NRS: CHAPTER 689A - INDIVIDUAL HEALTH INSURANCE

[Rev. 6/29/2024 4:59:56 PM--2023]

CHAPTER 689A - INDIVIDUAL HEALTH INSURANCE

GENERAL PROVISIONS

NRS 689A.030 General requirements.

NRS 689A.032 Insurer required to offer and issue plan regardless of health status of persons; prohibited acts.

NRS 689A.033 Insurer prohibited from discriminating against person with respect to participation or coverage on basis of gender identity or expression.

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

REQUIRED PROVISIONS

NRS 689A.040 Contents of policy; substitution of provisions; captions; omission or modification of provisions.

NRS 689A.0403 Procedure for arbitration of disputes concerning independent medical, dental or chiropractic evaluations.

NRS 689A.04033 Coverage for certain treatment received as part of clinical trial or study for treatment of cancer or chronic fatigue syndrome required; authority of insurer to require certain information; immunity from liability.

NRS 689A.04036 Coverage for continued medical treatment required in certain policies; exceptions; regulations.

NRS 689A.0404 Coverage for use of certain drugs and related services for treatment of cancer required in certain policies.

NRS 689A.04041 Policy covering prescription drug for treatment of cancer or cancer symptom that is part of step therapy protocol: Insurer required to allow insured or attending practitioner to apply for exemption from step therapy protocol in certain circumstances; procedure for applying for and granting exemption.

NRS 689A.04042 Coverage for colorectal cancer screening required in policy covering treatment of colorectal cancer.

NRS 689A.04043 Policy covering prescription drug for treatment of medical condition that is part of step therapy protocol: Use of certain guidelines required; establishment of process to request exemption from step therapy protocol; granting of request; applicability of provisions.

NRS 689A.04044 Policy covering prescription drugs: Required actions by insurer related to acquisition of prescription drugs for certain insureds residing in area for which emergency or disaster has been declared.

NRS 689A.04045 Policy covering prescription drugs prohibited from limiting or excluding coverage for prescription drug previously approved for medical condition of insured; exception.

NRS 689A.04046 Coverage for prescription drugs irregularly dispensed for purpose of synchronization of chronic medications required in policy covering prescription drugs; prohibited acts; exception.

NRS 689A.04047 Policy covering prescription drugs: Denial of coverage prohibited for early refills of otherwise covered topical ophthalmic products.

NRS 689A.04048 Policy covering prescription drugs: Submission to step therapy protocol for drug to treat psychiatric condition prohibited in certain circumstances.

NRS 689A.04049 Coverage for screening, genetic counseling and testing related to BRCA gene required in certain circumstances.

NRS 689A.0405 Coverage for certain screenings and tests for breast cancer required; prohibited acts.

NRS 689A.041 Coverage relating to mastectomy required in policy covering mastectomies; prohibited acts.

NRS 689A.0412 Coverage for examination of person who is pregnant for certain diseases required.

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

NRS 689A.0415 Coverage for hormone replacement therapy in certain circumstances required in policy covering prescription drugs or devices; prohibited acts; exception.

NRS 689A.0417 Coverage for health care services related to hormone replacement therapy required in policy covering outpatient care; prohibited acts.

NRS 689A.0418 Coverage for drug or device for contraception and related health services required; prohibited acts; exceptions.

NRS 689A.0419 Coverage for certain services, screenings and tests relating to wellness required; prohibited acts.

NRS 689A.042 Policy containing exclusion, reduction or limitation of coverage relating to complications of pregnancy prohibited; exception.

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

NRS 689A.0424 Policy covering maternity care: Prohibited acts by insurer if insured is acting as gestational carrier; child deemed child of intended parent for purposes of policy.

NRS 689A.0427 Coverage for management and treatment of diabetes required in policy covering hospital, medical or surgical expenses.

NRS 689A.0428 Coverage for management and treatment of sickle cell disease and its variants required; coverage for medically necessary prescription drugs to treat sickle cell disease and its variants required by plan covering prescription drugs.

NRS 689A.043 Policy covering family on expense-incurred basis required to include certain coverage for insured’s newly born and adopted children and children placed with insured for adoption.

NRS 689A.0432 Coverage for medically necessary treatment of conditions relating to gender dysphoria and gender incongruence required; restriction on refusal to cover certain treatments; authority of insurer to prescribe requirements for covering surgical treatments for minors; determination of medical necessity.

NRS 689A.0435 Option of coverage for autism spectrum disorders for certain persons required; prohibited acts.

NRS 689A.0437 Coverage for drugs, laboratory testing and certain services related to human immunodeficiency virus and hepatitis C required; reimbursement of certain providers of health care for certain services; prohibited acts.

NRS 689A.0438 Coverage for testing, treatment and prevention of sexually transmitted diseases required; coverage for condoms for certain insureds required.

NRS 689A.044 Coverage for certain tests and vaccines relating to human papillomavirus required; prohibited acts.

NRS 689A.0445 Coverage for prostate cancer screening.

NRS 689A.0446 Coverage for biomarker testing for diagnosis, treatment, management and monitoring of cancer required in certain circumstances; establishment of process to request exception or appeal denial of coverage; time for responding to request for prior authorization.

NRS 689A.0447 Policy covering treatment of cancer through use of chemotherapy: Prohibited acts related to orally administered chemotherapy.

NRS 689A.0455 Coverage for treatment of conditions relating to severe mental illness required.

NRS 689A.0459 Coverage for certain drugs and services related to substance use disorder and opioid use disorder required; reimbursement of pharmacists and pharmacies for certain services; prohibited acts.

NRS 689A.046 Benefits for treatment of alcohol or substance use disorder required.

NRS 689A.0463 Coverage for services provided through telehealth required to same extent as though provided in person or by other means; reimbursement for certain services provided through telehealth required in same amount as though provided in person or by other means; prohibited acts.

NRS 689A.0464 Policy covering anatomical gifts, organ transplants or treatments or services related to organ transplants: Prohibited acts by insurer if insured is person with disability.

NRS 689A.0465 Policy prohibited from excluding coverage of treatment of temporomandibular joint; exception.

REIMBURSEMENT FOR CERTAIN MEDICALLY RELATED TREATMENT AND SERVICES

NRS 689A.0475 Acupuncture.

NRS 689A.048 Treatment by licensed psychologist.

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

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

NRS 689A.0487 Treatment by licensed podiatrist.

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

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

NRS 689A.0495 Services provided by certain registered nurses.

NRS 689A.0497 Provider of medical transportation.

MISCELLANEOUS PROVISIONS

NRS 689A.050 Entire contract; changes.

NRS 689A.060 Time limit on certain defenses.

NRS 689A.070 Grace period.

NRS 689A.075 Cancellation and rescission of short-term limited duration medical plan.

NRS 689A.080 Reinstatement.

NRS 689A.090 Notice of claim.

NRS 689A.100 Claim forms: Required provision.

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

NRS 689A.110 Claim forms: Proofs of loss.

NRS 689A.120 Time of payment of claims.

NRS 689A.130 Payment of claims.

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

NRS 689A.140 Physical examination and autopsy.

NRS 689A.150 Legal actions.

NRS 689A.160 Change of beneficiary.

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

NRS 689A.180 Optional provisions: Requirements; substitution of provisions; captions.

NRS 689A.190 Extended disability benefit.

NRS 689A.200 Change of occupation.

NRS 689A.210 Misstatement of age.

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

NRS 689A.230 Coordination of benefits: All coverages.

NRS 689A.240 Relation of earnings to insurance.

NRS 689A.250 Unpaid premiums.

NRS 689A.260 Conformity with state statutes.

NRS 689A.270 Illegal occupation.

NRS 689A.290 Renewability.

NRS 689A.300 Order of certain provisions.

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

NRS 689A.320 Requirements of other jurisdictions.

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

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

NRS 689A.350 Age limit.

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

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

NRS 689A.410 Approval or denial of claims; payment of claims and interest; requests for additional information; award of costs and attorney’s fees; compliance with requirements; imposition of administrative fine or suspension or revocation of certificate of authority for failure to comply.

NRS 689A.413 Insurer prohibited from denying coverage solely because claim involves act that constitutes domestic violence or applicant or insured was victim of domestic violence.

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

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

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

ELIGIBILITY FOR COVERAGE

NRS 689A.420 Definitions.

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

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

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

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

PORTABILITY AND ACCOUNTABILITY

General Provisions

NRS 689A.470 Definitions.

NRS 689A.475 “Affiliated” defined.

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

NRS 689A.490 “Church plan” defined.

NRS 689A.495 “Control” defined.

NRS 689A.505 “Creditable coverage” defined.

NRS 689A.510 “Dependent” defined.

NRS 689A.525 “Geographic rating area” defined.

NRS 689A.527 “Geographic service area” defined.

NRS 689A.530 “Governmental plan” defined.

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

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

NRS 689A.550 “Individual carrier” defined.

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

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

NRS 689A.580 “Plan sponsor” defined.

NRS 689A.590 “Producer” defined.

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

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

Individual Carriers

NRS 689A.630 Requirement to renew coverage at option of individual; exceptions; discontinuation of product; discontinuation of health benefit plan available through bona fide association.

NRS 689A.635 Coverage offered through network plan not required to be offered to person who does not reside or work in geographic service area or geographic rating area.

NRS 689A.637 Coverage offered through plan that provides for restricted network: Contracts with certain federally qualified health centers.

NRS 689A.696 Information and documents required to be made available to Commissioner; proprietary information.

NRS 689A.700 Regulations regarding rates.

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

NRS 689A.710 Prohibited acts; denial of application for coverage; regulations; violation may constitute unfair trade practice; applicability of section.

Individual Health Insurance Coverage

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

NRS 689A.717 Individual health benefit plan covering maternity care and pediatric care: Requirement to allow minimum stay in hospital in connection with childbirth; prohibited acts.

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

Bona Fide Associations

NRS 689A.725 Requirements for plan for coverage.

Miscellaneous Provisions

NRS 689A.740 Regulations.

SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS

NRS 689A.745 Establishment; approval; requirements; examination; exception.

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

NRS 689A.755 Written notice required to be provided by insurer to insured explaining right to file complaint; written notice to insured required when insurer denies coverage of health care service.

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GENERAL PROVISIONS

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

(Added to NRS by 1971, 1751)

NRS 689A.020 Scope. Nothing in this chapter applies to or affects:

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

2. Any group or blanket policy.

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

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

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

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

5. Any policy of insurance offered on the Silver State Health Insurance Exchange in accordance with NRS 695I.505.

(Added to NRS by 1971, 1751; A 1997, 2899; 2013, 3608; 2017, 2358; 2021, 3622)

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

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

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

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

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

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

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

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

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

9. Except as otherwise provided in this subsection, the policy must provide benefits for expenses incurred for the treatment of alcohol or substance use disorder. Except for the benefits required by NRS 689A.0459, such benefits must be provided:

(a) At the option of the applicant; and

(b) Unless the policy provides coverage only for a specified disease or provides for the payment of a specific amount of money if the insured is hospitalized or receiving health care in his or her home.

