRS 689B.029        Annual report regarding system for resolving complaints; insurer to maintain records of complaints concerning something other than health care services.

NRS 689B.0295      Written notice to insured explaining right to file complaint; notice to insured required when insurer denies coverage of health care service.

 

Coverage

NRS 689B.030        Required provisions.

NRS 689B.0303      Required provision concerning coverage for continued medical treatment.

NRS 689B.0306      Required provision concerning coverage for treatment received as part of clinical trial or study.

NRS 689B.031        Required provision concerning coverage of certain gynecological or obstetrical services without authorization or referral from primary care physician.

NRS 689B.0313      Required provision concerning coverage for human papillomavirus vaccine. [Effective through December 31, 2013.]

NRS 689B.0313      Required provision concerning coverage for human papillomavirus vaccine. [Effective January 1, 2014.]

NRS 689B.0317      Required provision concerning coverage for prostate cancer screening.

NRS 689B.033        Required provision concerning coverage for newly born and adopted children and children placed for adoption. [Effective through December 31, 2013.]

NRS 689B.033        Required provision concerning coverage for newly born and adopted children and children placed for adoption. [Effective January 1, 2014.]

NRS 689B.0335      Required provision concerning coverage for autism spectrum disorders.

NRS 689B.034        Required provision concerning effect of benefits under other valid group coverage; subrogation.

NRS 689B.0345      Required provision concerning coverage for employee or member on leave without pay as result of total disability.

NRS 689B.035        Required provision concerning termination of coverage on dependent child.

NRS 689B.0353      Required provision concerning coverage for treatment of certain inherited metabolic diseases.

NRS 689B.0357      Required provision concerning coverage for management and treatment of diabetes.

NRS 689B.0362      Required provision concerning coverage for orally administered chemotherapy.

NRS 689B.0365      Required provision concerning coverage for use of certain drugs for treatment of cancer.

NRS 689B.0367      Required provision concerning coverage for screening for colorectal cancer.

NRS 689B.0368      Required provision concerning coverage for prescription drug previously approved for medical condition of insured.

NRS 689B.0374      Required provision concerning coverage for cytologic screening tests and mammograms for certain women.

NRS 689B.0375      Required provision concerning coverage relating to mastectomy.

NRS 689B.0376      Policy covering prescription drugs or devices to provide coverage for drug or device for contraception and of hormone replacement therapy in certain circumstances; prohibited actions by insurer; exceptions.

NRS 689B.0377      Policy covering outpatient care to provide coverage for health care services related to contraceptives and hormone replacement therapy; prohibited actions by insurer; exceptions.

NRS 689B.0379      Required provision concerning coverage for treatment of temporomandibular joint.

 

Reimbursement and Payment

NRS 689B.038        Reimbursement for treatments by licensed psychologist.

NRS 689B.0383      Reimbursement for treatments by licensed marriage and family therapist or licensed clinical professional counselor.

NRS 689B.0385      Reimbursement for treatments by licensed associate in social work, social worker, independent social worker or clinical social worker.

NRS 689B.039        Reimbursement for treatments by chiropractor.

NRS 689B.0393      Reimbursement for treatments by podiatrist.

NRS 689B.0397      Reimbursement for treatment by licensed clinical alcohol and drug abuse counselor.

NRS 689B.040        Direct payment for hospital and medical services and home health care; payment to assignee.

NRS 689B.045        Reimbursement for services provided by certain nurses; prohibited limitations; exception.

NRS 689B.047        Reimbursement to provider of medical transportation.

NRS 689B.049        Reimbursement for acupuncture.

 

Miscellaneous Provisions

NRS 689B.050        Extended disability benefit.

NRS 689B.060        Readjustment of premiums; dividends.

NRS 689B.061        Limitations on deductibles and copayments charged under policy which offers difference of payment between preferred providers of health care and providers who are not preferred. [Effective through December 31, 2013.]

NRS 689B.061        Limitations on deductibles and copayments charged under policy which offers difference of payment between preferred providers of health care and providers who are not preferred. [Effective January 1, 2014.]

NRS 689B.063        Primary and secondary policies: Determination of benefits. [Effective through December 31, 2013.]

NRS 689B.063        Primary and secondary policies: Determination of benefits. [Effective January 1, 2014.]

NRS 689B.064        Primary and secondary policies: Order of benefits.

NRS 689B.065        Policy issued to replace discontinued policy or coverage: Requirements; notice of reduction of benefits; statement of benefits; applicability of section.

NRS 689B.067        Provision in policy requiring binding arbitration for disputes with insurer authorized; procedure for arbitration; declaratory relief.

NRS 689B.068        Insurer prohibited from denying coverage solely because person was victim of domestic violence.

NRS 689B.069        Insurer prohibited from requiring or using information concerning genetic testing; exceptions.

BLANKET POLICIES

NRS 689B.070        “Blanket accident and health insurance” defined.

NRS 689B.080        Authority to issue; required provisions.

NRS 689B.090        Application and certificates.

NRS 689B.100        Payment of benefits.

NRS 689B.110        Legal liability of policyholders for death of or injury to insured member unaffected.

NRS 689B.115        Access by Commissioner to information concerning rates; confidentiality of information.

CONVERSION OF GROUP POLICIES TO INDIVIDUAL POLICIES

NRS 689B.120        Policies of group health insurance to contain provision for conversion; exceptions; conditions. [Effective through December 31, 2013.]

NRS 689B.130        Conversion privilege available to spouse and children; conditions. [Effective through December 31, 2013.]

NRS 689B.140        Denial of converted policy because of overinsurance; notice concerning cancellation of other coverage. [Effective through December 31, 2013.]

NRS 689B.150        Choice of plans for converted policy. [Effective through December 31, 2013.]

NRS 689B.170        Benefits payable under converted policy may be reduced by amount payable under group policy. [Effective through December 31, 2013.]

NRS 689B.180        Issuance and effective date of converted policy; premiums; persons covered. [Effective through December 31, 2013.]

NRS 689B.200        Notice of conversion privilege. [Effective through December 31, 2013.]

NRS 689B.210        Converted policy delivered outside Nevada: Form. [Effective through December 31, 2013.]

CONTINUATION OF COVERAGE UNDER CERTAIN GROUP POLICIES

NRS 689B.245        Required provision concerning continuation of coverage. [Effective through December 31, 2013.]

NRS 689B.246        Notice of eligibility or election to continue coverage. [Effective through December 31, 2013.]

NRS 689B.247        Payment of premium for continued coverage. [Effective through December 31, 2013.]

NRS 689B.248        New insurer to provide continued coverage. [Effective through December 31, 2013.]

NRS 689B.249        Termination of continued coverage before end of period. [Effective through December 31, 2013.]

MISCELLANEOUS PROVISIONS

NRS 689B.250        Acceptance of uniform forms for billing and claims.

NRS 689B.255        Approval or denial of claims; payment of claims and interest; requests for additional information; award of costs and attorney’s fees; compliance with requirements.

NRS 689B.260        Required provision concerning coverage relating to complications of pregnancy.

NRS 689B.270        Required procedure for arbitration of disputes concerning independent medical evaluations.

NRS 689B.275        Contents, approval and provision of summary of coverage; provision of information about guaranteed availability of certain plans for benefits.

NRS 689B.280        Disclosure of information concerning medication of insured prohibited.

NRS 689B.283        Mandatory renewal of coverage under conversion health benefit plan. [Effective through December 31, 2013.]

NRS 689B.285        Offering policy of health insurance for purposes of establishing health savings account.

NRS 689B.287        Insurer prohibited from denying coverage solely because insured was intoxicated or under influence of controlled substance; exceptions.

ELIGIBILITY FOR COVERAGE UNDER GROUP POLICY

NRS 689B.290        Definitions.

NRS 689B.300        Effect of eligibility for medical assistance under Medicaid; assignment of rights to state agency.

NRS 689B.310        Insurer prohibited from asserting certain grounds to deny enrollment of child of insured pursuant to order.

NRS 689B.320        Certain accommodations to be made when child is covered under policy of noncustodial parent.

NRS 689B.330        Insurer to authorize enrollment of child of parent who is required by order to provide medical coverage for child.

PORTABILITY AND ACCOUNTABILITY

NRS 689B.340        Definitions. [Effective through December 31, 2013.]

NRS 689B.340        Definitions. [Effective January 1, 2014.]

NRS 689B.350        “Affiliation period” defined.

NRS 689B.355        “Blanket accident and health insurance” defined.

NRS 689B.360        “Carrier” defined.

NRS 689B.370        “Contribution” defined.

NRS 689B.380        “Creditable coverage” defined.

NRS 689B.390        “Group health plan” defined.

NRS 689B.400        “Group participation” defined.

NRS 689B.410        “Health benefit plan” defined. [Effective through December 31, 2013.]

NRS 689B.420        “Health status-related factor” defined. [Effective through December 31, 2013.]

NRS 689B.430        “Open enrollment” defined.

NRS 689B.440        “Plan sponsor” defined.

NRS 689B.450        “Preexisting condition” defined.

NRS 689B.460        “Waiting period” defined.

NRS 689B.470        Certain plan, fund or program to be treated as employee welfare benefit plan which is group health plan; partnership deemed employer of each partner. [Effective through December 31, 2013.]

NRS 689B.480        Determination of applicable creditable coverage of person; determination of period of creditable coverage of person; required statement. [Effective through December 31, 2013.]

NRS 689B.480        Determination of applicable creditable coverage of person; determination of period of creditable coverage of person; required statement. [Effective January 1, 2014.]

NRS 689B.490        Written certification of coverage required for purpose of determining period of creditable coverage accumulated by person.

NRS 689B.500        Coverage of preexisting conditions; when health maintenance organization may require affiliation period. [Effective through December 31, 2013.]

NRS 689B.500        Coverage of preexisting conditions. [Effective January 1, 2014.]

NRS 689B.510        Carrier authorized to modify coverage for insurance product under certain circumstances.

NRS 689B.520        Group plan or coverage that includes coverage for maternity care and pediatric care: Required to allow minimum stay in hospital in connection with childbirth; prohibited acts.

NRS 689B.530        Carrier required to permit eligible employee or dependent of employee to enroll for coverage under certain circumstances.

NRS 689B.540        Manner and period for enrollment of dependent of covered employee; period of special enrollment.

NRS 689B.550        Carrier prohibited from imposing restriction on participation inconsistent with chapter; restrictions on rules of eligibility that may be established; premiums to be equitable.

NRS 689B.560        Carrier required to renew coverage at option of plan sponsor; exceptions; discontinuation of form of product of group health insurance; discontinuation of group health insurance through bona fide association. [Effective through December 31, 2013.]

NRS 689B.560        Carrier required to renew coverage at option of plan sponsor; exceptions; discontinuation of form of product of group health insurance; discontinuation of group health insurance through bona fide association. [Effective January 1, 2014.]

NRS 689B.570        Carrier that offers coverage through network plan not required to offer coverage to employer that does not employ enrollees who reside or work in geographic area for which carrier is authorized to transact insurance. [Effective through December 31, 2013.]

NRS 689B.570        Carrier that offers coverage through network plan not required to offer coverage to employer that does not employ enrollees who reside or work in geographic service area for which carrier is authorized to transact insurance. [Effective January 1, 2014.]

NRS 689B.575        Carrier that offers coverage through network plan: Contracts with certain federally qualified health centers. [Effective through December 31, 2013.]

NRS 689B.580        Plan sponsor of governmental plan authorized to elect to exclude governmental plan from compliance with certain statutes; duties of plan sponsor. [Effective through December 31, 2013.]

NRS 689B.580        Plan sponsor of governmental plan authorized to elect to exclude governmental plan from compliance with certain statutes; duties of plan sponsor. [Effective January 1, 2014.]

NRS 689B.590        Converted policies: Carrier may only offer choice of basic and standard plans; election of basic or standard plan; premium; rates must be same for persons with similar case characteristics; losses must be spread across book. [Effective through December 31, 2013.]