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

(Added to NRS by 1971, 1752; A 1973, 546; 1975, 446, 1108, 1848; 1979, 1176; 1983, 1933, 2035; 1985, 1568, 1772; 1989, 738, 1031; 2013, 3609; 2023, 2370, 3509)

NRS 689A.032 Insurer required to offer and issue plan regardless of health status of persons; prohibited acts.

1. An insurer shall offer and issue a health benefit plan to any person regardless of the health status of the person or any dependent of the person. Such health status includes, without limitation:

(a) Any preexisting medical condition of the person, including, without limitation, any physical or mental illness;

(b) The claims history of the person, including, without limitation, any prior health care services received by the person;

(d) Any increased risk for illness, injury or any other medical condition of the person, including, without limitation, any medical condition caused by an act of domestic violence.

2. An insurer that offers or issues a health benefit plan shall not:

(a) Deny, limit or exclude a covered benefit based on the health status of an insured; or

(b) Require an insured, as a condition of enrollment or renewal, to pay a premium, deductible, copay or coinsurance based on his or her health status which is greater than the premium, deductible, copay or coinsurance charged to a similarly situated insured who does not have such a health status.

3. An insurer that offers or issues a health benefit plan shall not adjust a premium, deductible, copay or coinsurance for any insured on the basis of genetic information relating to the insured or the covered dependent of the insured.

4. As used in this section, “health benefit plan” has the meaning ascribed to it in NRS 687B.470.

(Added to NRS by 2019, 298)

NRS 689A.033 Insurer prohibited from discriminating against person with respect to participation or coverage on basis of gender identity or expression. An insurer that issues a policy of health insurance shall not discriminate against any person with respect to participation or coverage under the policy on the basis of actual or perceived gender identity or expression. Prohibited discrimination includes, without limitation:

1. Denying, cancelling, limiting or refusing to issue or renew a policy of health insurance on the basis of the actual or perceived gender identity or expression of a person or a family member of the person;

2. Imposing a payment or premium that is based on the actual or perceived gender identity or expression of an insured or a family member of the insured;

3. Designating the actual or perceived gender identity or expression of a person or a family member of the person as grounds to deny, cancel or limit participation or coverage; and

4. Denying, cancelling or limiting participation or coverage on the basis of actual or perceived gender identity or expression, including, without limitation, by limiting or denying coverage for health care services that are:

(a) Related to gender transition, provided that there is coverage under the policy for the services when the services are not related to gender transition; or

(b) Ordinarily or exclusively available to persons of any sex.

(Added to NRS by 2023, 2029)

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

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

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

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

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

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

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

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

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

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

REQUIRED PROVISIONS

NRS 689A.040 Contents of policy; substitution of provisions; captions; omission or modification of provisions.

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

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

(Added to NRS by 1971, 1753; A 1973, 547; 1985, 1059; 2007, 3237; 2013, 3610; 2019, 1429)

NRS 689A.0403 Procedure for arbitration of disputes concerning independent medical, dental or chiropractic evaluations.

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

2. If an insurer, for any final determination of benefits or care, requires an independent evaluation of the medical, dental or chiropractic care of any person for whom such care is covered under the terms of the contract of insurance, only a physician, dentist or chiropractic physician who is certified to practice in the same field of practice as the primary treating physician, dentist or chiropractic physician 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, dentist or chiropractic physician. A certified copy of all reports of findings must be sent to the primary treating physician, dentist or chiropractic physician and the insured person within 10 working days after the evaluation. If the insured person disagrees with the finding of the evaluation, the insured person must submit an appeal to the insurer pursuant to the procedure for binding arbitration set forth in the policy of insurance within 30 days after the insured person receives the finding of the evaluation. Upon its receipt of an appeal, the insurer shall so notify in writing the primary treating physician, dentist or chiropractic physician.

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, dentist or chiropractic physician may not recover any payment from either the insurer, insured person or the patient for services that the primary treating physician, dentist or chiropractic physician 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; A 2015, 195)

1. A policy of health insurance must provide coverage for medical treatment which a policyholder or subscriber receives as part of a clinical trial or study if:

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

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

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

(2) A cooperative group;

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

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

(5) The United States Department of Defense;

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

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

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

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

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

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

(1) The procedure to be undertaken;

(2) Alternative methods of treatment; and

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(a) Include in any disclosure of the coverage provided by the policy notice to each policyholder and subscriber under the policy of the availability of the benefits required by this section.

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

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

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

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

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

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

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

9. As used in this section:

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

(1) The Clinical Trials Cooperative Group Program; and

(2) The Community Clinical Oncology Program.

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

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

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

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

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

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

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

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

(1) A hospital; or

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

(Added to NRS by 2003, 3519; A 2005, 2009; 2017, 2358)

NRS 689A.04036 Coverage for continued medical treatment required in certain policies; exceptions; regulations.

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

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

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

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

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

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

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

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

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

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

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

(1) The date of delivery; or

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

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

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

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

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

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

(Added to NRS by 2003, 3354)

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

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

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

(1) The United States Pharmacopoeia Drug Information; or

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

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

2. The coverage required pursuant to this section:

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

(b) Does not include coverage for any:

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

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

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

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

1. An insurer that offers or issues a policy of health insurance which provides coverage of a prescription drug for the treatment of cancer or any symptom of cancer that is part of a step therapy protocol shall allow an insured who has been diagnosed with stage 3 or 4 cancer or the attending practitioner of the insured to apply for an exemption from the step therapy protocol. The application process for such an exemption must:

(a) Allow the insured or attending practitioner, or a designated advocate for the insured or attending practitioner, to present to the insurer the clinical rationale for the exemption and any relevant medical information.

(b) Clearly prescribe the information and supporting documentation that must be submitted with the application, the criteria that will be used to evaluate the request and the conditions under which an expedited determination pursuant to subsection 4 is warranted.

2. The information and supporting documentation required pursuant to paragraph (b) of subsection 1:

(a) May include, without limitation:

(1) The medical history or other health records of the insured demonstrating that the insured has:

(I) Tried other drugs included in the pharmacological class of drugs for which the exemption is requested without success; or

(II) Taken the requested drug for a clinically appropriate amount of time to establish stability in relation to the cancer and the guidelines of the prescribing practitioner; and

(2) Any other relevant clinical information.

(b) Must not include any information or supporting documentation that is not necessary to make a determination about the application.

3. Except as otherwise provided in subsection 4, an insurer that receives an application for an exemption pursuant to subsection 1 shall:

(a) Make a determination concerning the application if the application is complete or request additional information or documentation necessary to complete the application not later than 72 hours after receiving the application; and

(b) If it requests additional information or documentation, make a determination concerning the application not later than 72 hours after receiving the requested information or documentation.

4. If, in the opinion of the attending practitioner, a step therapy protocol may seriously jeopardize the life or health of the insured, an insurer that receives an application for an exemption pursuant to subsection 1 must make a determination concerning the application as expeditiously as necessary to avoid serious jeopardy to the life or health of the insured.

5. An insurer shall disclose to the insured or attending practitioner who submits an application for an exemption from a step therapy protocol pursuant to subsection 1 the qualifications of each person who will review the application.

6. An insurer must grant an exemption from a step therapy protocol in response to an application submitted pursuant to subsection 1 if:

(a) Any treatment otherwise required under the step therapy or any drug in the same pharmacological class or having the same mechanism of action as the drug for which the exemption is requested has not been effective at treating the cancer or symptom of the insured when prescribed in accordance with clinical indications, clinical guidelines or other peer-reviewed evidence;

(b) Delay of effective treatment would have severe or irreversible consequences for the insured and the treatment otherwise required under the step therapy is not reasonably expected to be effective based on the physical or mental characteristics of the insured and the known characteristics of the treatment;

(1) Is contraindicated for the insured or has caused or is likely, based on peer-reviewed clinical evidence, to cause an adverse reaction or other physical harm to the insured; or

(2) Has prevented or is likely to prevent the insured from performing the responsibilities of his or her occupation or engaging in activities of daily living, as defined in 42 C.F.R. § 441.505;

(d) The condition of the insured is stable while being treated with the prescription drug for which the exemption is requested and the insured has previously received approval for coverage of that drug; or

(e) Any other condition for which such an exemption is required by regulation of the Commissioner is met.

7. If an insurer approves an application for an exemption from a step therapy protocol pursuant to this section, the insurer must cover the prescription drug to which the exemption applies in accordance with the terms of the applicable policy of health insurance. The insurer may initially limit the coverage to a 1-week supply of the drug for which the exemption is granted. If the attending practitioner determines after 1 week that the drug is effective at treating the cancer or symptom for which it was prescribed, the insurer must continue to cover the drug for as long as it is necessary to treat the insured for the cancer or symptom. The insurer may conduct a review not more frequently than once each quarter to determine, in accordance with available medical evidence, whether the drug remains necessary to treat the insured for the cancer or symptom. The insurer shall provide a report of the review to the insured.

8. An insurer shall post in an easily accessible location on an Internet website maintained by the insurer a form for requesting an exemption pursuant to this section.

9. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2022, 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.

10. As used in this section, “attending practitioner” means the practitioner, as defined in NRS 639.0125, who has primary responsibility for the treatment of the cancer or any symptom of such cancer of an insured.

(Added to NRS by 2021, 2659)

NRS 689A.04042 Coverage for colorectal cancer screening required in policy covering treatment of colorectal cancer.

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

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

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

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

(Added to NRS by 2003, 1334)

1. When developing a step therapy protocol, an insurer shall use guidelines based on medical or scientific evidence, if such guidelines are available.

2. An insurer that offers or issues a policy of health insurance which includes coverage for a prescription drug for the treatment of any medical condition that is part of a step therapy protocol shall:

(a) Establish a clear, convenient and readily accessible process by which an insured and his or her attending practitioner may:

(1) Request an exemption for the insured from the step therapy protocol; and

(2) Appeal a decision made by the insurer concerning a request for an exemption from the step therapy protocol pursuant to subparagraph (1);

(b) Make the process described in paragraph (a) accessible through an Internet website maintained by the insurer; and

(c) Except as otherwise provided in this paragraph, respond to a request made or an appeal submitted pursuant to paragraph (a) not later than 2 business days after the request is made or the appeal is submitted, as applicable. If the attending practitioner indicates that exigent circumstances exist, the insurer shall respond to the request or appeal within 24 hours after the request is made or the appeal is submitted, as applicable.

3. An insurer shall grant a request to exempt an insured from a step therapy protocol made in accordance with the process established pursuant to subsection 2 if the attending practitioner for the insured submits to the insurer a statement which provides an adequate justification for the exemption and any documentation necessary to support the statement. The insurer shall determine whether such justification exists if the statement and documentation demonstrate that:

(a) Each prescription drug that is required to be used earlier in the step therapy protocol:

(1) Is contraindicated or will likely cause an adverse reaction or physical or mental harm to the insured;

(2) Is expected to be ineffective based on the known clinical characteristics of the insured and the known characteristics of the required prescription drug;

(3) Has been tried by the insured, regardless of whether the insured was covered by the current policy of health insurance at the time, and was discontinued due to lack of efficacy or effectiveness, diminished effect or an adverse event relating to the prescription drug; or

(4) Is not in the best interest of the insured, based on medical necessity; or

(b) The insured is stable on a prescription drug selected by his or her attending practitioner for the medical condition under consideration, regardless of whether the insured was covered by his or her current policy of health insurance at the time the attending practitioner selected the drug.

4. If an insurer does not respond to a request for an exemption from a step therapy protocol or an appeal concerning a decision relating to such a request within the time frame prescribed by paragraph (c) of subsection 2, the request shall be deemed to have been granted.

5. If a request for an exemption from a step therapy protocol is granted pursuant to subsection 3 or deemed granted pursuant to subsection 4, the insurer shall immediately authorize coverage for and dispensing of the drug chosen by the attending practitioner for the insured.

6. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2024, has the legal effect of including the coverage by this section, and any provisions of the policy that conflict with the provisions of this section is void.

7. The provisions of this section do not apply to any prescription drug to which the provisions of NRS 689A.04041 apply.

8. As used in this section:

(a) “Attending practitioner” means the practitioner, as defined in NRS 639.0125, who has primary responsibility for the treatment of the medical condition of an insured for which a prescription drug is prescribed.

(b) “Medical or scientific evidence” has the meaning ascribed to it in NRS 695G.053.

(Added to NRS by 2023, 807)

1. If the Governor or the Legislature proclaims the existence of a state of emergency or issues a declaration of disaster pursuant to NRS 414.070, an insurer who has issued a policy of health insurance which provides coverage for prescription drugs shall, notwithstanding any provision of the policy to the contrary:

(a) Waive any provision of the policy restricting the time within which an insured may refill a covered prescription if the insured:

(1) Has not exceeded the number of refills authorized by the prescribing practitioner;

(2) Resides in the area for which the emergency or disaster has been declared; and

(3) Requests the refill not later than the end of the state of emergency or disaster or 30 days after the issuance of the proclamation or declaration, whichever is later; and

(b) Authorize payment for, and may apply a copayment, coinsurance or deductible to, a supply of a covered prescription drug for up to 30 days for an insured who resides in the area for which the emergency or disaster has been declared.

2. The Commissioner may extend the time periods prescribed by subsection 1 in increments of 15 or 30 days as he or she determines to be necessary.

3. As used in this section, “practitioner” has the meaning ascribed to it in NRS 639.0125.

(Added to NRS by 2021, 823)

NRS 689A.04045 Policy covering prescription drugs prohibited from limiting or excluding coverage for prescription drug previously approved for medical condition of insured; exception.

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

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

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

2. The provisions of subsection 1 do not:

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

(b) Prohibit:

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

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

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

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

(Added to NRS by 2001, 857; A 2003, 2298; 2017, 636)

NRS 689A.04046 Coverage for prescription drugs irregularly dispensed for purpose of synchronization of chronic medications required in policy covering prescription drugs; prohibited acts; exception.

1. An insurer who offers or issues a policy of health insurance which provides coverage for prescription drugs:

(a) Must authorize coverage for and may apply a copayment and deductible to a prescription that is dispensed by a pharmacy for less than a 30-day supply if, for the purpose of synchronizing the insured’s chronic medications:

(1) The prescriber or pharmacist determines that filling or refilling the prescription in that manner is in the best interest of the insured; and

(2) The insured requests less than a 30-day supply.

(b) May not deny coverage for a prescription described in paragraph (a) which is otherwise approved for coverage by the insurer.

(c) Unless otherwise provided by a contract or other agreement, may not prorate any pharmacy dispensing fees for a prescription described in paragraph (a).

2. A policy subject to the provisions of this chapter which provides coverage for prescription drugs and that is delivered, issued for delivery or renewed on or after January 1, 2017, 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. The provisions of this section do not apply to unit-of-use packaging for which synchronization is not practicable or to a controlled substance.

4. As used in this section:

(a) “Chronic medication” means any drug that is prescribed to treat any disease or other condition which is determined to be permanent, persistent or lasting indefinitely.

(b) “Synchronization” means the alignment of the dispensing of multiple medications by a single contracted pharmacy for the purpose of improving a patient’s adherence to a prescribed course of medication.

(c) “Unit-of-use packaging” means medication that is prepackaged by the manufacturer in blister packs, compliance packs, course-of-therapy packs or any other packaging which is designed and intended to be dispensed directly to the patient without modification by the dispensing pharmacy, except for the addition of a prescription label.

(Added to NRS by 2015, 2123)

NRS 689A.04047 Policy covering prescription drugs: Denial of coverage prohibited for early refills of otherwise covered topical ophthalmic products.

1. An insurer who offers or issues a policy of health insurance which provides coverage for prescription drugs shall not deny coverage for a topical ophthalmic product which is otherwise approved for coverage by the insurer when the insured, pursuant to NRS 639.2395, receives a refill of the product:

(a) After 21 days or more but before 30 days after receiving any 30-day supply of the product;

(b) After 42 days or more but before 60 days after receiving any 60-day supply of the product; or

2. The provisions of this section do not affect any deductibles, copayments or coinsurance authorized or required pursuant to the policy of health insurance.

3. A policy of health insurance subject to the provisions of this chapter which provides coverage for prescription drugs and that is delivered, issued for delivery or renewed on or after January 1, 2016, has the legal effect of including the coverage required by this section, and any provision of the policy or renewal which is in conflict with this section is void.

4. As used in this section, “topical ophthalmic product” means a liquid prescription drug which is applied directly to the eye from a bottle or by means of a dropper.

(Added to NRS by 2015, 206)

NRS 689A.04048 Policy covering prescription drugs: Submission to step therapy protocol for drug to treat psychiatric condition prohibited in certain circumstances.

1. A policy of health insurance which provides coverage for prescription drugs must not require an insured to submit to a step therapy protocol before covering a drug approved by the Food and Drug Administration that is prescribed to treat a psychiatric condition of the insured, if:

(a) The drug has been approved by the Food and Drug Administration with indications for the psychiatric condition of the insured or the use of the drug to treat that psychiatric condition is otherwise supported by medical or scientific evidence;

(b) The drug is prescribed by:

(1) A psychiatrist;

(2) A physician assistant under the supervision of a psychiatrist;

(3) An advanced practice registered nurse who has the psychiatric training and experience prescribed by the State Board of Nursing pursuant to NRS 632.120; or

(4) A primary care provider that is providing care to an insured in consultation with a practitioner listed in subparagraph (1), (2) or (3), if the closest practitioner listed in subparagraph (1), (2) or (3) who participates in the network plan of the insurer is located 60 miles or more from the residence of the insured; and

(c) The practitioner listed in paragraph (b) who prescribed the drug knows, based on the medical history of the insured, or reasonably expects each alternative drug that is required to be used earlier in the step therapy protocol to be ineffective at treating the psychiatric condition.

2. Any provision of a policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2023, which is in conflict with this section is void.

3. As used in this section:

(a) “Medical or scientific evidence” has the meaning ascribed to it in NRS 695G.053.

(b) “Network plan” means a policy of health insurance offered by an insurer under which the financing and delivery of medical care is provided, in whole or in part, through a defined set of providers under contract with the insurer. The term does not include an arrangement for the financing of premiums.

(c) “Step therapy protocol” means a procedure that requires an insured to use a prescription drug or sequence of prescription drugs other than a drug that a practitioner recommends for treatment of a psychiatric condition of the insured before his or her policy of health insurance provides coverage for the recommended drug.

(Added to NRS by 2023, 1782)

NRS 689A.04049 Coverage for screening, genetic counseling and testing related to BRCA gene required in certain circumstances.

1. An insurer that issues a policy of health insurance shall provide coverage for screening, genetic counseling and testing for harmful mutations in the BRCA gene for women under circumstances where such screening, genetic counseling or testing, as applicable, is required by NRS 457.301.

2. An insurer shall ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the insurer.

3. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2022, has the legal effect of including the coverage required by subsection 1, and any provision of the policy that conflicts with the provisions of this section is void.

4. As used in this section:

(a) “Network plan” means a policy of health insurance offered by an insurer 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 insurer. The term does not include an arrangement for the financing of premiums.

(b) “Provider of health care” has the meaning ascribed to it in NRS 629.031.

(Added to NRS by 2021, 780)

NRS 689A.0405 Coverage for certain screenings and tests for breast cancer required; prohibited acts.

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

(a) A mammogram to screen for breast cancer annually for insureds who are 40 years of age or older.

(b) An imaging test to screen for breast cancer on an interval and at the age deemed most appropriate, when medically necessary, as recommended by the insured’s provider of health care based on personal or family medical history or additional factors that may increase the risk of breast cancer for the insured.

(c) A diagnostic imaging test for breast cancer at the age deemed most appropriate, when medically necessary, as recommended by the insured’s provider of health care to evaluate an abnormality which is:

(1) Seen or suspected from a mammogram described in paragraph (a) or an imaging test described in paragraph (b); or

(2) Detected by other means of examination.

2. An insurer must ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the insurer.

3. Except as otherwise provided in subsection 5, an insurer that offers or issues a policy of health insurance shall not:

(a) Except as otherwise provided in subsection 6, require an insured to pay a deductible, copayment, coinsurance or any other form of cost-sharing or require a longer waiting period or other condition to obtain any benefit provided in the policy of health insurance pursuant to subsection 1;

(b) Refuse to issue a policy of health insurance or cancel a policy of health insurance solely because the person applying for or covered by the policy uses or may use any such benefit;

(c) Offer or pay any type of material inducement or financial incentive to an insured to discourage the insured from obtaining any such benefit;

(d) Penalize a provider of health care who provides any such benefit to an insured, including, without limitation, reducing the reimbursement of the provider of health care;

(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 access to any such benefit to an insured; or

(f) Impose any other restrictions or delays on the access of an insured to any such benefit.

4. A policy subject to the provisions of this chapter which is delivered, issued for delivery or renewed on or after January 1, 2024, 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.

5. Except as otherwise provided in this section and federal law, an insurer may use medical management techniques, including, without limitation, any available clinical evidence, to determine the frequency of or treatment relating to any benefit required by this section or the type of provider of health care to use for such treatment.

6. If the application of paragraph (a) of subsection 3 would result in the ineligibility of a health savings account of an insured pursuant to 26 U.S.C. § 223, the prohibitions of paragraph (a) of subsection 3 shall apply only for a qualified policy of health insurance with respect to the deductible of such a policy of health insurance after the insured has satisfied the minimum deductible pursuant to 26 U.S.C. § 223, except with respect to items or services that constitute preventive care pursuant to 26 U.S.C. § 223(c)(2)(C), in which case the prohibitions of paragraph (a) of subsection 3 shall apply regardless of whether the minimum deductible under 26 U.S.C. § 223 has been satisfied.

7. As used in this section:

(a) “Medical management technique” means a practice which is used to control the cost or utilization of health care services or prescription drug use. The term includes, without limitation, the use of step therapy, prior authorization or categorizing drugs and devices based on cost, type or method of administration.

(b) “Network plan” means a policy of health insurance offered by an insurer 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 insurer. The term does not include an arrangement for the financing of premiums.

(d) “Qualified policy of health insurance” means 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 1989, 1888; A 1997, 1729; 2017, 1809; 2023, 1343)

NRS 689A.041 Coverage relating to mastectomy required in policy covering mastectomies; prohibited acts.

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

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

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

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

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

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

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

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

Ê whichever is earlier.