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GENERAL PROVISIONS

      NRS 689B.010  Short title; scope.

      1.  This chapter may be cited as the Group or Blanket Health Insurance Law.

      2.  This chapter applies only to group health insurance contracts and to blanket accident and health insurance contracts as provided in this chapter.

      (Added to NRS by 1971, 1767; A 2001, 2220)

      NRS 689B.015  Contracts between insurer and provider of health care: Prohibiting insurer from charging provider of health care fee for inclusion on list of providers given to insureds; form to obtain information on provider of health care; modification; schedule of fees.

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

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

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

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

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

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

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

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

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

      (Added to NRS by 1999, 1648; A 2001, 2730; 2003, 3357; 2011, 2533)

GROUP POLICIES

General Provisions

      NRS 689B.020  “Group health insurance” defined; eligible groups and benefits.

      1.  “Group health insurance” is hereby declared to be that form of health insurance covering groups of two or more persons, formed for a purpose other than obtaining insurance.

      2.  Any group health policy which contains provisions for the payment by the insurer of benefits for expenses incurred on account of hospital, nursing, medical, dental or surgical services, home health care or health supportive services for members of the family or dependents of a person in the insured group may provide for the continuation of such benefit provisions, or any part or parts thereof, after the death of the person in the insured group.

      3.  The Commissioner may, in the discretion of the Commissioner, require the form of each certificate proposed to be delivered in this state under a group health policy not made under the laws of this state to be filed with the Commissioner by the insurer for informational purposes only.

      (Added to NRS by 1971, 1767; A 1971, 1954; 1975, 447)

      NRS 689B.026  Delivery of policy to group formed to purchase health insurance prohibited; exception.

      1.  Except as otherwise provided in this section, no policy of group health insurance may be delivered or issued for delivery in this state to a group which was formed for the purpose of purchasing one or more policies of group health insurance.

      2.  A policy of group health insurance may be delivered to a group described in subsection 1 if the Commissioner approves the issuance. The Commissioner shall not grant approval unless the Commissioner finds that:

      (a) The benefits of the policy are reasonable in relation to the premiums charged;

      (b) The group to which the policy is issued is organized and operated in a fiscally sound manner; and

      (c) All policy rates and forms are filed with and approved by the Division before marketing to a resident or employer in this State.

      3.  The Commissioner shall use the provisions of this chapter and chapter 689C of NRS to review insurance products marketed to employers in this State. The Commissioner shall use the provisions of chapter 689A of NRS to review insurance products marketed to natural persons in this State.

      4.  The provisions of this section apply to the offering in this state of a policy issued in another state.

      (Added to NRS by 1985, 1060; A 1995, 1628; 2011, 3381)

      NRS689B.0265  Policy to guaranteed association.

      1.  An insurer may offer a policy of group health insurance to a guaranteed association if the policy provides coverage for 200 or more members, employees of members or employees of the guaranteed association or their dependents.

      2.  When an insurer offers coverage to a guaranteed association pursuant to subsection 1, the insurer shall offer coverage to all members, employees of members and employees of the guaranteed association and all dependents thereof without regard to the actual or expected health status of any such member or employee or dependent thereof. The provisions of this subsection apply only for the purpose of requiring coverage to be offered to all such members, employees and dependents.

      3.  An insurer offering coverage to a guaranteed association pursuant to subsection 1 shall establish rates for premiums as follows:

      (a) For the initial 12-month period of coverage, the insurer shall submit to the Commissioner the opinion of a qualified actuary that the rates charged by the guaranteed association for premiums are actuarially sound. The opinion must certify the accuracy of the rating methodology as established by the American Academy of Actuaries or a successor organization approved by the Commissioner. The Commissioner by regulation may further define or enlarge the scope of this opinion.

      (b) For any subsequent 12-month period of coverage, according to a rating methodology as established by the American Academy of Actuaries or a successor organization approved by the Commissioner.

      4.  Except as otherwise provided in subsection 5, a member, employee of a member or employee of a guaranteed association may apply for coverage offered pursuant to subsection 1 only:

      (a) If, as applicable, the person has been an active member of the association or employed by a member or the guaranteed association for not less than 30 days;

      (b) During an annual open enrollment period offered by the guaranteed association; and

      (c) After meeting any additional eligibility requirements agreed upon by the guaranteed association and the insurer.

      5.  If a member, employee of a member or employee of a guaranteed association or a dependent thereof terminates coverage offered pursuant to subsection 1, the member, employee or dependent must be excluded from such coverage until the beginning of the next annual enrollment period. During the next annual enrollment period or any annual enrollment period thereafter, such a member or employee may enroll for coverage of the member or employee or dependent thereof pursuant to subsection 4.

      6.  The provisions of this section do not apply to or affect the status of a person, including, without limitation, whether the person is an employee, self-employed or an independent contractor, for the purposes of industrial insurance or any other law relating to labor or employment.

      7.  As used in this section:

      (a) “Guaranteed association” means an association which:

             (1) Has a constitution and bylaws;

             (2) Is determined by the Commissioner to be a bona fide association which was organized and is maintained in good faith for purposes other than that of obtaining insurance; and

             (3) Has been in existence for at least 5 years.

      (b)“Qualified actuary” means a member in good standing of the American Academy of Actuaries, or a successor organization approved by the Commissioner.

      (Added to NRS by 2007, 2457)

      NRS 689B.027  Summary of coverage: Contents of disclosure; approval by Commissioner; copy to be made available to employer or producer acting on behalf of employer.

      1.  The Commissioner shall adopt regulations which require an insurer to file with the Commissioner, for approval by the Commissioner, a disclosure summarizing the coverage provided by each policy of group health insurance offered by the insurer. The disclosure must include:

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

      (b) Any restrictions on payments for emergency care, including related definitions of an emergency and medical necessity;

      (c) Any provisions concerning the insurer’s right to change premium rates and the characteristics, other than claim experience, that affect changes in premium rates;

      (d) Any provisions relating to renewability;

      (e) Any provisions relating to preexisting conditions; and

      (f) Any other information,

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

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

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

      4.  The insurer shall make available to an employer or a producer acting on behalf of an employer upon request a copy of the disclosure approved by the Commissioner pursuant to this section for each policy of health insurance coverage for which that employer may be eligible.

      (Added to NRS by 1989, 1249; A 1991, 1846; 1997, 2913; 1999, 2806)

      NRS 689B.028  Summary of coverage: Copy to be provided before policy issued; policy may not be offered unless summary approved by Commissioner.  An insurer shall provide to the group policyholder to whom it offers a policy of group health insurance a copy of the disclosure approved for that policy pursuant to NRS 689B.027 before the policy is issued. An insurer shall not offer a policy of health insurance unless the disclosure for that policy has been approved by the Commissioner.

      (Added to NRS by 1989, 1249)

      NRS 689B.0283  Coverage for prescription drugs: Provision of notice and information regarding use of formulary.

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

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

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

      (c) If a formulary is used, include:

             (1) An explanation of:

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

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

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

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

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

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

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

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

      (Added to NRS by 2001, 857)

      NRS 689B.0285  System for resolving complaints: Approval; requirements; examination.

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

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

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

      4.  Each insurer that issues a policy of group health insurance in this State that provides, delivers, arranges for, pays for or reimburses any cost of health care services through managed care shall provide a system for resolving any complaints of an insured concerning the health care services that complies with the provisions of NRS 695G.200 to 695G.310, inclusive.

      (Added to NRS by 1997, 309; A 2003, 775; 2011, 3382)

      NRS 689B.029  Annual report regarding system for resolving complaints; insurer to maintain records of complaints concerning something other than health care services.

      1.  Each insurer that issues a policy of group health insurance in this State shall submit to the Commissioner and the State Board of Health an annual report regarding its system for resolving complaints established pursuant to subsection 1 of NRS 689B.0285 on a form prescribed by the Commissioner in consultation with the State Board of Health which includes, without limitation:

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

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

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

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

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

      (Added to NRS by 1997, 309; A 2003, 775)

      NRS 689B.0295  Written notice to insured explaining right to file complaint; notice to insured required when insurer denies coverage of health care service.

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

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

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

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

      2.  Any time that an insurer denies coverage of a health care service, including, without limitation, denying a claim relating to a policy of group health insurance or blanket insurance pursuant to NRS 689B.255, to an insured it shall notify the insured in writing within 10 working days after it denies coverage of the health care service of:

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

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

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

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

      (Added to NRS by 1997, 309; A 1999, 3084)

Coverage

      NRS 689B.030  Required provisions.  Each group health insurance policy must contain in substance the following provisions:

      1.  A provision that, in the absence of fraud, all statements made by applicants or the policyholders or by an insured person are representations and not warranties, and that no statement made for the purpose of effecting insurance voids the insurance or reduces its benefits unless the statement is contained in a written instrument signed by the policyholder or the insured person, a copy of which has been furnished to the policyholder or insured person or a beneficiary of the policyholder or insured person.

      2.  A provision that the insurer will furnish to the policyholder for delivery to each employee or member of the insured group a statement in summary form of the essential features of the insurance coverage of that employee or member and to whom benefits thereunder are payable. If dependents are included in the coverage, only one statement need be issued for each family.

      3.  A provision that to the group originally insured may be added from time to time eligible new employees or members or dependents, as the case may be, in accordance with the terms of the policy.

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

      5.  A provision for benefits for expenses arising from hospice care.

      (Added to NRS by 1971, 1767; A 1975, 448, 1850; 1979, 1178; 1983, 1934, 2037; 1985, 1774; 1989, 1032; 2009, 1810)

      NRS 689B.0303  Required provision concerning coverage for continued medical treatment.

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

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

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

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

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

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

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

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

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

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

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

             (1) The date of delivery; or

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

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

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

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

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

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

      (Added to NRS by 2003, 3356)

      NRS 689B.0306  Required provision concerning coverage for treatment received as part of clinical trial or study.

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

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

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

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

             (2) A cooperative group;

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

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

             (5) The United States Department of Defense;

      (c) In the case of:

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

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

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

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

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

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

             (1) The procedure to be undertaken;

             (2) Alternative methods of treatment; and

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

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

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

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

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

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

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

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

Ê Except as otherwise provided in NRS 689B.0303, the services provided pursuant to paragraphs (b), (c), (e) and (f) must be covered only if the services are provided by a provider with whom the insurer has contracted for such services. If the insurer has not contracted for the provision of such services, the insurer shall pay the provider the rate of reimbursement that is paid to other providers with whom the insurer has contracted for similar services and the provider shall accept that rate of reimbursement as payment in full.

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

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

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

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

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

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

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

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

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

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

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

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

      (a) Include in the disclosure required pursuant to NRS 689B.027 notice to each group policyholder of the availability of the benefits required by this section.

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

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

      8.  An insurer who delivers or issues for delivery a policy of group health insurance specified in subsection 1 is immune from liability for:

      (a) Any injury to the insured caused by:

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

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

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

      9.  As used in this section:

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

             (1) The Clinical Trials Cooperative Group Program; and

             (2) The Community Clinical Oncology Program.

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

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

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

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

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

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

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

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

      (c) “Provider of health care” means:

             (1) A hospital; or

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

      (Added to NRS by 2003, 3522; A 2005, 2012)

      NRS 689B.031  Required provision concerning coverage of certain gynecological or obstetrical services without authorization or referral from primary care physician.

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

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

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

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

      (Added to NRS by 1999, 1944)

      NRS689B.0313  Required provision concerning coverage for human papillomavirus vaccine. [Effective through December 31, 2013.]

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

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

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

      (Added to NRS by 2007, 3237)

      NRS689B.0313  Required provision concerning coverage for human papillomavirus vaccine. [Effective January 1, 2014.]

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

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

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

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

      (Added to NRS by 2007, 3237; A 2013, 3618, effective January 1, 2014)

      NRS689B.0317  Required provision concerning coverage for prostate cancer screening.