5. A plan or issuer may not:

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

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

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

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

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

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

(Added to NRS by 1983, 614; A 1989, 1889; 2001, 2218)

NRS 689A.0412 Coverage for examination of person who is pregnant for certain diseases required.

1. An insurer that issues a policy of health insurance shall provide coverage for the examination of a person who is pregnant for the discovery of:

(a) Chlamydia trachomatis, gonorrhea, hepatitis B and hepatitis C in accordance with NRS 442.013.

(b) Syphilis in accordance with NRS 442.010.

2. The coverage required by this section must be provided:

(a) Regardless of whether the benefits are provided to the insured by a provider of health care, facility or medical laboratory that participates in the network plan of the insurer; and

(b) Without prior authorization.

3. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2021, has the legal effect of including the coverage required by subsection 1, and any provision of the policy that conflicts with the provisions of this section is void.

4. As used in this section:

(a) “Medical laboratory” has the meaning ascribed to it in NRS 652.060.

(Added to NRS by 2021, 2577)

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

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

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

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

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

(Added to NRS by 1999, 1943)

NRS 689A.0415 Coverage for hormone replacement therapy in certain circumstances required in policy covering prescription drugs or devices; prohibited acts; exception.

1. An insurer that offers or issues a policy of health insurance which provides coverage for prescription drugs or devices shall include in the policy coverage for any type of hormone replacement therapy which is lawfully prescribed or ordered and which has been approved by the Food and Drug Administration.

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

(a) Require an insured to pay a higher deductible, any copayment or coinsurance or require a longer waiting period or other condition for coverage for a prescription for hormone replacement therapy;

(b) Refuse to issue a policy of health insurance or cancel a policy of health insurance solely because the person applying for or covered by the policy uses or may use in the future hormone replacement therapy;

(c) Offer or pay any type of material inducement or financial incentive to an insured to discourage the insured from accessing hormone replacement therapy;

(d) Penalize a provider of health care who provides hormone replacement therapy 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 hormone replacement therapy to an insured.

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 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 require an insurer to provide coverage for fertility drugs.

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

(Added to NRS by 1999, 1995; A 2017, 1810, 3934)

NRS 689A.0417 Coverage for health care services related to hormone replacement therapy required in policy covering outpatient care; prohibited acts.

1. An insurer that offers or issues a policy of health insurance which provides coverage for outpatient care shall include in the policy coverage for any health care service related to hormone replacement therapy.

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

(a) Require an insured to pay a higher deductible, any copayment or coinsurance or require a longer waiting period or other condition for coverage for outpatient care related to hormone replacement therapy;

(c) Offer or pay any type of material inducement or financial incentive to an insured to discourage the insured from accessing hormone replacement therapy;

(d) Penalize a provider of health care who provides hormone replacement therapy 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 hormone replacement therapy to an insured.

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 subsection 1, and any provision of the policy or the renewal which is in conflict with this section is void.

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

(Added to NRS by 1999, 1996; A 2017, 1811, 3935)

NRS 689A.0418 Coverage for drug or device for contraception and related health services required; prohibited acts; exceptions.

1. Except as otherwise provided in subsection 8, an insurer that offers or issues a policy of health insurance shall include in the policy coverage for:

(a) Up to a 12-month supply, per prescription, of any type of drug for contraception or its therapeutic equivalent which is:

(1) Lawfully prescribed or ordered;

(2) Approved by the Food and Drug Administration;

(3) Listed in subsection 11; and

(4) Dispensed in accordance with NRS 639.28075;

(b) Any type of device for contraception which is:

(1) Lawfully prescribed or ordered;

(2) Approved by the Food and Drug Administration; and

(3) Listed in subsection 11;

(d) Insertion of a device for contraception or removal of such a device if the device was inserted while the insured was covered by the same policy of health insurance;

(e) Education and counseling relating to the initiation of the use of contraception and any necessary follow-up after initiating such use;

(f) Management of side effects relating to contraception; and

(g) Voluntary sterilization for women.

2. An insurer shall provide coverage for any services listed in subsection 1 which are within the authorized scope of practice of a pharmacist when such services are provided by a pharmacist who is employed by or serves as an independent contractor of an in-network pharmacy and in accordance with the applicable provider network contract. Such coverage must be provided to the same extent as if the services were provided by another provider of health care, as applicable to the services being provided. The terms of the policy must not limit:

(a) Coverage for services listed in subsection 1 and provided by such a pharmacist to a number of occasions less than the coverage for such services when provided by another provider of health care.

(b) Reimbursement for services listed in subsection 1 and provided by such a pharmacist to an amount less than the amount reimbursed for similar services provided by a physician, physician assistant or advanced practice registered nurse.

3. An insurer must ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the insurer.

4. If a covered therapeutic equivalent listed in subsection 1 is not available or a provider of health care deems a covered therapeutic equivalent to be medically inappropriate, an alternate therapeutic equivalent prescribed by a provider of health care must be covered by the insurer.

5. Except as otherwise provided in subsections 9, 10 and 12, an insurer that offers or issues a policy of health insurance shall not:

(a) Require an insured to pay a higher deductible, any copayment or coinsurance or require a longer waiting period or other condition for coverage to obtain any benefit included in the policy pursuant to subsection 1;

(b) Refuse to issue a policy of health insurance or cancel a policy of health insurance solely because the person applying for or covered by the policy uses or may use any such benefit;

(c) Offer or pay any type of material inducement or financial incentive to an insured to discourage the insured from obtaining any such benefit;

(d) Penalize a provider of health care who provides any such benefit to an insured, including, without limitation, reducing the reimbursement of the provider of health care;

(f) Impose any other restrictions or delays on the access of an insured any such benefit.

6. Coverage pursuant to this section for the covered dependent of an insured must be the same as for the insured.

7. Except as otherwise provided in subsection 8, a policy subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2024, 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.

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

9. An insurer may require an insured to pay a higher deductible, copayment or coinsurance for a drug for contraception if the insured refuses to accept a therapeutic equivalent of the drug.

10. For each of the 18 methods of contraception listed in subsection 11 that have been approved by the Food and Drug Administration, a policy of health insurance must include at least one drug or device for contraception within each method for which no deductible, copayment or coinsurance may be charged to the insured, but the insurer may charge a deductible, copayment or coinsurance for any other drug or device that provides the same method of contraception. If the insurer charges a copayment or coinsurance for a drug for contraception, the insurer may only require an insured to pay the copayment or coinsurance:

(a) Once for the entire amount of the drug dispensed for the plan year; or

(b) Once for each 1-month supply of the drug dispensed.

11. The following 18 methods of contraception must be covered pursuant to this section:

(a) Voluntary sterilization for women;

(b) Surgical sterilization implants for women;

(d) Copper-based intrauterine devices;

(e) Progesterone-based intrauterine devices;

(f) Injections;

(g) Combined estrogen- and progestin-based drugs;

(h) Progestin-based drugs;

(i) Extended- or continuous-regimen drugs;

(j) Estrogen- and progestin-based patches;

(k) Vaginal contraceptive rings;

(l) Diaphragms with spermicide;

(m) Sponges with spermicide;

(n) Cervical caps with spermicide;

(o) Female condoms;

(p) Spermicide;

(q) Combined estrogen- and progestin-based drugs for emergency contraception or progestin-based drugs for emergency contraception; and

(r) Ulipristal acetate for emergency contraception.

12. Except as otherwise provided in this section and federal law, an insurer may use medical management techniques, including, without limitation, any available clinical evidence, to determine the frequency of or treatment relating to any benefit required by this section or the type of provider of health care to use for such treatment.

13. An insurer shall not:

(a) Use medical management techniques to require an insured to use a method of contraception other than the method prescribed or ordered by a provider of health care;

(b) Require an insured to obtain prior authorization for the benefits described in paragraphs (a) and (c) of subsection 1; or

(c) Refuse to cover a contraceptive injection or the insertion of a device described in paragraph (c), (d) or (e) of subsection 11 at a hospital immediately after an insured gives birth.

14. An insurer must provide an accessible, transparent and expedited process which is not unduly burdensome by which an insured, or the authorized representative of the insured, may request an exception relating to any medical management technique used by the insurer to obtain any benefit required by this section without a higher deductible, copayment or coinsurance.

15. As used in this section:

(a) “In-network pharmacy” means a pharmacy that has entered into a contract with an insurer to provide services to insureds through a network plan offered or issued by the insurer.

(b) “Medical management technique” means a practice which is used to control the cost or utilization of health care services or prescription drug use. The term includes, without limitation, the use of step therapy, prior authorization or categorizing drugs and devices based on cost, type or method of administration.

(c) “Network plan” means a policy of health insurance offered by an insurer 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 insurer. The term does not include an arrangement for the financing of premiums.

(d) “Provider network contract” means a contract between an insurer and a provider of health care or pharmacy specifying the rights and responsibilities of the insurer and the provider of health care or pharmacy, as applicable, for delivery of health care services pursuant to a network plan.

(e) “Provider of health care” has the meaning ascribed to it in NRS 629.031.

(f) “Therapeutic equivalent” means a drug which:

(1) Contains an identical amount of the same active ingredients in the same dosage and method of administration as another drug;

(2) Is expected to have the same clinical effect when administered to a patient pursuant to a prescription or order as another drug; and

(3) Meets any other criteria required by the Food and Drug Administration for classification as a therapeutic equivalent.

(Added to NRS by 2017, 1805, 3932; A 2021, 3273; 2023, 914, 2112)

NRS 689A.0419 Coverage for certain services, screenings and tests relating to wellness required; prohibited acts.

1. An insurer that offers or issues a policy of health insurance shall include in the policy coverage for:

(a) Counseling, support and supplies for breastfeeding, including breastfeeding equipment, counseling and education during the antenatal, perinatal and postpartum period for not more than 1 year;

(b) Screening and counseling for interpersonal and domestic violence for women at least annually with intervention services consisting of education, strategies to reduce harm, supportive services or a referral for any other appropriate services;

(c) Behavioral counseling concerning sexually transmitted diseases from a provider of health care for sexually active women who are at increased risk for such diseases;

(d) Such prenatal screenings and tests as recommended by the American College of Obstetricians and Gynecologists or its successor organization;

(e) Screening for blood pressure abnormalities and diabetes, including gestational diabetes, after at least 24 weeks of gestation or as ordered by a provider of health care;

(f) Screening for cervical cancer at such intervals as are recommended by the American College of Obstetricians and Gynecologists or its successor organization;

(g) Screening for depression;

(h) Screening and counseling for the human immunodeficiency virus consisting of a risk assessment, annual education relating to prevention and at least one screening for the virus during the lifetime of the insured or as ordered by a provider of health care;

(i) Smoking cessation programs for an insured who is 18 years of age or older consisting of not more than two cessation attempts per year and four counseling sessions per year;

(j) All vaccinations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention of the United States Department of Health and Human Services or its successor organization; and

(k) Such well-woman preventative visits as recommended by the Health Resources and Services Administration, which must include at least one such visit per year beginning at 14 years of age.

2. An insurer must ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the insurer.

3. Except as otherwise provided in subsection 5, an insurer that offers or issues a policy of health insurance shall not:

(a) Require an insured to pay a higher deductible, any copayment or coinsurance or require a longer waiting period or other condition to obtain any benefit provided in the policy of health insurance pursuant to subsection 1;

(b) Refuse to issue a policy of health insurance or cancel a policy of health insurance solely because the person applying for or covered by the policy uses or may use any such benefit;

(c) Offer or pay any type of material inducement or financial incentive to an insured to discourage the insured from obtaining any such benefit;

(d) Penalize a provider of health care who provides any such benefit to an insured, including, without limitation, reducing the reimbursement of the provider of health care;

(f) Impose any other restrictions or delays on the access of an insured to any such benefit.

4. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2018, 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.

6. As used in this section:

(Added to NRS by 2017, 1807)

NRS 689A.042 Policy containing exclusion, reduction or limitation of coverage relating to complications of pregnancy prohibited; exception.

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

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

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

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

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

(Added to NRS by 1977, 415)

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

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

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

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

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

3. A policy subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2021, 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) “Enteral formula” includes, without limitation, a formula that is ingested orally.

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

(c) “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; A 2021, 3623)

NRS 689A.0424 Policy covering maternity care: Prohibited acts by insurer if insured is acting as gestational carrier; child deemed child of intended parent for purposes of policy.

1. An insurer that offers or issues a policy of health insurance that includes coverage for maternity care shall not deny, limit or seek reimbursement for maternity care because the insured is acting as a gestational carrier.

2. If an insured acts as a gestational carrier, the child shall be deemed to be a child of the intended parent, as defined in NRS 126.590, for purposes related to the policy of health insurance.

3. As used in this section, “gestational carrier” has the meaning ascribed to it in NRS 126.580.

(Added to NRS by 2019, 1005)

NRS 689A.0427 Coverage for management and treatment of diabetes required in policy covering hospital, medical or surgical expenses.

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

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

(a) Shall include in any disclosure of the coverage provided by the policy notice to each policyholder and subscriber under the policy of the availability of the benefits required by this section.

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

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

4. As used in this section:

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

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

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

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

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

(Added to NRS by 1997, 742; A 2017, 2361)

1. An insurer that issues a policy of health insurance shall include in the policy coverage for:

(a) Necessary case management services for an insured diagnosed with sickle cell disease and its variants; and

(b) Medically necessary care for an insured who has been diagnosed with sickle cell disease and its variants.

2. An insurer that issues a policy of health insurance which provides coverage for prescription drugs shall include in the policy coverage for medically necessary prescription drugs to treat sickle cell disease and its variants.

3. An insurer may use medical management techniques, including, without limitation, any available clinical evidence, to determine the frequency of or treatment relating to any benefit required by this section or the type of provider of health care to use for such treatment.

4. As used in this section:

(a) “Case management services” means medical or other health care management services to assist patients and providers of health care, including, without limitation, identifying and facilitating additional resources and treatments, providing information about treatment options and facilitating communication between providers of services to a patient.

(b) “Medical management technique” means a practice which is used to control the cost or utilization of health care services. The term includes, without limitation, the use of step therapy, prior authorization or categorizing drugs and devices based on cost, type or method of administration.

(d) “Sickle cell disease and its variants” has the meaning ascribed to it in NRS 439.4927.

(Added to NRS by 2019, 2169)

NRS 689A.043 Policy covering family on expense-incurred basis required to include certain coverage for insured’s newly born and adopted children and children placed with insured for adoption.

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

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

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

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

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

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

(a) The birth of a newly born child;

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

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

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

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

1. Except as otherwise provided in this section, an insurer that issues a policy of health insurance shall include in the policy coverage for the medically necessary treatment of conditions relating to gender dysphoria and gender incongruence. Such coverage must include coverage of medically necessary psychosocial and surgical intervention and any other medically necessary treatment for such disorders provided by:

(a) Endocrinologists;

(b) Pediatric endocrinologists;

(d) Psychiatrists;

(e) Psychologists;

(f) Gynecologists;

(g) Speech-language pathologists;

(h) Primary care physicians;

(i) Advanced practice registered nurses;

(j) Physician assistants; and

(k) Any other providers of medically necessary services for the treatment of gender dysphoria or gender incongruence.

2. This section does not require a policy of health insurance to include coverage for cosmetic surgery performed by a plastic surgeon or reconstructive surgeon that is not medically necessary.

3. An insurer that issues a policy of health insurance shall not categorically refuse to cover medically necessary gender-affirming treatments or procedures or revisions to prior treatments if the policy provides coverage for any such services, procedures or revisions for purposes other than gender transition or affirmation.

4. An insurer that issues a policy of health insurance may prescribe requirements that must be satisfied before the insurer covers surgical treatment of conditions relating to gender dysphoria or gender incongruence for an insured who is less than 18 years of age. Such requirements may include, without limitation, requirements that:

(a) The treatment must be recommended by a psychologist, psychiatrist or other mental health professional;

(b) The treatment must be recommended by a physician;

(d) A written plan for treatment that covers at least 1 year must be developed and approved by at least two providers of health care; and

(e) Parental consent is provided for the insured unless the insured is expressly authorized by law to consent on his or her own behalf.

5. When determining whether treatment is medically necessary for the purposes of this section, an insurer must consider the most recent Standards of Care published by the World Professional Association for Transgender Health, or its successor organization.

6. An insurer shall make a reasonable effort to ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the insurer. If, after a reasonable effort, the insurer is unable to make such benefits available through such a provider of health care, the insurer may treat the treatment that the insurer is unable to make available through such a provider of health care in the same manner as other services provided by a provider of health care who does not participate in the network plan of the insurer.

7. If an insured appeals the denial of a claim or coverage under this section on the grounds that the treatment requested by the insured is not medically necessary, the insurer must consult with a provider of health care who has experience in prescribing or delivering gender-affirming treatment concerning the medical necessity of the treatment requested by the insured when considering the appeal.

8. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2023, 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.

9. As used in this section:

(a) “Cosmetic surgery”:

(1) Means a surgical procedure that:

(I) Does not meaningfully promote the proper function of the body;

(II) Does not prevent or treat illness or disease; and

(III) Is primarily directed at improving the appearance of a person.

(2) Includes, without limitation, cosmetic surgery directed at preserving beauty.

(b) “Gender dysphoria” means distress or impairment in social, occupational or other areas of functioning caused by a marked difference between the gender identity or expression of a person and the sex assigned to the person at birth which lasts at least 6 months and is shown by at least two of the following:

(1) A marked difference between gender identity or expression and primary or secondary sex characteristics or anticipated secondary sex characteristics in young adolescents.

(2) A strong desire to be rid of primary or secondary sex characteristics because of a marked difference between such sex characteristics and gender identity or expression or a desire to prevent the development of anticipated secondary sex characteristics in young adolescents.

(3) A strong desire for the primary or secondary sex characteristics of the gender opposite from the sex assigned at birth.

(4) A strong desire to be of the opposite gender or a gender different from the sex assigned at birth.

(5) A strong desire to be treated as the opposite gender or a gender different from the sex assigned at birth.

(6) A strong conviction of experiencing typical feelings and reactions of the opposite gender or a gender different from the sex assigned at birth.

(c) “Medically necessary” means health care services or products that a prudent provider of health care would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that are necessary and:

(1) Provided in accordance with generally accepted standards of medical practice;

(2) Clinically appropriate with regard to type, frequency, extent, location and duration;

(3) Not provided primarily for the convenience of the patient or provider of health care;

(4) Required to improve a specific health condition of a patient or to preserve the existing state of health of the patient; and

(5) The most clinically appropriate level of health care that may be safely provided to the patient.

Ê A provider of health care prescribing, ordering, recommending or approving a health care service or product does not, by itself, make that health care service or product medically necessary.

(d) “Network plan” means a policy of health insurance offered by an insurer 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 insurer. The term does not include an arrangement for the financing of premiums.

(e) “Provider of health care” has the meaning ascribed to it in NRS 629.031.

(Added to NRS by 2023, 2027)

NRS 689A.0435 Option of coverage for autism spectrum disorders for certain persons required; prohibited acts.

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

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

(a) A maximum benefit of not less than the actuarial equivalent of $72,000 per year for applied behavior analysis treatment; and

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

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

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

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

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

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

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

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

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

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

7. As used in this section:

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

(b) “Autism spectrum disorder” has the meaning ascribed to it in NRS 427A.875.

(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 registered behavior technician.

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

(e) “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.

(f) “Licensed assistant behavior analyst” has the meaning ascribed to the term “assistant behavior analyst” in NRS 641D.020.

(g) “Licensed behavior analyst” has the meaning ascribed to the term “behavior analyst” in NRS 641D.030.

(h) “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.

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

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

(k) “Registered behavior technician” has the meaning ascribed to it in NRS 641D.100.

(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-language pathologists, occupational therapists and physical therapists.

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

(Added to NRS by 2009, 1465; A 2015, 677, 679; 2017, 1496, 4252; 2019, 2557; 2021, 1647)

1. An insurer that offers or issues a policy of health insurance shall include in the policy coverage for:

(a) All drugs approved by the United States Food and Drug Administration for preventing the acquisition of human immunodeficiency virus or treating human immunodeficiency virus or hepatitis C in the form recommended by the prescribing practitioner, regardless of whether the drug is included in the formulary of the insurer;

(b) Laboratory testing that is necessary for therapy that uses a drug to prevent the acquisition of human immunodeficiency virus;

(c) Any service to test for, prevent or treat human immunodeficiency virus or hepatitis C provided by a provider of primary care if the service is covered when provided by a specialist and:

(1) The service is within the scope of practice of the provider of primary care; or

(2) The provider of primary care is capable of providing the service safely and effectively in consultation with a specialist and the provider engages in such consultation; and

(d) The services described in NRS 639.28085, when provided by a pharmacist who participates in the network plan of the insurer.

2. An insurer that offers or issues a policy of health insurance shall reimburse:

(a) A pharmacist who participates in the network plan of the insurer for the services described in NRS 639.28085 at a rate equal to the rate of reimbursement provided to a physician, physician assistant or advanced practice registered nurse for similar services.

(b) An advanced practice registered nurse or a physician assistant who participates in the network plan of the insurer for any service to test for, prevent or treat human immunodeficiency virus or hepatitis C at a rate equal to the rate of reimbursement provided to a physician for similar services.

3. An insurer shall not:

(a) Subject the benefits required by subsection 1 to medical management techniques, other than step therapy;

(b) Limit the covered amount of a drug described in paragraph (a) of subsection 1;

(c) Refuse to cover a drug described in paragraph (a) of subsection 1 because the drug is dispensed by a pharmacy through mail order service; or

(d) Prohibit or restrict access to any service or drug to treat human immunodeficiency virus or hepatitis C on the same day on which the insured is diagnosed.

4. An insurer shall ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the insurer.

5. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2024, has the legal effect of including the coverage required by subsection 1, and any provision of the policy that conflicts with the provisions of this section is void.

6. As used in this section:

(a) “Medical management technique” means a practice which is used to control the cost or use of health care services or prescription drugs. The term includes, without limitation, the use of step therapy, prior authorization and categorizing drugs and devices based on cost, type or method of administration.

(c) “Primary care” means the practice of family medicine, pediatrics, internal medicine, obstetrics and gynecology and midwifery.