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

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

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

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

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

      (Added to NRS by 2007, 3238)

      NRS 689B.033  Required provision concerning coverage for newly born and adopted children and children placed for adoption. [Effective through December 31, 2013.]

      1.  All group health insurance policies providing coverage on an expense-incurred basis and all employee welfare plans providing medical, surgical or hospital care or benefits established or maintained for employees or their families or dependents, or for both, must as to the family members’ coverage provide that the health benefits applicable for children are payable with respect to:

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

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

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

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

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

      (a) The birth of a newly born child;

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

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

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

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

      4.  An insurer shall not restrict the coverage of a dependent child adopted or placed for adoption solely because of a preexisting condition the child has at the time the child would otherwise become eligible for coverage pursuant to the group health policy. Any provision relating to an exclusion for a preexisting condition must comply with NRS 689B.500.

      (Added to NRS by 1975, 1109; A 1989, 740; 1995, 2430; 1997, 2914)

      NRS 689B.033  Required provision concerning coverage for newly born and adopted children and children placed for adoption. [Effective January 1, 2014.]

      1.  All group health insurance policies providing coverage on an expense-incurred basis and all employee welfare plans providing medical, surgical or hospital care or benefits established or maintained for employees or their families or dependents, or for both, must as to the family members’ coverage provide that the health benefits applicable for children are payable with respect to:

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

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

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

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

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

      (a) The birth of a newly born child;

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

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

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

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

      (Added to NRS by 1975, 1109; A 1989, 740; 1995, 2430; 1997, 2914; 2013, 3618, effective January 1, 2014)

      NRS 689B.0335  Required provision concerning coverage for autism spectrum disorders.

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

      2.  Coverage provided under this section is subject to:

      (a) A maximum benefit of $36,000 per year for applied behavior analysis treatment; and

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

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

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

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

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

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

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

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

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

      6.  A policy subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2011, has the legal effect of including the coverage required by subsection 1, and any provision of the policy or the renewal which is in conflict with subsection 1 or 2 is void.

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

      8.  As used in this section:

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

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

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

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

             (1) A licensed psychologist;

             (2) A licensed behavior analyst; or

             (3) A licensed assistant behavior analyst.

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

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

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

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

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

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

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

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

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

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

      (Added to NRS by 2009, 1467)

      NRS 689B.034  Required provision concerning effect of benefits under other valid group coverage; subrogation.

      1.  Every policy of group health insurance must contain a provision which reduces the insurer’s liability because of benefits under other valid group coverage. To the extent authorized by the Commissioner, such a provision may include subrogation.

      2.  A provision for subrogation may include a lien upon any recovery by an insured from a third person for the cost of medical benefits paid by the insurer for injuries incurred as a result of the actions of the third person. The lien may not exceed the amount paid by the insurer.

      3.  An insurer may not deny payment for services because of the inclusion of a provision required by this section.

      (Added to NRS by 1985, 1060; A 1995, 1628)

      NRS 689B.0345  Required provision concerning coverage for employee or member on leave without pay as result of total disability.

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

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

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

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

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

      (c) The date on which the group policy of health insurance is terminated; or

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

Ê whichever occurs first.

      (Added to NRS by 1989, 1249)

      NRS 689B.035  Required provision concerning termination of coverage on dependent child.

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

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

      (b) Dependent on the member of the insured group for support and maintenance.

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

      (Added to NRS by 1973, 548; A 2013, 699)

      NRS 689B.0353  Required provision concerning coverage for treatment of certain inherited metabolic diseases.

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

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

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

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

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

      4.  As used in this section:

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

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

      (Added to NRS by 1997, 1526)

      NRS 689B.0357  Required provision concerning coverage for management and treatment of diabetes.

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

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

      (a) Shall include in the disclosure required pursuant to NRS 689B.027 notice to each policyholder and subscriber under the policy of the availability of the benefits required by this section.

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

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

      4.  As used in this section:

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

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

             (1) The training and education provided to the employee or member of the insured group after the employee or member is initially diagnosed with diabetes which is medically necessary for the care and management of diabetes, including, without limitation, counseling in nutrition and the proper use of equipment and supplies for the treatment of diabetes;

             (2) Training and education which is medically necessary as a result of a subsequent diagnosis that indicates a significant change in the symptoms or condition of the employee or member of the insured group and which requires modification of his or her program of self-management of diabetes; and

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

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

      (Added to NRS by 1997, 743)

      NRS 689B.0362  Required provision concerning coverage for orally administered chemotherapy.

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

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

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

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

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

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

      (Added to NRS by 2013, 1998; A 2013, 3658)

      NRS 689B.0365  Required provision concerning coverage for use of certain drugs for treatment of cancer.  Except as otherwise provided in NRS 689B.0306:

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

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

             (1) The United States Pharmacopoeia Drug Information; or

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

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

      2.  The coverage required pursuant to this section:

      (a) Includes coverage for any medical services necessary to administer the drug to the employee or member of the insured group.

      (b) Does not include coverage for any:

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

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

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

      (Added to NRS by 1999, 760; A 2003, 3525)

      NRS 689B.0367  Required provision concerning coverage for screening for colorectal cancer.

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

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

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

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

      (Added to NRS by 2003, 1335)

      NRS 689B.0368  Required provision concerning coverage for prescription drug previously approved for medical condition of insured.

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

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

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

      2.  The provisions of subsection 1 do not:

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

      (b) Prohibit:

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

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

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

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

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

      (Added to NRS by 2001, 858; A 2003, 2298)

      NRS 689B.0374  Required provision concerning coverage for cytologic screening tests and mammograms for certain women.

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

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

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

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

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

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

      (Added to NRS by 1989, 1889; A 1997, 1730)

      NRS 689B.0375  Required provision concerning coverage relating to mastectomy.

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

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

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

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

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

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

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

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

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

Ê whichever is earlier.

      5.  A plan or issuer may not:

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

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

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

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

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

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

      (Added to NRS by 1983, 615; A 1989, 1889; 2001, 2220)

      NRS 689B.0376  Policy covering prescription drugs or devices to provide coverage for drug or device for contraception and of hormone replacement therapy in certain circumstances; prohibited actions by insurer; exceptions.

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

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

      (b) Any type of hormone replacement therapy,

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

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

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

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

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

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

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

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

      4.  The provisions of this section do not:

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

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

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

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

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

      (Added to NRS by 1999, 1997)

      NRS 689B.0377  Policy covering outpatient care to provide coverage for health care services related to contraceptives and hormone replacement therapy; prohibited actions by insurer; exceptions.

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

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

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

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

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

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

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

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

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

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

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

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

      (Added to NRS by 1999, 1998)

      NRS 689B.0379  Required provision concerning coverage for treatment of temporomandibular joint.

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

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

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

      (b) Treatment which is medically necessary.

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

      (Added to NRS by 1989, 2138)

Reimbursement and Payment

      NRS 689B.038  Reimbursement for treatments by licensed psychologist.  If any policy of group health insurance provides coverage for treatment of an illness which is within the authorized scope of the practice of a qualified psychologist, the insured is entitled to reimbursement for treatment by a psychologist who is licensed pursuant to chapter 641 of NRS.

      (Added to NRS by 1981, 575; A 1989, 1553)

      NRS 689B.0383  Reimbursement for treatments by licensed marriage and family therapist or licensed clinical professional counselor.  If any policy of group health insurance provides coverage for treatment of an illness which is within the authorized scope of practice of a licensed marriage and family therapist or licensed clinical professional counselor, the insured is entitled to reimbursement for treatment by a marriage and family therapist or clinical professional counselor who is licensed pursuant to chapter 641A of NRS.

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

      NRS 689B.0385  Reimbursement for treatments by licensed associate in social work, social worker, independent social worker or clinical social worker.  If any policy of group health insurance provides coverage for treatment of an illness which is within the authorized scope of the practice of a licensed associate in social work, social worker, independent social worker or clinical social worker, the insured is entitled to reimbursement for treatment by an associate in social work, social worker, independent social worker or clinical social worker who is licensed pursuant to chapter 641B of NRS.

      (Added to NRS by 1987, 1123)

      NRS 689B.039  Reimbursement for treatments by chiropractor.

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

      2.  The terms of the policy must not limit:

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

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

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

      NRS689B.0393  Reimbursement for treatments by podiatrist.

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

      2.  The terms of the policy must not limit:

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

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

      (Added to NRS by 2007, 1046)

      NRS689B.0397  Reimbursement for treatment by licensed clinical alcohol and drug abuse counselor.  If any policy of group health insurance provides coverage for treatment of an illness which is within the authorized scope of practice of a licensed clinical alcohol and drug abuse counselor, the insured is entitled to reimbursement for treatment by a clinical alcohol and drug abuse counselor who is licensed pursuant to chapter 641C of NRS.

      (Added to NRS by 2007, 3093)

      NRS 689B.040  Direct payment for hospital and medical services and home health care; payment to assignee.

      1.  Any group health policy may provide that all or any portion of any indemnities provided by any such policy on account of hospital, nursing, medical or surgical services, home health care or supportive services:

      (a) May, at the insurer’s option; or

      (b) Must, upon the written request of the insured,

Ê be paid directly to the hospital or person rendering the services. Payments made in this manner discharge the insurer’s obligation.

      2.  If the insured assigns his or her benefits pursuant to this section but the insurer after receiving a copy of the assignment pays the benefits to the insured, the insurer shall also pay the benefits to the assignee as soon as the insurer receives the notice of the incorrect payment.

      (Added to NRS by 1971, 1767; A 1975, 448; 1983, 880)

      NRS 689B.045  Reimbursement for services provided by certain nurses; prohibited limitations; exception.

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

      2.  The terms of the policy must not limit:

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

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

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

      (Added to NRS by 1985, 1447)

      NRS 689B.047  Reimbursement to provider of medical transportation.

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

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

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

      (Added to NRS by 1989, 1273)

      NRS 689B.049  Reimbursement for acupuncture.  If any policy of group health insurance provides coverage for acupuncture performed by a physician, the insured is entitled to reimbursement for acupuncture performed by a person who is licensed pursuant to chapter 634A of NRS.

      (Added to NRS by 1991, 1134)

Miscellaneous Provisions

      NRS 689B.050  Extended disability benefit.  Any group health policy may provide for payment not exceeding three times the amount of the monthly benefit under the policy as an extended disability benefit upon the insured’s death from any cause. The extended disability benefit must not be construed as life insurance.

      (Added to NRS by 1971, 1768; A 1993, 1982)

      NRS 689B.060  Readjustment of premiums; dividends.

      1.  Any contract of group health insurance may provide for the readjustment of the rate of premium based upon the experience thereunder. If a policy dividend is declared after January 1, 1972, or a reduction in rate is made after January 1, 1972, or continued for the first or any subsequent year of insurance under any policy of group health insurance issued before, on or after January 1, 1972, to any policyholder, the excess, if any, of the aggregate dividends or rate reductions under such a policy and all other group insurance policies of the policyholder over the aggregate expenditure for insurance under such policies made from money contributed by the policyholder, or by an employer of insured persons, or by a union or association to which the insured persons belong, including expenditures made in connection with administration of such policies, must be applied by the policyholder for the sole benefit of insured employees or members.

      2.  This section does not apply as to debtor groups.

      (Added to NRS by 1971, 1768; A 1997, 1627)

      NRS 689B.061  Limitations on deductibles and copayments charged under policy which offers difference of payment between preferred providers of health care and providers who are not preferred. [Effective through December 31, 2013.]  A policy of group health insurance which offers a difference of payment between preferred providers of health care and providers of health care who are not preferred:

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

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

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

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

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

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

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

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

      (Added to NRS by 1987, 1781; A 1991, 1329; 1995, 1629)

      NRS 689B.061  Limitations on deductibles and copayments charged under policy which offers difference of payment between preferred providers of health care and providers who are not preferred. [Effective January 1, 2014.]  A policy of group health insurance which offers a difference of payment between preferred providers of health care and providers of health care who are not preferred:

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

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

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

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

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

      (Added to NRS by 1987, 1781; A 1991, 1329; 1995, 1629; 2013, 3619, effective January 1, 2014)

      NRS 689B.063  Primary and secondary policies: Determination of benefits. [Effective through December 31, 2013.]

      1.  When a policy of group insurance is primary, its benefits are determined before those of another policy and the benefits of another policy are not considered. When a policy of group insurance is secondary, its benefits are determined after those of another policy. Secondary benefits may not be reduced because of benefits under the primary policy. When there are more than two policies, a policy may be primary as to one and may be secondary as to another.

      2.  The benefits payable under a policy of group health insurance may not be reduced because of any benefits payable under an individual health insurance policy, health insurance on a franchise plan or first-party coverage under an automobile insurance policy.

      3.  As used in this section, “a policy of group insurance” includes Medicare.

      (Added to NRS by 1987, 848; A 1989, 1250; 1995, 1629)

      NRS 689B.063  Primary and secondary policies: Determination of benefits. [Effective January 1, 2014.]

      1.  When a policy of group insurance is primary, its benefits are determined before those of another policy and the benefits of another policy are not considered. When a policy of group insurance is secondary, its benefits are determined after those of another policy. Secondary benefits may not be reduced because of benefits under the primary policy. When there are more than two policies, a policy may be primary as to one and may be secondary as to another.

      2.  The benefits payable under a policy of group health insurance may not be reduced because of any benefits payable under health insurance on a franchise plan or first-party coverage under an automobile insurance policy.

      3.  As used in this section, “a policy of group insurance” includes Medicare.

      (Added to NRS by 1987, 848; A 1989, 1250; 1995, 1629; 2013, 3620, effective January 1, 2014)

      NRS 689B.064  Primary and secondary policies: Order of benefits.  A policy of group insurance determines its order of benefits using the first of the following which applies:

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

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

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

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

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

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

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

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

      5.  The primary policy is the policy which covers a person as an employee who is neither laid off or retired, or that employee’s dependent. The secondary policy is the policy which covers that person as a laid off or retired employee, or that employee’s dependent.

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

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

      (Added to NRS by 1987, 848)

      NRS 689B.065  Policy issued to replace discontinued policy or coverage: Requirements; notice of reduction of benefits; statement of benefits; applicability of section.

      1.  A policy of group health insurance issued to replace any discontinued policy or coverage for group health insurance must:

      (a) Provide coverage for all persons who were covered under the previous policy or coverage on the date it was discontinued; and

      (b) Except as otherwise provided in subsection 2, provide benefits which are at least as extensive as the benefits provided by the previous policy or coverage, except that benefits may be reduced or excluded to the extent that such a reduction or exclusion was permissible under the terms of the previous policy or coverage,

Ê if that replacement policy is issued within 60 days after the date on which the previous policy or coverage was discontinued.

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

      3.  Any insurer which issues a replacement policy pursuant to subsection 1 may submit a written request to the insurer who provided the previous policy or coverage for a statement of benefits which were provided under that policy or coverage. Upon receiving such a request, the insurer who provided the previous policy or coverage shall give a written statement to the insurer providing the replacement policy which indicates what benefits were provided and what exclusions or reductions were in effect under the previous policy or coverage.

      4.  The provisions of this section:

      (a) Apply to a self-insured employer who provides health benefits to the employees of the employer and replaces those benefits with a policy of group health insurance.

      (b) Do not apply to the Public Employees’ Benefits Program established pursuant to NRS 287.0402 to 287.049, inclusive.

      (Added to NRS by 1987, 849; A 1991, 251; 1999, 3042)

      NRS 689B.067  Provision in policy requiring binding arbitration for disputes with insurer authorized; procedure for arbitration; declaratory relief.

      1.  Except as otherwise provided in NRS 689B.270 and subject to the approval of the Commissioner, a policy of group health insurance may include a provision which requires a member or a dependent of a member of the insured group and the insurer to submit for binding arbitration any dispute between the member or dependent and the insurer concerning any matter directly or indirectly related to, or associated with, the policy. If such a provision is included in the policy:

      (a) A member and any dependent of the member must be given the opportunity to decline to participate in binding arbitration at the time they elect to be covered by the policy.

      (b) It must clearly state that the insurer and a member or dependent of a member of the insured group who has not declined to participate in binding arbitration agree to forego their right to resolve any such dispute in a court of law or equity.

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

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

      4.  If a provision described in subsection 1 is included in a policy of group health insurance, the provision shall not be deemed unenforceable as an unreasonable contract of adhesion if the provision is included in compliance with the provisions of subsection 1.

      (Added to NRS by 1995, 2557)

      NRS 689B.068  Insurer prohibited from denying coverage solely because person was victim of domestic violence.  An insurer shall not deny a claim, refuse to issue a policy of group health insurance or cancel a policy of group health insurance solely because the claim involves an act that constitutes domestic violence pursuant to NRS 33.018, or because the person applying for or covered by the policy of group health insurance was the victim of such an act of domestic violence, regardless of whether the insured or applicant contributed to any loss or injury.

      (Added to NRS by 1997, 1096)

      NRS 689B.069  Insurer prohibited from requiring or using information concerning genetic testing; exceptions.

      1.  Except as otherwise provided in subsection 2, an insurer who provides group health insurance shall not:

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

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

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

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

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

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

      3.  As used in this section:

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

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

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

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

      (Added to NRS by 1997, 1460)

BLANKET POLICIES

      NRS 689B.070  “Blanket accident and health insurance” defined.  “Blanket accident and health insurance” is that form of accident insurance, health insurance, or both, covering groups of persons as enumerated in one of the following subsections under a policy or contract issued to:

      1.  Any common carrier or to any operator, owner or lessee of a means of transportation, who or which shall be deemed the policyholder, covering a group of persons who may become passengers defined by reference to their travel status on the common carrier or means of transportation.

      2.  An employer, who shall be deemed the policyholder, covering any group of employees, dependents or guests, defined by reference to specified hazards incident to an activity or activities or operations of the policyholder.

      3.  A college, school or other institution of learning, a school district or districts, or school jurisdictional unit, or to the head, principal or governing board of any such educational unit, who or which shall be deemed the policyholder, covering students, teachers or employees.

      4.  A religious, charitable, recreational, educational or civic organization, or branch thereof, which shall be deemed the policyholder, covering any group of members or participants defined by reference to specified hazards incident to an activity or activities or operations sponsored or supervised by the policyholder.

      5.  A sports team, camp or sponsor thereof, which shall be deemed the policyholder, covering members, campers, employees, officials or supervisors.

      6.  A volunteer fire department, organization providing first aid, organization for emergency management or other such volunteer organization, which shall be deemed the policyholder, covering any group of members or participants defined by reference to specified hazards incident to an activity or activities or operations sponsored or supervised by the policyholder.

      7.  A newspaper or other publisher, which shall be deemed the policyholder, covering its carriers.

      8.  An association, including a labor union, which has a constitution and bylaws and which has been organized and is maintained in good faith for purposes other than that of obtaining insurance, which shall be deemed the policyholder, covering any group of members or participants defined by reference to specified hazards incident to an activity or activities or operations sponsored or supervised by the policyholder.

      9.  Cover any other risk or class of risks which, in the discretion of the Commissioner, may be properly eligible for blanket accident and health insurance. The discretion of the Commissioner may be exercised on the basis of an individual risk or class of risks, or both.

      (Added to NRS by 1971, 1768; A 1983, 177; 2001, 2221)

      NRS 689B.080  Authority to issue; required provisions.  Any insurer authorized to write health insurance in this state, including a nonprofit corporation for hospital, medical or dental services that has a certificate of authority issued pursuant to chapter 695B of NRS, may issue blanket accident and health insurance. No blanket policy, except as provided in subsection 5 of NRS 687B.120, may be issued or delivered in this state unless a copy of the form thereof has been filed in accordance with NRS 687B.120. Every blanket policy must contain provisions which in the opinion of the Commissioner are not less favorable to the policyholder and the individual insured than the following:

      1.  A provision that the policy, including endorsements and a copy of the application, if any, of the policyholder and the persons insured constitutes the entire contract between the parties, and that any statement made by the policyholder or by a person insured is in the absence of fraud a representation and not a warranty, and that no such statements may be used in defense to a claim under the policy, unless contained in a written application. The insured or the beneficiary or assignee of the insured has the right to make a written request to the insurer for a copy of an application, and the insurer shall, within 15 days after the receipt of a request at its home office or any branch office of the insurer, deliver or mail to the person making the request a copy of the application. If a copy is not so delivered or mailed, the insurer is precluded from introducing the application as evidence in any action based upon or involving any statements contained therein.

      2.  A provision that written notice of sickness or of injury must be given to the insurer within 20 days after the date when the sickness or injury occurred. Failure to give notice within that time does not invalidate or reduce any claim if it is shown that it was not reasonably possible to give notice and that notice was given as soon as was reasonably possible.

      3.  A provision that the insurer will furnish to the claimant or to the policyholder for delivery to the claimant such forms as are usually furnished by it for filing proof of loss. If the forms are not furnished before the expiration of 15 days after giving written notice of sickness or injury, the claimant shall be deemed to have complied with the requirements of the policy as to proof of loss upon submitting, within the time fixed in the policy for filing proof of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made.

      4.  A provision that in the case of a claim for loss of time for disability, written proof of the loss must be furnished to the insurer within 90 days after the commencement of the period for which the insurer is liable, and that subsequent written proofs of the continuance of the disability must be furnished to the insurer at such intervals as the insurer may reasonably require, and that in the case of a claim for any other loss, written proof of the loss must be furnished to the insurer within 90 days after the date of the loss. Failure to furnish such proof within that time does not invalidate or reduce any claim if it is shown that it was not reasonably possible to furnish proof and that the proof was furnished as soon as was reasonably possible.

      5.  A provision that all benefits payable under the policy other than benefits for loss of time will be payable immediately upon receipt of written proof of loss, and that, subject to proof of loss, all accrued benefits payable under the policy for loss of time will be paid not less frequently than monthly during the continuance of the period for which the insurer is liable, and that any balance remaining unpaid at the termination of that period will be paid immediately upon receipt of proof.

      6.  A provision that the insurer at its own expense has the right and opportunity to examine the person of the insured when and so often as it may reasonably require during the pendency of claim under the policy and also the right and opportunity to make an autopsy where it is not prohibited by law.

      7.  A provision, if applicable, setting forth the provisions of NRS 689B.035.

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

      9.  A provision that no action at law or in equity may be brought to recover under the policy before the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of the policy and that no such action may be brought after the expiration of 3 years after the time written proof of loss is required to be furnished.

      (Added to NRS by 1971, 1769; A 1973, 548; 1975, 448; 1985, 1775; 1993, 500; 2001, 2221; 2011, 3382)

      NRS 689B.090  Application and certificates.

      1.  An individual application need not be required from a person covered under a blanket health policy or contract, nor shall it be necessary for the insurer to furnish each person a certificate, if such person does not pay all or part of the premium for such insurance.

      2.  The Commissioner may, by rule or regulation, require the delivery of an individual certificate or a statement of the coverage to individuals insured under such a blanket policy or contract who are either required to make an individual written application or pay part or all of the premium therefor, and applying to such classes of cases and circumstances, specified in such rule or regulation, as the Commissioner may find such delivery to be reasonably necessary and practicable.

      (Added to NRS by 1971, 1770)

      NRS 689B.100  Payment of benefits.

      1.  Except as provided in subsection 2, all benefits under any blanket health policy or contract must be payable to the person insured, or to the designated beneficiary or beneficiaries of the person insured, or to the estate of the person insured, except that if the person insured is a minor or otherwise not competent to give a valid release, these benefits may be made payable to the parent or guardian of the person insured or to another person actually supporting the person insured.