(d) “Provider of health care” has the meaning ascribed to it in NRS 629.031.

(Added to NRS by 2021, 3206; A 2023, 3511)

NRS 689A.0438 Coverage for testing, treatment and prevention of sexually transmitted diseases required; coverage for condoms for certain insureds required.

1. An insurer that offers or issues a policy of health insurance shall include in the policy:

(a) Coverage of testing for and the treatment and prevention of sexually transmitted diseases, including, without limitation, Chlamydia trachomatis, gonorrhea, syphilis, human immunodeficiency virus and hepatitis B and C, for all insureds, regardless of age. Such coverage must include, without limitation, the coverage required by NRS 689A.0412 and 689A.0437.

(b) Unrestricted coverage of condoms for insureds who are 13 years of age or older.

2. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2024, has the legal effect of including the coverage required by subsection 1, and any provision of the policy that conflicts with the provisions of this section is void.

(Added to NRS by 2023, 3509)

NRS 689A.044 Coverage for certain tests and vaccines relating to human papillomavirus required; prohibited acts.

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

(a) Deoxyribonucleic acid testing for high-risk strains of human papillomavirus every 3 years for women 30 years of age or older; and

(b) 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. An insurer must ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the insurer.

3. Except as otherwise provided in subsection 5, an insurer that offers or issues a policy of health insurance shall not:

(b) Refuse to issue a policy of health insurance or cancel a policy of health insurance solely because the person applying for or covered by the policy uses or may use any such benefit;

(c) Offer or pay any type of material inducement or financial incentive to an insured to discourage the insured from obtaining any such benefit;

(d) Penalize a provider of health care who provides any such benefit to an insured, including, without limitation, reducing the reimbursement of the provider of health care;

(f) Impose any other restrictions or delays on the access of an insured to any such benefit.

4. A policy subject to the provisions of this chapter which is delivered, issued for delivery or renewed on or after January 1, 2018, 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.

6. As used in this section:

(a) “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.

(d) “Provider of health care” has the meaning ascribed to it in NRS 629.031.

(Added to NRS by 2007, 3236; A 2013, 3610; 2017, 1812)

NRS 689A.0445 Coverage for prostate cancer screening.

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

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

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

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

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

(Added to NRS by 2007, 3236)

1. Subject to the limitations prescribed by subsection 4, an insurer that issues a policy of health insurance shall include in the policy coverage for medically necessary biomarker testing for the diagnosis, treatment, appropriate management and ongoing monitoring of cancer when such biomarker testing is supported by medical and scientific evidence. Such evidence includes, without limitation:

(a) The labeled indications for a biomarker test or medication that has been approved or cleared by the United States Food and Drug Administration;

(b) The indicated tests for a drug that has been approved by the United States Food and Drug Administration or the warnings and precautions included on the label of such a drug;

(c) A national coverage determination or local coverage determination, as those terms are defined in 42 C.F.R. § 400.202; or

(d) Nationally recognized clinical practice guidelines or consensus statements.

2. An insurer shall:

(a) Provide the coverage required by subsection 1 in a manner that limits disruptions in care and the need for multiple specimens.

(b) Establish a clear and readily accessible process for an insured or provider of health care to:

(1) Request an exception to a policy excluding coverage for biomarker testing for the diagnosis, treatment, management or ongoing monitoring of cancer; or

(2) Appeal a denial of coverage for such biomarker testing; and

3. If an insurer requires an insured to obtain prior authorization for a biomarker test described in subsection 1, the insurer shall respond to a request for such prior authorization:

(a) Within 24 hours after receiving an urgent request; or

(b) Within 72 hours after receiving any other request.

4. The provisions of this section do not require an insurer to provide coverage of biomarker testing:

(a) For screening purposes;

(b) Conducted by a provider of health care for whom the biomarker testing is not within his or her scope of practice, training and experience;

(c) Conducted by a provider of health care or a facility that does not participate in the network plan of the insurer; or

(d) That has not been determined to be medically necessary by a provider of health care for whom such a determination is within his or her scope of practice, training and experience.

5. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 2023, has the legal effect of including the coverage required by this section, and any provision of the policy or renewal which is in conflict with the provisions of this section is void.

6. As used in this section:

(a) “Biomarker” means a characteristic that is objectively measured and evaluated as an indicator of a normal biological process, a pathogenic process or a pharmacological response to a specific therapeutic intervention and includes, without limitation:

(1) An interaction between a gene and a drug that is being used by or considered for use by the patient;

(2) A mutation or characteristic of a gene; and

(3) The expression of a protein.

(b) “Biomarker testing” means the analysis of the tissue, blood or other biospecimen of a patient for the presentation of a biomarker and includes, without limitation, single-analyte tests, multiplex panel tests and whole genome, whole exome and whole transcriptome sequencing.

(1) Made for the purpose of optimizing the outcomes of clinical care;

(2) Made by an independent, multidisciplinary panel of experts that has established a policy to avoid conflicts of interest;

(3) Based on scientific evidence; and

(4) Made using a transparent methodology and reporting procedure.

(d) “Medically necessary” means health care services or products that a prudent provider of health care would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that are necessary and:

(1) Provided in accordance with generally accepted standards of medical practice;

(2) Not primarily provided for the convenience of the patient or provider of health care; and

(3) Significant in guiding and informing the provider of health care in providing the most appropriate course of treatment for the patient in order to prevent, delay or lessen the magnitude of an adverse health outcome.

(e) “Nationally recognized clinical practice guidelines” means evidence-based guidelines establishing standards of care that include, without limitation, recommendations intended to optimize care of patients and are:

(1) Informed by a systemic review of evidence and an assessment of the risks and benefits of alternative options for care; and

(2) Developed using a transparent methodology and reporting procedure by an independent organization or society of medical professionals that has established a policy to avoid conflicts of interest.

(f) “Network plan” means a policy of health insurance offered by an insurer 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 insurer. The term does not include an arrangement for the financing of premiums.

(g) “Provider of health care” has the meaning ascribed to it in NRS 629.031.

(Added to NRS by 2023, 2212)

NRS 689A.0447 Policy covering treatment of cancer through use of chemotherapy: Prohibited acts related to orally administered chemotherapy.

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

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

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

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

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

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

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

NRS 689A.0455 Coverage for treatment of conditions relating to severe mental illness required.

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

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

(a) Schizophrenia.

(b) Schizoaffective disorder.

(d) Major depressive disorders.

(e) Panic disorder.

(f) Obsessive-compulsive disorder.

(Added to NRS by 1999, 3100; A 2013, 3610)

1. An insurer that offers or issues a policy of health insurance shall include in the policy coverage for:

(a) All drugs approved by the United States Food and Drug Administration to support safe withdrawal from substance use disorder, including, without limitation, lofexidine.

(b) All drugs approved by the United States Food and Drug Administration to provide medication-assisted treatment for opioid use disorder, including, without limitation, buprenorphine, methadone and naltrexone.

(c) The services described in NRS 639.28079 when provided by a pharmacist or pharmacy that participates in the network plan of the insurer. The Commissioner shall adopt regulations governing the provision of reimbursement for such services.

(d) Any service for the treatment of substance use disorder provided by a provider of primary care if the service is covered when provided by a specialist and:

(1) The service is within the scope of practice of the provider of primary care; or

(2) The provider of primary care is capable of providing the service safely and effectively in consultation with a specialist and the provider engages in such consultation.

2. An insurer that offers or issues a policy of health insurance shall reimburse a pharmacist or pharmacy that participates in the network plan of the insurer for the services described in NRS 639.28079 at a rate equal to the rate of reimbursement provided to a physician, physician assistant or advanced practice registered nurse for similar services.

3. An insurer shall provide the coverage required by paragraphs (a) and (b) of subsection 1 regardless of whether the drug is included in the formulary of the insurer.

4. Except as otherwise provided in this subsection, an insurer shall not subject the benefits required by paragraphs (a), (b) and (c) of subsection 1 to medical management techniques, other than step therapy. An insurer may subject the benefits required by paragraphs (b) and (c) of subsection 1 to other reasonable medical management techniques when the benefits are provided by a pharmacist in accordance with NRS 639.28079.

5. An insurer shall not:

(a) Limit the covered amount of a drug described in paragraph (a) or (b) of subsection 1; or

(b) Refuse to cover a drug described in paragraph (a) or (b) of subsection 1 because the drug is dispensed by a pharmacy through mail order service.

6. An insurer shall ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the insurer.

7. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2024, has the legal effect of including the coverage required by subsection 1, and any provision of the policy that conflicts with the provisions of this section is void.

8. As used in this section:

(c) “Primary care” means the practice of family medicine, pediatrics, internal medicine, obstetrics and gynecology and midwifery.

(d) “Provider of health care” has the meaning ascribed to it in NRS 629.031.

(Added to NRS by 2023, 2370, 3508)

NRS 689A.046 Benefits for treatment of alcohol or substance use disorder required.

1. In addition to the benefits required by NRS 689A.0459, the benefits provided by a policy for health insurance for treatment of alcohol or substance use disorder must include, without limitation:

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

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

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

2. Except as otherwise provided in NRS 687B.409, these benefits must be paid in the same manner as benefits for any other illness covered by a similar policy are paid.

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

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

(b) Hospital or other medical facility or facility for the dependent which is licensed by the Division of Public and Behavioral Health of the Department of Health and Human Services, accredited by The Joint Commission or CARF International and provides a program for the treatment of alcohol or substance use disorder as part of its accredited activities.

(Added to NRS by 1979, 1176; A 1983, 2036; 1985, 1569, 1773; 1993, 1918; 1997, 1301; 1999, 1888; 2001, 438; 2017, 2209; 2023, 2372, 3512)

1. A policy of health insurance must include coverage for services provided to an insured through telehealth to the same extent as though provided in person or by other means.

2. A policy of health insurance must provide reimbursement for services described in subsection 1 in the same amount as though provided in person or by other means:

(a) If the services:

(1) Are received at an originating site described in 42 U.S.C. § 1395m(m)(4)(C) or furnished by a federally-qualified health center or a rural health clinic; and

(2) Except for services described in paragraph (b), are not provided through audio-only interaction; or

(b) For counseling or treatment relating to a mental health condition or a substance use disorder, including, without limitation, when such counseling or treatment is provided through audio-only interaction.

3. An insurer shall not:

(a) Require an insured to establish a relationship in person with a provider of health care or provide any additional consent to or reason for obtaining services through telehealth as a condition to providing the coverage described in subsection 1 or the reimbursement described in subsection 2;

(b) Require a provider of health care to demonstrate that it is necessary to provide services to an insured through telehealth or receive any additional type of certification or license to provide services through telehealth as a condition to providing the coverage described in subsection 1 or the reimbursement described in subsection 2;

(1) The distant site from which a provider of health care provides services through telehealth or the originating site at which an insured receives services through telehealth; or

(2) The technology used to provide the services;

(d) Require covered services to be provided through telehealth as a condition to providing coverage for such services; or

(e) Categorize a service provided through telehealth differently for purposes relating to coverage or reimbursement than if the service had been provided in person or through other means.