      2.  The policy may provide that all or a portion of any indemnities provided by any such policy on account of hospital, nursing, medical or surgical services, home health care or supportive services:

      (a) May, at the option of the insurer and unless the insured requests otherwise in writing not later than the time of filing proofs of such loss; or

      (b) Must, upon the written request of the insured,

Ê be paid directly to the hospital or person rendering those services. The policy may not require that the service be rendered by a particular hospital or person. Payment so made discharges the obligation of the insurer with respect to the amount of insurance so paid.

      3.  If the insured assigns his or her benefits pursuant to this section but the insurer after receiving a copy of the assignment pays the benefits to the insured, the insurer shall also pay the benefits to the assignee as soon as the insurer receives the notice of the incorrect payment.

      (Added to NRS by 1971, 1771; A 1975, 450; 1983, 880)

      NRS 689B.110  Legal liability of policyholders for death of or injury to insured member unaffected.  Nothing contained in NRS 689B.070 to 689B.100, inclusive, shall be deemed to affect the legal liability of policyholders for death of or injury to any member insured under a blanket insurance policy.

      (Added to NRS by 1971, 1771)

      NRS 689B.115  Access by Commissioner to information concerning rates; confidentiality of information.  An insurer providing blanket health insurance shall make all information concerning rates available to the Commissioner upon request. The information is proprietary, constitutes a trade secret, and may not be disclosed by the Commissioner to any person outside the Division except as agreed by the insurer or ordered by a court of competent jurisdiction.

      (Added to NRS by 2001, 2219)

CONVERSION OF GROUP POLICIES TO INDIVIDUAL POLICIES

      NRS 689B.120  Policies of group health insurance to contain provision for conversion; exceptions; conditions. [Effective through December 31, 2013.]

      1.  Except as otherwise provided in subsection 3, all policies of group health insurance delivered or issued for delivery in this state providing for hospital, surgical or major medical expense insurance, or any combination of these coverages, on an expense-incurred basis must contain a provision that the employee or member is entitled to have issued to him or her by the insurer a policy of health insurance when the employee or member is no longer covered by the group policy.

      2.  The requirement in subsection 1 does not apply to policies providing benefits only for specific diseases or accidental injuries, and it applies to other policies only if:

      (a) The termination of coverage under the group policy is not due to termination of the group policy itself unless the termination of the group policy has resulted from failure of the policyholder to remit the required premiums;

      (b) The termination is not due to failure of the employee or member to remit any required contributions;

      (c) The employee or member has been continuously insured under any group policy of the employer for at least 3 consecutive months immediately before the termination; and

      (d) The employee or member applies in writing for the converted policy and pays the first premium to the insurer no later than 31 days after the termination.

      3.  If an employee or member was a recipient of benefits under the coverage provided pursuant to NRS 689B.0345, the employee or member is not entitled to have issued to him or her by a replacement insurer a policy of health insurance unless the employee or member has reported for his or her normal employment for a period of 90 consecutive days after last being eligible to receive any benefits under the coverage provided pursuant to NRS 689B.0345.

      (Added to NRS by 1979, 1084; A 1985, 1060; 1989, 1250; R 2013, 3661, effective January 1, 2014)

      NRS 689B.130  Conversion privilege available to spouse and children; conditions. [Effective through December 31, 2013.]  Subject to the conditions set forth in NRS 689B.120 to 689B.210, inclusive, the conversion privilege must also be made available:

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

      2.  To the spouse of the employee or member upon termination of coverage of the spouse while the employee or member remains insured under the group policy, if the spouse ceases to be a qualified family member under the group policy, and to any child whose coverage under the group policy terminates at the same time; or

      3.  To a child solely with respect to the child upon termination of the child’s coverage because the child ceases to be a qualified family member under the group policy, if a conversion privilege is not otherwise provided with respect to the termination.

      (Added to NRS by 1979, 1086; A 2001, 2223; R 2013, 3661, effective January 1, 2014)

      NRS 689B.140  Denial of converted policy because of overinsurance; notice concerning cancellation of other coverage. [Effective through December 31, 2013.]

      1.  The insurer is not required to issue a converted policy to any person who:

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

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

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

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

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

      (Added to NRS by 1979, 1085; R 2013, 3661, effective January 1, 2014)

      NRS 689B.150  Choice of plans for converted policy. [Effective through December 31, 2013.]  A person who is entitled to a converted policy must be given a choice of a basic or standard health benefit plan in the manner provided in NRS 689B.590.

      (Added to NRS by 1979, 1085; A 1981, 907; 2001, 2223; R 2013, 3661, effective January 1, 2014)

      NRS 689B.170  Benefits payable under converted policy may be reduced by amount payable under group policy. [Effective through December 31, 2013.]

      1.  A converted policy must not exclude a preexisting condition not excluded by the group policy, but a converted policy may provide that any hospital, surgical or medical benefits payable under it may be reduced by the amount of any benefits payable under the group policy after its termination. A converted policy may provide that during the first policy year the benefits payable under it, together with the benefits payable under the group policy, must not exceed those that would have been payable if the policyholder’s insurance under the group policy had remained in effect.

      2.  Any exclusion for a preexisting condition provided by a converted policy must comply with NRS 689B.500.

      (Added to NRS by 1979, 1085; A 1997, 2915; R 2013, 3661, effective January 1, 2014)

      NRS 689B.180  Issuance and effective date of converted policy; premiums; persons covered. [Effective through December 31, 2013.]  The insurer shall:

      1.  Issue the converted policy, as described in NRS 689B.590, without evidence of insurability;

      2.  Establish the premium on the converted policies in the manner provided in subsections 3, 4 and 5, or pursuant to subsection 6, of NRS 689B.590, and may not require that premiums be paid annually, semi-annually or quarterly unless so requested by the employee, a member or a dependent;

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

      4.  Provide that the converted policy covers the employee or member and the dependents of the employee or member who were covered by the group policy on the date of its termination. A separate converted policy may be issued to cover any dependent.

      (Added to NRS by 1979, 1084; A 2001, 2223; R 2013, 3661, effective January 1, 2014)

      NRS 689B.200  Notice of conversion privilege. [Effective through December 31, 2013.]  A notification of the conversion privilege must be included in each certificate of coverage. A written notice of the existence of the conversion privilege must also be given by the policyholder to the employee or member at least 15 days before the expiration of the 31 days permitted a person to make a written application for the converted policy. The insurer shall prepare the notice in a form approved by the Commissioner and give the notice to the policyholder for distribution to the employees or members. If written notice of the right to convert is not given as required under this section, an additional period must be allowed the person to apply for the converted policy. The additional period expires 15 days after written notice of the conversion privilege has been given, or 60 days after the expiration of the 31-day period, whichever is earlier.

      (Added to NRS by 1979, 1086; A 1985, 1061; R 2013, 3661, effective January 1, 2014)

      NRS 689B.210  Converted policy delivered outside Nevada: Form. [Effective through December 31, 2013.]  A converted policy which is to be delivered outside this state must be in such form as would be deliverable in the other jurisdiction as a converted policy if the group policy had been issued in that jurisdiction.

      (Added to NRS by 1979, 1086; R 2013, 3661, effective January 1, 2014)

CONTINUATION OF COVERAGE UNDER CERTAIN GROUP POLICIES

      NRS 689B.245  Required provision concerning continuation of coverage. [Effective through December 31, 2013.]

      1.  If an employer who employs less than 20 employees maintains a policy of group health insurance which covers those employees, the policy must contain a provision which permits:

      (a) An employee to elect to continue identical coverage under the policy, excluding coverage provided for eye or dental care, if:

             (1) The employee’s employment is terminated for any reason other than gross misconduct; or

             (2) The number of his or her working hours is reduced so that the employee ceases to be eligible for coverage.

      (b) The spouse or dependent child of an employee to elect to continue coverage, excluding coverage provided for eye or dental care, if:

             (1) The employee’s employment is terminated for any reason other than gross misconduct or the number of his or her working hours is reduced so that the employee ceases to be eligible for coverage;

             (2) The employee dies;

             (3) The employee and his or her spouse are divorced or legally separated;

             (4) The dependent child ceases to be eligible for coverage under the terms of the policy; or

             (5) The spouse ceases to be eligible for coverage after becoming eligible for Medicare.

      2.  The period of continued coverage is limited to:

      (a) Eighteen months for an employee.

      (b) Thirty-six months for an employee’s spouse or dependent child.

      3.  An employee who voluntarily leaves his or her employment, or the spouse or dependent child of that employee, is not eligible to continue coverage pursuant to this section.

      4.  An employee, spouse or dependent child who has not been covered under any group policy of the employer for at least 12 consecutive months before the termination of his or her coverage is not eligible to continue coverage pursuant to this section.

      5.  A provision for continued coverage must include coverage for any child born to, legally adopted by or placed for adoption with the employee during the period of continued coverage. Such a child is eligible for continued coverage only to the end of the period of continued coverage as established pursuant to subsection 2.

      (Added to NRS by 1987, 2233; A 1997, 2915; R 2013, 3661, effective January 1, 2014)

      NRS 689B.246  Notice of eligibility or election to continue coverage. [Effective through December 31, 2013.]

      1.  An employee, spouse or dependent child shall notify the employer that the employee, spouse or dependent child is eligible to continue his or her coverage pursuant to NRS 689B.245 not later than 60 days after becoming eligible to do so.

      2.  The employer shall, within 14 days after receipt of the notification given pursuant to subsection 1, provide adequate information to the employee, spouse or dependent child regarding the election to continue coverage and the premium required to be paid.

      3.  If the employee, spouse or dependent child elects to continue coverage, the employee, spouse or dependent child shall notify the insurer of his or her election and pay to the insurer the premium required by NRS 689B.247 within 60 days after receipt of the information provided pursuant to subsection 2.

      (Added to NRS by 1987, 2234; R 2013, 3661, effective January 1, 2014)

      NRS 689B.247  Payment of premium for continued coverage. [Effective through December 31, 2013.]

      1.  Any person who elects to continue coverage pursuant to NRS 689B.245 shall pay the premium for that coverage in an amount not to exceed 110 percent of the premium charged to the employer by the insurer on the date on which that person became eligible for continued coverage.

      2.  If there is a change in the rate charged or benefits provided under the policy during the time of continued coverage, the premium may not exceed 110 percent of the new rate charged to the employer.

      3.  The premiums must be paid to the insurer on a monthly basis.

      4.  If the payment of a premium is not received by the insurer within 30 days after the date on which it is due, continued coverage must be terminated.

      (Added to NRS by 1987, 2234; A 2009, 2452; R 2013, 3661, effective January 1, 2014)

      NRS 689B.248  New insurer to provide continued coverage. [Effective through December 31, 2013.]  If an employer changes his or her insurer during a period of a person’s continued coverage, the new insurer shall provide continued coverage for that person for the remainder of the continuation period.

      (Added to NRS by 1987, 2234; R 2013, 3661, effective January 1, 2014)

      NRS 689B.249  Termination of continued coverage before end of period. [Effective through December 31, 2013.]  Continued coverage pursuant to NRS 689B.245 ceases before the end of the period provided in that section if:

      1.  The employer discontinues group health insurance for the employer’s employees;

      2.  The employee, spouse or dependent child fails to pay the required premiums;

      3.  The employee, spouse or dependent child becomes covered under any other policy of group health insurance;

      4.  The employee or spouse qualifies for Medicare; or

      5.  The spouse remarries and becomes eligible for coverage under the new spouse’s policy of group health insurance.

      (Added to NRS by 1987, 2234; R 2013, 3661, effective January 1, 2014)

MISCELLANEOUS PROVISIONS

      NRS 689B.250  Acceptance of uniform forms for billing and claims.  Every insurer under a group health insurance contract or a blanket accident and health insurance contract and every state agency, for its records shall accept from:

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

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

      (Added to NRS by 1975, 897; A 2001, 2224)

      NRS 689B.255  Approval or denial of claims; payment of claims and interest; requests for additional information; award of costs and attorney’s fees; compliance with requirements.