4. A policy of health insurance must not require an insured to obtain prior authorization for any service provided through telehealth that is not required for the service when provided in person. A policy of health insurance may require prior authorization for a service provided through telehealth if such prior authorization would be required if the service were provided in person or by other means.

5. The provisions of this section do not require an insurer to:

(a) Ensure that covered services are available to an insured through telehealth at a particular originating site;

(b) Provide coverage for a service that is not a covered service or that is not provided by a covered provider of health care; or

(c) Enter into a contract with any provider of health care or cover any service if the insurer is not otherwise required by law to do so.

6. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2023, 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.

7. As used in this section:

(a) “Distant site” has the meaning ascribed to it in NRS 629.515.

(b) “Federally-qualified health center” has the meaning ascribed to it in 42 U.S.C. § 1396d(l)(2)(B).

(d) “Provider of health care” has the meaning ascribed to it in NRS 439.820.

(e) “Rural health clinic” has the meaning ascribed to it in 42 U.S.C. § 1395x(aa)(2).

(f) “Telehealth” has the meaning ascribed to it in NRS 629.515.

(Added to NRS by 2015, 637; A 2021, 3016, 3017, 3018, 3019; 2023, 225, 237)

NRS 689A.0464 Policy covering anatomical gifts, organ transplants or treatments or services related to organ transplants: Prohibited acts by insurer if insured is person with disability.

1. An insurer that offers or issues a policy of health insurance that includes coverage for anatomical gifts, organ transplants or treatments or services related to an organ transplant shall not:

(a) Deny, limit or seek reimbursement from an insured for care related to an organ transplant because the insured is a person with a disability;

(b) Deny a person with a disability eligibility or continued eligibility to enroll or renew coverage to avoid providing coverage in accordance with this section;

(c) Reduce or limit the reimbursement of or otherwise penalize a provider of medical or related services because the provider of medical or related services acted in accordance with NRS 460.160; or

(d) Provide monetary or nonmonetary incentives for a provider of medical or related services to induce the provider of medical or related services to provide care to an insured in a manner inconsistent with NRS 460.160.

2. As used in this section:

(a) “Anatomical gift” has the meaning ascribed to it in NRS 451.513.

(b) “Disability” has the meaning ascribed to it in 42 U.S.C. § 12102(1).

(Added to NRS by 2021, 1170)

NRS 689A.0465 Policy prohibited from excluding coverage of treatment of temporomandibular joint; exception.

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

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

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

(b) Treatment which is medically necessary.

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

(Added to NRS by 1989, 2137)

REIMBURSEMENT FOR CERTAIN MEDICALLY RELATED TREATMENT AND SERVICES

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

(Added to NRS by 1991, 1133)

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

(Added to NRS by 1979, 367; A 1989, 1553; 2017, 935)

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

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

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

(Added to NRS by 1987, 1123; A 2021, 3507)

NRS 689A.0487 Treatment by licensed podiatrist.

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

2. The terms of the policy must not limit:

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

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

(Added to NRS by 2007, 1046)

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

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

2. The terms of the policy must not limit:

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

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

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

NRS 689A.0493 Treatment by licensed clinical alcohol and drug counselor. If any policy of health insurance provides coverage for treatment of an illness which is within the authorized scope of practice of a licensed clinical alcohol and drug counselor, the insured is entitled to reimbursement for treatment by a clinical alcohol and drug counselor who is licensed pursuant to chapter 641C of NRS unless the clinical alcohol and drug counselor must be directly reimbursed pursuant to:

1. An assignment of benefits described in NRS 687B.409; or

2. Any other applicable assignment of benefits.

(Added to NRS by 2007, 3093; A 2017, 2210)

NRS 689A.0495 Services provided by certain registered nurses.

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

2. The terms of the policy must not limit:

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

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

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

(Added to NRS by 1985, 1446)

NRS 689A.0497 Provider of medical transportation.

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

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

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

(Added to NRS by 1989, 1273)

MISCELLANEOUS PROVISIONS

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

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

(Added to NRS by 1971, 1753)

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

Time Limit on Certain Defenses:

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

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

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

(Added to NRS by 1971, 1753)

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

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

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

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

(Added to NRS by 1971, 1754)

NRS 689A.075 Cancellation and rescission of short-term limited duration medical plan.

1. A short-term limited duration medical plan shall not be cancelled by the carrier during the coverage period except for the following:

(a) Nonpayment of premium;

(b) Violation of published policies of the carrier approved by the Commissioner;

(c) Failure of a member to pay any deductible or copayment amount owed to the carrier and not the provider of health care services;

(d) Members committing fraudulent acts as to the carrier;

(e) A member’s material breach of the medical plan; or

(f) Change or implementation of federal or state laws that no longer permit the continued offering of such coverage.

2. Except as otherwise provided in subsections 3 and 4, a short-term limited duration medical plan must not be rescinded by the carrier during the coverage period except for nonpayment of premium.

3. Except as provided in subsection 4 of this section, no oral or written misrepresentation or warranty made by the person applying for coverage or on his or her behalf in the process of applying for a short-term limited duration medical plan shall be deemed material or allow the carrier to rescind the medical plan, unless the misrepresentation or warranty is made to deceive.

4. In any application for a short-term limited duration medical plan made in writing by a person, all statements in the application by the person shall, in the absence of fraud, be deemed representations and not warranties. The falsity of any such statement shall not bar the right to recovery under the contract unless such false statement was made with actual intent to deceive or unless it materially affected either the acceptance of the risk or the hazard assumed by the carrier.

5. When cancellation or rescission is for nonpayment of premium, the carrier must notify the member in writing 10 days prior to the cancellation or rescission that his or her short-term limited duration medical plan will be cancelled, unless payment is made prior to the cancellation date. When cancellation is for any other reason allowed under subsection 1, the carrier must notify the member in writing 20 days prior to the cancellation date. The notice must specifically state the reason or reasons for the cancellation. The written communications required by this subsection must be phrased in simple language that is readily understood.

(Added to NRS by 2019, 1429)

NRS 689A.080 Reinstatement.

1. There shall be a provision as follows:

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

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

(a) Until at least age 50; or

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

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

(Added to NRS by 1971, 1754)

NRS 689A.090 Notice of claim.

1. There shall be a provision as follows:

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

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

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

(Added to NRS by 1971, 1755)

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

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

(Added to NRS by 1971, 1756)

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

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

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

(Added to NRS by 1975, 897; A 2021, 1648)

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

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

(Added to NRS by 1971, 1756)

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

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

(Added to NRS by 1971, 1756)

NRS 689A.130 Payment of claims.

1. There shall be a provision as follows:

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

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

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

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

(Added to NRS by 1971, 1756)

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

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

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

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

(Added to NRS by 1983, 879)

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

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

(Added to NRS by 1971, 1757)

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

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

(Added to NRS by 1971, 1757)

NRS 689A.160 Change of beneficiary.

1. There shall be a provision as follows:

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

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

(Added to NRS by 1971, 1757)

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

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

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

(Added to NRS by 1971, 1758)

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

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

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

(Added to NRS by 1971, 1758)

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

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

(Added to NRS by 1971, 1758)

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

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

(Added to NRS by 1971, 1759)

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

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

Or, in lieu thereof:

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

(Added to NRS by 1971, 1759)

NRS 689A.230 Coordination of benefits: All coverages.

1. There may be a provision as follows:

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

For the purposes of this provision:

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

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

or, in lieu thereof:

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

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

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

(a) Other valid coverage with other insurers; and

(b) Other valid coverage with the same insurer.

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

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

(Added to NRS by 1971, 1760; A 2013, 3612)

NRS 689A.240 Relation of earnings to insurance.

1. There may be a provision as follows:

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

For purposes of this provision:

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

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

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

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

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

(Added to NRS by 1971, 1761)

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

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

(Added to NRS by 1971, 1763)

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

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

(Added to NRS by 1971, 1763)

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

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

(Added to NRS by 1971, 1763)

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

(Added to NRS by 1971, 1764)

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

(Added to NRS by 1971, 1764)

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

(Added to NRS by 1971, 1764)

NRS 689A.320 Requirements of other jurisdictions.

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

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

(Added to NRS by 1971, 1764)

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

(Added to NRS by 1971, 1765; A 1985, 1447; 1989, 1273; 1997, 743; 1999, 760, 1997; 2003, 1334, 3355, 3522; 2007, 3237; 2009, 1467; 2013, 1998; 2015, 206, 638, 2124; 2017, 1813, 3936; 2019, 299, 1005, 2169; 2021, 781, 824, 1171, 2578, 2661, 3207; 2023, 809, 1782, 2029, 2213, 2372, 3512)

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

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

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

(Added to NRS by 1971, 1765)

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

(Added to NRS by 1971, 1765)

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

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

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

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

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

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

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

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

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

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

(1) An explanation of:

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

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

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

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

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

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

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

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

(c) During each period for open enrollment, publish on an Internet website that is operated by the insurer and accessible to the public or include in any enrollment materials distributed by the insurer a notice of all prescription drugs that:

(1) Are included on the most recent list of drugs that are essential for treating diabetes in this State compiled by the Department of Health and Human Services pursuant to paragraph (a) of subsection 1 of NRS 439B.630; and

(2) Have been removed or will be removed from the formulary during the current plan year or the next plan year.

(d) Update the notice required by paragraph (c) throughout the period for open enrollment.

(Added to NRS by 2001, 856; A 2017, 4308; 2019, 1466; 2021, 3731)

1. Except as otherwise provided in subsection 2 and NRS 439B.754, an insurer shall approve or deny a claim relating to a policy of health insurance within 30 days after the insurer receives the claim. If the claim is approved, the insurer shall pay the claim within 30 days after it is approved. Except as otherwise provided in this section, if the approved claim is not paid within that period, the insurer shall pay interest on the claim at a rate of interest equal to the prime rate at the largest bank in Nevada, as ascertained by the Commissioner of Financial Institutions, on January 1 or July 1, as the case may be, immediately preceding the date on which the payment was due, plus 6 percent. The interest must be calculated from 30 days after the date on which the claim is approved until the date on which the claim is paid.

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

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

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

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

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

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

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

(Added to NRS by 1991, 1328; A 1999, 1647; 2001, 2729; 2003, 3355; 2019, 329)

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

(Added to NRS by 1997, 1095)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(c) Determine the rates or any other aspect of the coverage or benefits for health care provided to an insured person based on whether the insured person or any member of the family of the insured person has taken a genetic test.

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

3. As used in this section:

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

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

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

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

(Added to NRS by 1997, 1459; A 2019, 299)

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

(Added to NRS by 2005, 2136)

ELIGIBILITY FOR COVERAGE

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

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

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

(Added to NRS by 1995, 2427)

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

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

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

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

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

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

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

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

(a) Eligible for medical assistance under Medicaid; and

(b) Covered by a policy of health insurance,

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

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

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

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

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

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

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

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

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

5. As used in this section, “insurer” includes, without limitation, a 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. § 1167(1), service benefit plan or other organization that has issued a policy of health insurance or any other party described in section 1902(a)(25)(A), (G) or (I) of the Social Security Act, 42 U.S.C. § 1396a(a)(25)(A), (G) or (I), as being legally responsible for payment of a claim for a health care item or service.