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

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

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

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

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

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

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

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

      (Added to NRS by 1991, 1328; A 1999, 1648; 2001, 2730; 2003, 3358)

      NRS 689B.260  Required provision concerning coverage relating to complications of pregnancy.

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

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

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

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

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

      (Added to NRS by 1977, 415)

      NRS 689B.270  Required procedure for arbitration of disputes concerning independent medical evaluations.

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

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

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

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

      (Added to NRS by 1989, 2114)

      NRS 689B.275  Contents, approval and provision of summary of coverage; provision of information about guaranteed availability of certain plans for benefits.

      1.  An insurer shall provide to each policyholder, or producer of insurance acting on behalf of a policyholder, on a form approved by the Commissioner, a summary of the coverage provided by each policy of group or blanket health insurance offered by the insurer. The summary must disclose any:

      (a) Significant exception, reduction or limitation that applies to the policy;

      (b) Restriction on payment for care in an emergency, including related definitions of emergency and medical necessity;

      (c) Right of the insurer to change the rate of premium and the factors, other than claims experienced, which affect changes in rate;

      (d) Provisions relating to renewability;

      (e) Provisions relating to preexisting conditions; and

      (f) Other information that the Commissioner finds necessary for full and fair disclosure of the provisions of the policy.

      2.  The language of the disclosure must be easily understood. The disclosure must state that it is only a summary of the policy and that the policy should be read to ascertain the governing contractual provisions.

      3.  The Commissioner shall not approve a proposed disclosure that does not satisfy the requirements of this section and of applicable regulations.

      4.  In addition to the disclosure, the insurer shall provide information about guaranteed availability of basic and standard plans for benefits to an eligible person.

      5.  The insurer shall provide the summary before the policy is issued.

      (Added to NRS by 2001, 2219)

      NRS 689B.280  Disclosure of information concerning medication of insured prohibited.

      1.  Except as otherwise provided in subsection 2, an insurer or any agent or employee of an insurer who delivers or issues for delivery a policy of group health or blanket health insurance in this State shall not disclose to the policyholder or any agent or employee of the policyholder:

      (a) The fact that an insured is taking a prescribed drug or medicine; or

      (b) The identity of that drug or medicine.

      2.  The provisions of subsection 1 do not prohibit disclosure to an administrator who acts as an intermediary for claims for insurance coverage.

      (Added to NRS by 1989, 1978)

      NRS 689B.283  Mandatory renewal of coverage under conversion health benefit plan. [Effective through December 31, 2013.]  Coverage provided under a conversion health benefit plan must be renewed by the carrier that issued the plan, at the option of the person covered under the health benefit plan, unless:

      1.  The person 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;

      2.  The person committed an act or practice that constitutes fraud or has made an intentional misrepresentation of material fact under the terms of the coverage; or

      3.  The carrier who is obligated to offer a conversion health benefit plan pursuant to NRS 689B.590 or a health maintenance organization organized pursuant to chapter 695C of NRS decides to discontinue offering and renewing all health benefit plans delivered or issued for delivery in this State. If the carrier or health maintenance organization decides to discontinue offering and renewing those plans, the carrier or health maintenance organization shall:

      (a) Provide notice of its intention to the Commissioner and the chief regulatory officer for insurance in each state in which the carrier or health maintenance organization 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;

      (b) Provide notice of its intention at least 180 days before the renewal of any conversion health benefit plan to all persons covered under its conversion health benefit plans and to the Commissioner and the chief regulatory officer for insurance in each state in which the carrier or health maintenance organization is licensed to transact insurance; and

      (c) Discontinue all group health insurance delivered or issued for delivery to persons in this State and not renew coverage under any policy of group health insurance issued to those persons.

      (Added to NRS by 2005, 2136; R 2013, 3661, effective January 1, 2014)

      NRS 689B.285  Offering policy of health insurance for purposes of establishing health savings account.  An insurer may, subject to regulation by the Commissioner, offer a policy of health insurance that has a high deductible and is in compliance with 26 U.S.C. § 223 for the purposes of establishing a health savings account.

      (Added to NRS by 2005, 2137)

      NRS 689B.287  Insurer prohibited from denying coverage solely because insured was intoxicated or under influence of controlled substance; exceptions.

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

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

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

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

      2.  The provisions of subsection 1 do not prohibit an insurer from enforcing a provision included in a policy of group health insurance to:

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

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

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

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

      (Added to NRS by 2005, 2344; A 2007, 84)

ELIGIBILITY FOR COVERAGE UNDER GROUP POLICY

      NRS 689B.290  Definitions.  As used in NRS 689B.290 to 689B.330, inclusive, unless the context otherwise requires:

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

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

      (Added to NRS by 1995, 2428)

      NRS 689B.300  Effect of eligibility for medical assistance under Medicaid; assignment of rights to state agency.

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

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

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

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

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

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

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

      (a) Eligible for medical assistance under Medicaid; and

      (b) Covered by a group health policy,

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

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

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

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

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

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

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

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

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

      (Added to NRS by 1995, 2429; A 2007, 2403)

      NRS 689B.310  Insurer prohibited from asserting certain grounds to deny enrollment of child of insured pursuant to order.  An insurer shall not deny the enrollment of a child pursuant to an order for medical coverage under a group health policy pursuant to which a parent of the child is insured, on the ground that the child:

      1.  Was born out of wedlock;

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

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

      (Added to NRS by 1995, 2429)

      NRS 689B.320  Certain accommodations to be made when child is covered under policy of noncustodial parent.  If a child has coverage under a group health policy pursuant to which a noncustodial parent of the child is insured, the health insurer issuing that policy shall:

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

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

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

      (Added to NRS by 1995, 2429)

      NRS 689B.330  Insurer to authorize enrollment of child of parent who is required by order to provide medical coverage for child.  If a parent is required by an order for medical coverage to provide coverage under a group health policy for a child and the parent is eligible for coverage of members of his or her family under a group health policy, the insurer that issued the policy:

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

      2.  Shall, if:

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

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

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

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

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

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

      (Added to NRS by 1995, 2429)

PORTABILITY AND ACCOUNTABILITY

      NRS 689B.340  Definitions. [Effective through December 31, 2013.]  As used in NRS 689B.340 to 689B.590, inclusive, unless the context otherwise requires, the words and terms defined in NRS 689B.350 to 689B.460, inclusive, have the meanings ascribed to them in those sections.

      (Added to NRS by 1997, 2900; A 2001, 1923, 2224)

      NRS 689B.340  Definitions. [Effective January 1, 2014.]  As used in NRS 689B.340 to 689B.580, inclusive, unless the context otherwise requires, the words and terms defined in NRS 689B.350 to 689B.460, inclusive, have the meanings ascribed to them in those sections.

      (Added to NRS by 1997, 2900; A 2001, 1923, 2224; 2013, 3620, effective January 1, 2014)

      NRS 689B.350  “Affiliation period” defined.  “Affiliation period” means a period not to exceed 60 days for new enrollees and 90 days for late enrollees during which no premiums may be collected from, and coverage issued would not become effective for, an employee or a dependent of the employee, if the affiliation period is applied uniformly and without regard to any health status-related factors.

      (Added to NRS by 1997, 2900)

      NRS 689B.355  “Blanket accident and health insurance” defined.  “Blanket accident and health insurance” has the meaning ascribed to it in NRS 689B.070.

      (Added to NRS by 2001, 2219)

      NRS 689B.360  “Carrier” defined.  “Carrier” means any person who provides health insurance in this state, including a fraternal benefit society, a health maintenance organization, a nonprofit hospital and health service corporation, a health insurance company and any other person providing a plan of health insurance or health benefits subject to this Title.

      (Added to NRS by 1997, 2900)

      NRS 689B.370  “Contribution” defined.  “Contribution” means the minimum employer contribution toward the premium for enrollment of participants and beneficiaries in a health benefit plan.

      (Added to NRS by 1997, 2900)

      NRS 689B.380  “Creditable coverage” defined.  “Creditable coverage” means health benefits or coverage provided to a person pursuant to:

      1.  A group health plan;

      2.  A health benefit plan;

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

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

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

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

      7.  A state health benefit risk pool;

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

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

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

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

      12.  A short-term health insurance policy; or

      13.  A blanket accident and health insurance policy.

      (Added to NRS by 1997, 2900; A 1999, 2240, 2806; 2001, 2224)

      NRS 689B.390  “Group health plan” defined.

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

      2.  The term does not include:

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

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

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

      (d) Workers’ compensation or similar insurance;

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

      (f) Credit insurance;

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

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

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

      (a) Limited-scope dental or vision benefits;

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

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

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

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

      (b) Hospital indemnity or other fixed indemnity insurance.

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

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

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

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

      (Added to NRS by 1997, 2900)

      NRS 689B.400  “Group participation” defined.  “Group participation” means the minimum number of participants or beneficiaries that must be enrolled in a health benefit plan in relation to a specified percentage or number of eligible persons or employees of the employer.

      (Added to NRS by 1997, 2901)

      NRS 689B.410  “Health benefit plan” defined. [Effective through December 31, 2013.]

      1.  “Health benefit plan” means a policy, contract, certificate or agreement offered by a carrier to provide 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 the Health Insurance Portability and Accountability Act of 1996, 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.  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, the term does not include the following benefits:

      (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.  For the purposes of NRS 689B.340 to 689B.590, inclusive, 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, the term does not include:

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

      (b) Hospital indemnity or other fixed indemnity insurance.

      5.  For the purposes of NRS 689B.340 to 689B.590, inclusive, if offered as a separate policy, certificate or contract of insurance, the term does not include:

      (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, 2901; A 1999, 2807, 3085, 3107; 2001, 204; R 2013, 3661, effective January 1, 2014)

      NRS 689B.420  “Health status-related factor” defined. [Effective through December 31, 2013.]  “Health status-related factor” means, with regard to an insured or a person 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, 2902; R 2013, 3661, effective January 1, 2014)

      NRS 689B.430  “Open enrollment” defined.  “Open enrollment” means the period designated for enrollment in a health benefit plan.

      (Added to NRS by 1997, 2903)

      NRS 689B.440  “Plan sponsor” defined.  “Plan sponsor” has the meaning ascribed to it in section 3(16)(B) of the Employee Retirement Income Security Act of 1974, as that section existed on July 16, 1997.

      (Added to NRS by 1997, 2903)

      NRS 689B.450  “Preexisting condition” defined.  “Preexisting condition” means a condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received during the 6 months immediately preceding the effective date of the new coverage. The term does not include genetic information in the absence of a diagnosis of the condition related to such information.

      (Added to NRS by 1997, 2903)

      NRS 689B.460  “Waiting period” defined.  “Waiting period” means the period established by a plan of health insurance that must pass before a person who is an eligible participant or beneficiary in a plan is covered for benefits under the terms of the plan. The term includes the period from the date a person submits an application to an individual carrier for coverage under a health benefit plan until the first day of coverage under that health benefit plan.

      (Added to NRS by 1997, 2903; A 1999, 2808)

      NRS 689B.470  Certain plan, fund or program to be treated as employee welfare benefit plan which is group health plan; partnership deemed employer of each partner. [Effective through December 31, 2013.]  For the purposes of NRS 689B.340 to 689B.590, 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, including items and services paid for as 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 the provisions of subsection 2, as an employee welfare benefit plan that 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, 2903; R 2013, 3661, effective January 1, 2014)

      NRS 689B.480  Determination of applicable creditable coverage of person; determination of period of creditable coverage of person; required statement. [Effective through December 31, 2013.]

      1.  In determining the applicable creditable coverage of a person for the purposes of NRS 689B.340 to 689B.590, inclusive, a period of creditable coverage must not be included if, after the expiration of that period but before the enrollment date, there was a 63-day period during all of which the person was not covered under any creditable coverage. To establish a period of creditable coverage, a person must present any certificates of coverage provided to the person in accordance with NRS 689B.490 and such other evidence of coverage as required by regulations adopted by the Commissioner. For the purposes of this subsection, any waiting period for coverage or an affiliation period must not be considered in determining the applicable period of creditable coverage.

      2.  In determining the period of creditable coverage of a person for the purposes of NRS 689B.500, a carrier shall include each applicable period of creditable coverage without regard to the specific benefits covered during that period, except that the carrier may elect to include applicable periods of creditable coverage based on coverage of specific benefits as specified in the regulations of the United States Department of Health and Human Services, if such an election is made on a uniform basis for all participants and beneficiaries of the health benefit plan or coverage. Pursuant to such an election, the carrier shall include each applicable period of creditable coverage with respect to any class or category of benefits if any level of benefits is covered within that class or category, as specified by those regulations.

      3.  Regardless of whether coverage is actually provided, if a carrier elects in accordance with subsection 2 to determine creditable coverage based on specified benefits, a statement that such an election has been made and a description of the effect of the election must be:

      (a) Included prominently in any disclosure statement concerning the health benefit plan; and

      (b) Provided to each person at the time of enrollment in the health benefit plan.

      (Added to NRS by 1997, 2903)

      NRS 689B.480  Determination of applicable creditable coverage of person; determination of period of creditable coverage of person; required statement. [Effective January 1, 2014.]

      1.  In determining the applicable creditable coverage of a person for the purposes of NRS 689B.340 to 689B.580, inclusive, a period of creditable coverage must not be included if, after the expiration of that period but before the enrollment date, there was a 63-day period during all of which the person was not covered under any creditable coverage. To establish a period of creditable coverage, a person must present any certificates of coverage provided to the person in accordance with NRS 689B.490 and such other evidence of coverage as required by regulations adopted by the Commissioner. For the purposes of this subsection, any waiting period for coverage or an affiliation period must not be considered in determining the applicable period of creditable coverage.

      2.  In determining the period of creditable coverage of a person, a carrier shall include each applicable period of creditable coverage without regard to the specific benefits covered during that period, except that the carrier may elect to include applicable periods of creditable coverage based on coverage of specific benefits as specified in the regulations of the United States Department of Health and Human Services, if such an election is made on a uniform basis for all participants and beneficiaries of the health benefit plan or coverage. Pursuant to such an election, the carrier shall include each applicable period of creditable coverage with respect to any class or category of benefits if any level of benefits is covered within that class or category, as specified by those regulations.

      3.  Regardless of whether coverage is actually provided, if a carrier elects in accordance with subsection 2 to determine creditable coverage based on specified benefits, a statement that such an election has been made and a description of the effect of the election must be:

      (a) Included prominently in any disclosure statement concerning the health benefit plan; and

      (b) Provided to each person at the time of enrollment in the health benefit plan.

      4.  The provisions of this section apply only to grandfathered plans.

      (Added to NRS by 1997, 2903; A 2013, 3620, effective January 1, 2014)

      NRS 689B.490  Written certification of coverage required for purpose of determining period of creditable coverage accumulated by person.

      1.  For the purpose of determining the period of creditable coverage of a person accumulated under a health benefit plan, blanket accident and health insurance or group health insurance, the insurer shall provide written certification on a form prescribed by the Commissioner of coverage to the person which certifies the length of:

      (a) The period of creditable coverage that the person accumulated under the plan and any coverage under any provision of the Consolidated Omnibus Budget Reconciliation Act of 1985, as that act existed on July 16, 1997, relating to the continuation of coverage; and

      (b) Any waiting and affiliation period imposed on the person pursuant to that coverage.

      2.  The certification of coverage must be provided to the person who was insured:

      (a) At the time that the person ceases to be covered under the plan, if the person does not otherwise become covered under any provision of the Consolidated Omnibus Budget Reconciliation Act of 1985, as that act existed on July 16, 1997, relating to the continuation of coverage;

      (b) If the person becomes covered under such a provision, at the time that the person ceases to be covered by that provision; and

      (c) Upon request, if the request is made not later than 24 months after the date on which the person ceased to be covered as described in paragraphs (a) and (b).

      (Added to NRS by 1997, 2904; A 2001, 2225)

      NRS 689B.500  Coverage of preexisting conditions; when health maintenance organization may require affiliation period. [Effective through December 31, 2013.]

      1.  Except as otherwise provided in this section, a carrier that issues a group health plan or coverage under blanket accident and health insurance or group health insurance shall not deny, exclude or limit a benefit for a preexisting condition for:

      (a) More than 12 months after the effective date of coverage if the employee or other insured enrolls through open enrollment or after the first day of the waiting period for that enrollment, whichever is earlier; or

      (b) More than 18 months after the effective date of coverage for a late enrollee.

Ê A carrier may not define a preexisting condition more restrictively than that term is defined in NRS 689B.450.

      2.  The period of any exclusion for a preexisting condition imposed by a group health plan or coverage under blanket accident and health insurance or group health insurance on a person to be insured in accordance with the provisions of this chapter must be reduced by the aggregate period of creditable coverage of that person, if the creditable coverage was continuous to a date not more than 63 days before the effective date of the coverage. The period of continuous coverage must not include:

      (a) Any waiting period for the effective date of the new coverage applied by the employer or the carrier; or

      (b) Any affiliation period not to exceed 60 days for a new enrollee and 90 days for a late enrollee required before becoming eligible to enroll in the group health plan.

      3.  A health maintenance organization authorized to transact insurance pursuant to chapter 695C of NRS that does not restrict coverage for a preexisting condition may require an affiliation period before coverage becomes effective under a plan of insurance if the affiliation period applies uniformly to all employees or other persons insured and without regard to any health status-related factors. During the affiliation period, the carrier shall not collect any premiums for coverage of the employee or other insured.

      4.  An insurer that restricts coverage for preexisting conditions shall not impose an affiliation period.

      5.  A carrier shall not impose any exclusion for a preexisting condition:

      (a) Relating to pregnancy.

      (b) In the case of a person who, as of the last day of the 30-day period beginning on the date of the birth of the person, is covered under creditable coverage.

      (c) In the case of a child who is adopted or placed for adoption before attaining the age of 18 years and who, as of the last day of the 30-day period beginning on the date of adoption or placement for adoption, whichever is earlier, is covered under creditable coverage. The provisions of this paragraph do not apply to coverage before the date of adoption or placement for adoption.

      (d) In the case of a condition for which medical advice, diagnosis, care or treatment was recommended or received for the first time while the covered person held creditable coverage, and the medical advice, diagnosis, care or treatment was a benefit under the plan, if the creditable coverage was continuous to a date not more than 63 days before the effective date of the new coverage.

Ê The provisions of paragraphs (b) and (c) do not apply to a person after the end of the first 63-day period during all of which the person was not covered under any creditable coverage.

      6.  As used in this section, “late enrollee” means an eligible employee, or a dependent of the eligible employee, who requests enrollment in a group health plan following the initial period of enrollment, if that initial period of enrollment is at least 30 days, during which the person is entitled to enroll under the terms of the health benefit plan. The term does not include an eligible employee or a dependent of the eligible employee if:

      (a) The employee or dependent:

             (1) Was covered under creditable coverage at the time of the initial enrollment;

             (2) Lost coverage under creditable coverage as a result of cessation of contributions by his or her employer, termination of employment or eligibility, reduction in the number of hours of employment, involuntary termination of creditable coverage, or death of, or divorce or legal separation from, a covered spouse; and

             (3) Requests enrollment not later than 30 days after the date on which the creditable coverage of the employee or dependent was terminated or on which the change in conditions that gave rise to the termination of the coverage occurred.

      (b) The employee enrolls during the open enrollment period, as provided in the contract or as otherwise specifically provided by specific statute.

      (c) The employer of the employee offers several health benefit plans and the employee elected a different plan during an open enrollment period.

      (d) A court has ordered coverage to be provided to the spouse or a minor or dependent child of an employee under a health benefit plan of the employee and a request for enrollment is made within 30 days after the issuance of the court order.

      (e) The employee changes status from not being an eligible employee to being an eligible employee and requests enrollment, subject to any waiting period, within 30 days after the change in status.

      (f) The person has continued coverage in accordance with the Consolidated Omnibus Budget Reconciliation Act of 1985, Public Law 99-272, and that coverage has been exhausted.

      (Added to NRS by 1997, 2904; A 1999, 2808; 2001, 2225)

      NRS 689B.500  Coverage of preexisting conditions. [Effective January 1, 2014.]  A carrier that issues a group health plan or coverage under blanket accident and health insurance or group health insurance shall not deny, exclude or limit a benefit for a preexisting condition.

      (Added to NRS by 1997, 2904; A 1999, 2808; 2001, 2225; 2013, 3621, effective January 1, 2014)

      NRS 689B.510  Carrier authorized to modify coverage for insurance product under certain circumstances.  A carrier may modify the health insurance coverage for a product offered pursuant to a group health plan by the carrier at the time of renewal of such coverage if the modification is consistent with the provisions of this chapter.

      (Added to NRS by 1997, 2906)

      NRS 689B.520  Group plan or coverage that includes coverage for maternity care and pediatric care: Required to allow minimum stay in hospital in connection with childbirth; prohibited acts.

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

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

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

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

      2.  Nothing in this section requires a mother to:

      (a) Deliver her baby in a hospital; or

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

      3.  A group health plan or coverage under group health insurance that offers coverage for maternity care and pediatric care of newborn infants may not:

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

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

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

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

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

      4.  Nothing in this section:

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

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

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

      (Added to NRS by 1997, 2906)

      NRS 689B.530  Carrier required to permit eligible employee or dependent of employee to enroll for coverage under certain circumstances.  A carrier offering group health insurance shall permit an employee or a dependent of an employee covered by the group health insurance who is eligible, but not enrolled, for coverage in connection with the group health insurance to enroll for coverage under the terms of the group health insurance if:

      1.  The employee or dependent was covered under a different group health insurance or had other health insurance coverage at the time coverage was previously offered to the employee or dependent;

      2.  The employee stated in writing at that time that the other coverage was the reason for declining enrollment, but only if the plan sponsor or carrier required such a written statement and informed the employee of that requirement and the consequences of the requirement; and

      3.  The employee or dependent:

      (a) Was covered under any provision of the Consolidated Omnibus Budget Reconciliation Act of 1985 relating to the continuation of coverage and such continuation of coverage was exhausted; or

      (b) Was not covered under such a provision and his or her insurance coverage was lost as a result of cessation of contributions by his or her employer, termination of employment or eligibility, reduction in the number of hours of employment, or the death of, or divorce or legal separation from, a covered spouse.

      (Added to NRS by 1997, 2907)

      NRS 689B.540  Manner and period for enrollment of dependent of covered employee; period of special enrollment.

      1.  A carrier that offers group health insurance which makes coverage available to the dependent of an employee covered by the group health plan shall permit the employee to enroll a dependent after the close of a period of open enrollment if:

      (a) The employee is a participant in the group health plan, or has met any waiting period applicable to becoming a participant and is eligible to be enrolled under the plan, except for a failure to enroll during a previous period of open enrollment; and

      (b) The person to be enrolled became a dependent of the employee through marriage, birth, adoption or placement for adoption.

      2.  The group health plan or carrier shall provide a period of special enrollment for the enrollment of a dependent of an employee pursuant to this section. Such a period must be not less than 30 days and must begin on:

      (a) The date specified by the group health plan or carrier for the period of special enrollment; or

      (b) The date of the marriage, birth, adoption or placement for adoption, as appropriate.

      3.  If an employee seeks to enroll a dependent during the first 30 days of the period for special enrollment provided pursuant to subsection 2, the coverage of the dependent becomes effective:

      (a) In the case of a marriage, not later than the first day of the first month beginning after the date on which the completed request for enrollment is received;

      (b) In the case of a birth, on the date of the birth; and

      (c) In the case of an adoption or placement for adoption, on the date of the adoption or the placement for adoption.