(Added to NRS by 1995, 2427; A 2007, 2402; 2015, 283)

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

1. Was born out of wedlock;

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

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

(Added to NRS by 1995, 2427)

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

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

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

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

(Added to NRS by 1995, 2428)

NRS 689A.460 Insurer required to authorize enrollment of child of parent who is required by order to provide medical coverage under certain circumstances; termination of coverage of child. If a parent is required by an order for medical coverage to provide coverage under a policy of health insurance for a child and the parent is eligible for coverage of members of the family of the parent under a policy of health insurance, the insurer that issued the policy:

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

2. Shall, if:

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

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

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

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

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

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

(Added to NRS by 1995, 2428)

PORTABILITY AND ACCOUNTABILITY

General Provisions

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

(Added to NRS by 1997, 2883; A 2001, 1922; 2005, 2136; 2013, 3613; 2017, 2362)

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

(Added to NRS by 1997, 2883)

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

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

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

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

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

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

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

(Added to NRS by 1997, 2883)

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

(Added to NRS by 1997, 2884)

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

(Added to NRS by 1997, 2884)

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

1. A group health plan;

2. A health benefit plan;

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

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

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

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

7. A state health benefit risk pool;

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

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

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

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

12. A short-term health insurance policy; or

13. A blanket student accident and health insurance policy.

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

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

(Added to NRS by 1997, 2884)

NRS 689A.525 “Geographic rating area” defined. “Geographic rating area” means an area established by the Commissioner for use in adjusting the rates for a health benefit plan.

(Added to NRS by 1997, 2885; A 2013, 3613)

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

(Added to NRS by 1997, 2885; A 2013, 3613)

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

(Added to NRS by 1997, 2885)

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

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

2. The term does not include:

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

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

(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

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

(Added to NRS by 1997, 2885)

NRS 689A.540 “Health benefit plan” defined. “Health benefit plan” has the meaning ascribed to it in NRS 687B.470.

(Added to NRS by 1997, 2886; A 1999, 2803; 2019, 1107, 1430)

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

(Added to NRS by 1997, 2887)

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

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

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

(Added to NRS by 1997, 2887)

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

(Added to NRS by 1997, 2888)

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

(Added to NRS by 1997, 2888)

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

(Added to NRS by 1997, 2888)

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

(Added to NRS by 1997, 2888)

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

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

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

(Added to NRS by 1997, 2889; A 2017, 2362)

Individual Carriers

NRS 689A.630 Requirement to renew coverage at option of individual; exceptions; discontinuation of product; discontinuation of health benefit plan available through bona fide association.

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

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

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

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

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

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

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

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

2. An individual carrier may discontinue a product pursuant to this subsection only if:

(a) The individual carrier notifies the Commissioner of its decision pursuant to this subsection to discontinue the product at least 60 days before the individual carrier notifies the persons covered by the discontinued product pursuant to paragraph (b).

(b) The individual carrier notifies each person covered by the discontinued product of the decision of the individual carrier to discontinue offering the product. The notice must be made to persons covered by the discontinued product at least 90 days before the date on which the individual carrier will discontinue offering the product.

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

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

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

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

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

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

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

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

(Added to NRS by 1997, 2890; A 2013, 3614; 2017, 2362)

NRS 689A.635 Coverage offered through network plan not required to be offered to person who does not reside or work in geographic service area or geographic rating area.

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

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

(Added to NRS by 1997, 2892; A 2013, 3615)

NRS 689A.637 Coverage offered through plan that provides for restricted network: Contracts with certain federally qualified health centers.

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

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

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

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

(b) Agrees to reasonable reimbursement rates that are generally consistent with those offered by the carrier to similarly situated providers of health care with which the carrier contracts.

2. As used in this section, “health center” has the meaning ascribed to it in 42 U.S.C. § 254b.

(Added to NRS by 2001, 1922; A 2013, 3615)

NRS 689A.696 Information and documents required to be made available to Commissioner; proprietary information.

1. An individual carrier shall make the unified rate review template and rate filing documentation used by the individual carrier and any information and documents described in any regulations adopted pursuant to NRS 689A.700 available to the Commissioner upon request. Except in cases of violations of the provisions of this chapter, the unified rate review template and rate filing documentation used by an individual carrier are considered proprietary, constitute a trade secret and are not subject to disclosure by the Commissioner to persons outside of the Division except as agreed to by the individual carrier or as ordered by a court of competent jurisdiction.

2. As used in this section, “rate filing documentation” and “unified rate review template” have the meanings ascribed to them in 45 C.F.R. § 154.215.

(Added to NRS by 2017, 2358)

NRS 689A.700 Regulations regarding rates. The Commissioner may adopt regulations to carry out the provisions of this section and to ensure that the practices used by individual carriers relating to the establishment of rates are consistent with the purposes of NRS 689A.470 to 689A.740, inclusive.

(Added to NRS by 1997, 2895; A 2013, 3617; 2015, 3485; 2017, 2364)

NRS 689A.705 Regulations concerning reissuance of health benefit plan. The Commissioner may adopt regulations to require an individual carrier, as a condition of transacting business with individuals in this state after July 16, 1997, to reissue a health benefit plan to any individual whose health benefit plan has been terminated or not renewed by the individual carrier after July 1, 1997. The Commissioner may prescribe such terms for the reissue of coverage as the Commissioner finds are reasonable and necessary to provide continuity of coverage to individuals.

(Added to NRS by 1997, 2897)

NRS 689A.710 Prohibited acts; denial of application for coverage; regulations; violation may constitute unfair trade practice; applicability of section.

1. Except as otherwise provided in this section, an individual carrier or a producer shall not, directly or indirectly:

(a) Encourage or direct an individual or family to refrain from filing an application for coverage with an individual carrier because of the health status, claims experience, industry, occupation or geographic location of the individual or family.

(b) Encourage or direct an individual or family to seek coverage from another carrier because of the health status, claims experience, industry, occupation or geographic location of the individual or family.

2. The provisions of subsection 1 do not apply to information provided to an individual or family by an individual carrier or a producer relating to the geographic service area or a provision for a restricted network of the individual carrier.

3. An individual carrier shall not, directly or indirectly, enter into any contract, agreement or arrangement with a producer if the contract, agreement or arrangement provides for or results in a variation to the compensation paid to a producer for the sale of a health benefit plan because of the health status, claims experience, industry, occupation or geographic location of the individual at the time that the health benefit plan is issued to or renewed by the individual.

4. An individual carrier shall not terminate, fail to renew, or limit its contract or agreement of representation with a producer for any reason related to the health status, claims experience, industry, occupation or geographic location of an individual at the time that the health benefit plan is issued to or renewed by the individual placed by the producer with the individual carrier.

5. A denial by an individual carrier of an application for coverage from an individual or family must be in writing and must state the reason for the denial.

6. The Commissioner may adopt regulations that set forth additional standards to provide for the fair marketing and broad availability of health benefit plans to individuals or families in this state.

7. A violation of any provision of this section by an individual carrier may constitute an unfair trade practice for the purposes of chapter 686A of NRS.

8. The provisions of this section apply to a third-party administrator if the third-party administrator enters into a contract, agreement or other arrangement with an individual carrier to provide administrative, marketing or other services related to the offering of a health benefit plan to individuals or families in this state.

9. Nothing in this section interferes with the right and responsibility of a producer to advise and represent the best interests of an individual or family who is seeking health insurance coverage from an individual carrier.

(Added to NRS by 1997, 2896; A 2013, 3617)

Individual Health Insurance Coverage

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

1. An employee welfare benefit plan for providing benefits for employees of more than one employer under which individual health insurance coverage is provided must comply with the provisions of NRS 679B.139 and 689A.470 to 689A.740, inclusive, and the regulations adopted by the Commissioner pursuant thereto.

2. As used in this section, the term “employee welfare benefit plan for providing benefits for employees of more than one employer” is intended to be equivalent to the term “employee welfare benefit plan which is a multiple employer welfare arrangement” as used in federal statutes and regulations.

(Added to NRS by 1997, 2890; A 2017, 2364)

NRS 689A.717 Individual health benefit plan covering maternity care and pediatric care: Requirement to allow minimum stay in hospital in connection with childbirth; prohibited acts.

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

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

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

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

2. Nothing in this section requires a pregnant or postpartum individual to:

(a) Deliver the baby in a hospital; or

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

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

(a) Deny a pregnant or postpartum individual or the 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 pregnant or postpartum individual to encourage the individual 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 pregnant or postpartum individual 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 pregnant or postpartum individual or newborn infant in a manner that is inconsistent with the provisions of this section; or

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

4. Nothing in this section:

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

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

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

(Added to NRS by 1997, 2898; A 2021, 2975)

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

1. To determine the period of creditable coverage of a person, a health insurance issuer offering individual health insurance coverage shall provide written certification of coverage on a form prescribed by the Commissioner to the person that certifies:

(a) The period of creditable coverage of the person under the individual health insurance coverage; and

(b) The date that a substantially completed application was received by the health insurance issuer from the person for individual health insurance coverage.

2. The certification of coverage must be provided to the insured:

(a) At the time that the insured ceases to be covered under the individual health insurance coverage or otherwise becomes covered under any provision of the Consolidated Omnibus Budget Reconciliation Act of 1985, as that act existed on July 16, 1997, relating to the continuation of coverage;

(b) If the insured becomes covered under such a provision, at the time that the insured ceases to be covered by that provision; and

(c) Upon the request of the insured, if the request is made not later than 24 months after the date on which the insured ceased to be covered as described in paragraphs (a) and (b).

(Added to NRS by 1997, 2897)

Bona Fide Associations

NRS 689A.725 Requirements for plan for coverage. For the purposes of NRS 689A.470 to 689A.740, inclusive, a plan for coverage of a bona fide association must:

1. Conform with any regulations adopted pursuant to NRS 689A.700 concerning rates.

2. Provide for the renewability of coverage for members of the bona fide association, and their dependents, if such coverage meets the criteria set forth in NRS 689A.630.

(Added to NRS by 1997, 2889; A 2013, 3618; 2015, 3485; 2017, 2364)

Miscellaneous Provisions

NRS 689A.740 Regulations. The Commissioner shall adopt regulations as necessary to carry out the provisions of NRS 689A.470 to 689A.740, inclusive.

(Added to NRS by 1997, 2896; A 2017, 2365)

SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS

NRS 689A.745 Establishment; approval; requirements; examination; exception.

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

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

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

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

(Added to NRS by 1997, 307; A 2003, 774; 2011, 3381; 2017, 2365)

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

1. Each insurer that issues a policy of health insurance in this State shall submit to the Commissioner an annual report regarding its system for resolving complaints established pursuant to subsection 1 of NRS 689A.745 on a form prescribed by the Commissioner 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;

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

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

(Added to NRS by 1997, 308; A 2003, 774; 2017, 2365)

NRS 689A.755 Written notice required to be provided by insurer to insured explaining right to file complaint; written notice to insured required when insurer denies coverage of health care service.

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

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

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

2. Any time that an insurer denies coverage of a health care service to an insured, including, without limitation, denying a claim relating to a policy of health insurance pursuant to NRS 689A.410, it shall notify the insured in writing within 10 working days after it denies coverage of the health care service of:

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

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

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

(Added to NRS by 1997, 308; A 1999, 3082)