      4.  In the case of a birth, an adoption or a placement for adoption of a child of an employee, the spouse of the employee may be enrolled as a dependent pursuant to this section if the spouse is otherwise eligible for coverage under the group health plan.

      (Added to NRS by 1997, 2908)

      NRS 689B.550  Carrier prohibited from imposing restriction on participation inconsistent with chapter; restrictions on rules of eligibility that may be established; premiums to be equitable.

      1.  A carrier shall not place any restriction on a person or a dependent of the person as a condition of being a participant in or a beneficiary of a policy of blanket accident and health insurance or group health insurance that is inconsistent with the provisions of this chapter.

      2.  A carrier that offers coverage under a policy of blanket accident and health insurance or group health insurance pursuant to this chapter shall not establish rules of eligibility, including rules which define applicable waiting periods, for the initial or continued enrollment under a group health plan offered by the carrier that are based on the following factors relating to the employee or a dependent of the employee:

      (a) Health status.

      (b) Medical condition, including physical and mental illnesses, or both.

      (c) Claims experience.

      (d) Receipt of health care.

      (e) Medical history.

      (f) Genetic information.

      (g) Evidence of insurability, including conditions which arise out of acts of domestic violence.

      (h) Disability.

      3.  Except as otherwise provided in NRS 689B.500, the provisions of subsection 1 do not:

      (a) Require a carrier to provide particular benefits other than those that would otherwise be provided under the terms of the blanket health and accident insurance or group health insurance or coverage; or

      (b) Prevent a carrier from establishing limitations or restrictions on the amount, level, extent or nature of the benefits or coverage for similarly situated persons.

      4.  As a condition of enrollment or continued enrollment under a policy of blanket accident and health insurance or group health insurance, a carrier shall not require an employee to pay a premium or contribution that is greater than the premium or contribution for a similarly situated person covered by similar coverage on the basis of any factor described in subsection 2 in relation to the employee or a dependent of the employee.

      5.  This section does not:

      (a) Restrict the amount that an employer or employee may be charged for coverage by a carrier;

      (b) Prevent a carrier from establishing premium discounts or rebates or from modifying otherwise applicable copayments or deductibles in return for adherence by the insured person to programs of health promotion and disease prevention; or

      (c) Preclude a carrier from establishing rules relating to employer contribution or group participation when offering health insurance coverage to small employers in this state.

      (Added to NRS by 1997, 2908; A 2001, 2227)

      NRS 689B.560  Carrier required to renew coverage at option of plan sponsor; exceptions; discontinuation of form of product of group health insurance; discontinuation of group health insurance through bona fide association. [Effective through December 31, 2013.]

      1.  Except as otherwise provided in this section, coverage under a policy of group health insurance must be renewed by the carrier at the option of the plan sponsor, unless:

      (a) The plan sponsor has failed to pay premiums or contributions in accordance with the terms of the group health insurance or the carrier has not received timely premium payments;

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

      (c) The plan sponsor has failed to comply with any material provision of the group health insurance relating to employer contributions and group participation; or

      (d) The carrier decides to discontinue offering coverage under group health insurance. If the carrier decides to discontinue offering and renewing such insurance, the carrier shall:

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

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

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

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

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

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

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

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

      3.  A carrier may discontinue the issuance and renewal of any type of group health insurance offered by the carrier in this state that is made available pursuant to this chapter only to a member of a bona fide association if:

      (a) The membership of the person in the bona fide association was the basis for the provision of coverage under the group health insurance;

      (b) The membership of the person in the bona fide association ceases; and

      (c) Coverage is terminated pursuant to this subsection for all such former members uniformly without regard to any health status-related factor relating to the former member.

      4.  A carrier that elects not to renew group health insurance pursuant to paragraph (d) of subsection 1 shall not write new business pursuant to this chapter for 5 years after the date on which notice is provided to the Commissioner pursuant to subparagraph (2) of paragraph (d) of subsection 1.

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

      6.  As used in this section, “bona fide association” has the meaning ascribed to it in NRS 689A.485.

      (Added to NRS by 1997, 2909)

      NRS 689B.560  Carrier required to renew coverage at option of plan sponsor; exceptions; discontinuation of form of product of group health insurance; discontinuation of group health insurance through bona fide association. [Effective January 1, 2014.]

      1.  Except as otherwise provided in this section, coverage under a policy of group health insurance must be renewed by the carrier at the option of the plan sponsor, unless:

      (a) The plan sponsor has failed to pay premiums or contributions in accordance with the terms of the group health insurance or the carrier has not received timely premium payments;

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

      (c) The plan sponsor has failed to comply with any material provision of the group health insurance relating to employer contributions and group participation; or

      (d) The carrier decides to discontinue offering coverage under group health insurance. If the carrier decides to discontinue offering and renewing such insurance, the carrier shall:

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

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

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

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

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

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

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

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

      3.  A carrier may discontinue the issuance and renewal of any type of group health insurance offered by the carrier in this state that is made available pursuant to this chapter only to a member of a bona fide association if:

      (a) The membership of the person in the bona fide association was the basis for the provision of coverage under the group health insurance;

      (b) The membership of the person in the bona fide association ceases; and

      (c) Coverage is terminated pursuant to this subsection for all such former members uniformly without regard to any health status-related factor relating to the former member.

      4.  A carrier that elects not to renew group health insurance pursuant to paragraph (d) of subsection 1 shall not write new business pursuant to this chapter for 5 years after the date on which notice is provided to the Commissioner pursuant to subparagraph (2) of paragraph (d) of subsection 1.

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

      6.  As used in this section, “bona fide association” has the meaning ascribed to it in NRS 689A.485.

      (Added to NRS by 1997, 2909; A 2013, 3623, effective January 1, 2014)

      NRS 689B.570  Carrier that offers coverage through network plan not required to offer coverage to employer that does not employ enrollees who reside or work in geographic area for which carrier is authorized to transact insurance. [Effective through December 31, 2013.]

      1.  A carrier that offers coverage through a network plan is not required to offer coverage to or accept an application from an employer that does not employ or no longer employs any enrollees who reside or work in the established geographic service area of the carrier or the geographic area for which the carrier is authorized to transact insurance, provided that such coverage is refused or terminated uniformly without regard to any health status-related factor for any employee of the employer.

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

      (Added to NRS by 1997, 2911)

      NRS 689B.570  Carrier that offers coverage through network plan not required to offer coverage to employer that does not employ enrollees who reside or work in geographic service area for which carrier is authorized to transact insurance. [Effective January 1, 2014.]

      1.  A carrier that offers coverage through a network plan is not required to offer coverage to or accept an application from an employer that does not employ or no longer employs any enrollees who reside or work in the geographic service area of the carrier, provided that such coverage is refused or terminated uniformly without regard to any health status-related factor for any employee of the employer.

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

      (Added to NRS by 1997, 2911; A 2013, 3624, effective January 1, 2014)

      NRS 689B.575  Carrier that offers coverage through network plan: Contracts with certain federally qualified health centers. [Effective through December 31, 2013.]

      1.  A carrier that offers coverage through a network plan shall use its best efforts to contract with at least one health center in each established geographic service area of the carrier or geographic area for which the carrier is authorized to transact insurance to provide medical care for enrollees 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:

      (a) “Health center” has the meaning ascribed to it in 42 U.S.C. § 254b.

      (b) “Network plan” has the meaning ascribed to it in NRS 689B.570.

      (Added to NRS by 2001, 1923; R 2013, 3661, effective January 1, 2014)

      NRS 689B.580  Plan sponsor of governmental plan authorized to elect to exclude governmental plan from compliance with certain statutes; duties of plan sponsor. [Effective through December 31, 2013.]

      1.  A plan sponsor of a governmental plan that is a group health plan to which the provisions of NRS 689B.340 to 689B.590, inclusive, otherwise apply may elect to exclude the governmental plan from compliance with those sections. Such an election:

      (a) Must be made in such a form and in such a manner as the Commissioner prescribes by regulation.

      (b) Is effective for a single specified year of the plan or, if the plan is provided pursuant to a collective bargaining agreement, for the term of that agreement.

      (c) May be extended by subsequent elections.

      (d) Excludes the governmental plan from those provisions in this chapter that apply only to group health plans.

      2.  If a plan sponsor of a governmental plan makes an election pursuant to this section, the plan sponsor shall:

      (a) Annually and at the time of enrollment, notify the enrollees in the plan of the election and the consequences of the election; and

      (b) Provide certification and disclosure of creditable coverage under the plan with respect to those enrollees pursuant to NRS 689B.490.

      3.  As used in this section, “governmental plan” has the meaning ascribed to in section 3(32) of the Employee Retirement Income Security Act of 1974, as that section existed on July 16, 1997.

      (Added to NRS by 1997, 2911)

      NRS 689B.580  Plan sponsor of governmental plan authorized to elect to exclude governmental plan from compliance with certain statutes; duties of plan sponsor. [Effective January 1, 2014.]

      1.  A plan sponsor of a governmental plan that is a group health plan to which the provisions of NRS 689B.340 to 689B.580, inclusive, otherwise apply may elect to exclude the governmental plan from compliance with those sections. Such an election:

      (a) Must be made in such a form and in such a manner as the Commissioner prescribes by regulation.

      (b) Is effective for a single specified year of the plan or, if the plan is provided pursuant to a collective bargaining agreement, for the term of that agreement.

      (c) May be extended by subsequent elections.

      (d) Excludes the governmental plan from those provisions in this chapter that apply only to group health plans.

      2.  If a plan sponsor of a governmental plan makes an election pursuant to this section, the plan sponsor shall:

      (a) Annually and at the time of enrollment, notify the enrollees in the plan of the election and the consequences of the election; and

      (b) Provide certification and disclosure of creditable coverage under the plan with respect to those enrollees pursuant to NRS 689B.490.

      3.  As used in this section, “governmental plan” has the meaning ascribed to in section 3(32) of the Employee Retirement Income Security Act of 1974, as that section existed on July 16, 1997.

      (Added to NRS by 1997, 2911; A 2013, 3624, effective January 1, 2014)

      NRS 689B.590  Converted policies: Carrier may only offer choice of basic and standard plans; election of basic or standard plan; premium; rates must be same for persons with similar case characteristics; losses must be spread across book. [Effective through December 31, 2013.]

      1.  Not later than 180 days after the date on which the basic and standard health benefit plans are approved pursuant to NRS 689C.770 as part of the plan of operation of the Program of Reinsurance, each carrier required to offer to a person a converted policy pursuant to NRS 689B.120 shall only offer as a converted policy a choice of the basic and standard health benefit plans.

      2.  A person with a converted policy issued before the effective date of the requirement set forth in subsection 1 may, at each annual renewal of the converted policy elect a basic or standard health benefit plan as a substitute converted policy, except that the carrier may, if the person has not made an election within 3 years after first becoming eligible to do so, require the person to make such an election. Once a person has elected the basic or standard health benefit plan as a substitute converted policy, the person may not elect another converted policy.

      3.  The premium for a converted policy may not exceed the small group index rate, as defined in paragraph (b) of subsection 3 of NRS 689C.230, applicable to the carrier by more than 75 percent. The small group index rate used by a carrier that does not write insurance to small employers in this state must be the average small group index rate, as determined by the Commissioner, of the five largest carriers that provide coverage to small employers pursuant to this chapter for their basic and standard health benefit plans. The Commissioner shall annually determine the average small group index rate, as measured by the premium volume of the plans, of those five largest carriers.

      4.  The rates for new and renewal converted policies for persons with the same converted policies whose case characteristics are similar must be the same.

      5.  Any losses suffered by a carrier on its converted policies issued pursuant to this section must be spread across the entire book of the health benefit coverage of the carrier issued or delivered for issuance to small employers and large group employers in this state.

      6.  The Commissioner shall adopt such regulations as are necessary to carry out the provisions of this section.

      (Added to NRS by 1997, 2911; A 1999, 2810; R 2013, 3661, effective January 1, 2014)