NRS: CHAPTER 689B - GROUP AND BLANKET HEALTH INSURANCE

[Rev. 6/29/2024 5:00:10 PM--2023]

CHAPTER 689B - GROUP AND BLANKET HEALTH INSURANCE

GENERAL PROVISIONS

NRS 689B.010 Short title; scope.

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

GROUP POLICIES

General Provisions

NRS 689B.020 “Group health insurance” defined; authority to provide in certain policies for continuation of certain benefit provisions after death of person in insured group; authority of Commissioner to require filing of form of certificate proposed for delivery in this state of policy made under laws of another state.

NRS 689B.026 Delivery of policy to group formed to purchase health insurance prohibited; exception; applicable provisions for review of marketed insurance products by Commissioner; applicability to policy issued in another state.

NRS 689B.0265 Policy to guaranteed association.

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

NRS 689B.0285 System for resolving complaints of insureds: Establishment; approval; requirements; examination; exception.

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

NRS 689B.0295 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.

Coverage

NRS 689B.030 Required provisions.

NRS 689B.0303 Required provision in certain policies concerning coverage for continued medical treatment; exceptions; regulations.

NRS 689B.0304 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 689B.0305 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 689B.0306 Required provision concerning coverage for certain treatment received as part of clinical trial or study for treatment of cancer or chronic fatigue syndrome; authority of insurer to require certain information; immunity from liability.

NRS 689B.0307 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 required; granting of request; applicability of provisions.

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

NRS 689B.0312 Required provision concerning coverage for drugs, laboratory testing and certain services related to human immunodeficiency virus and hepatitis C; reimbursement of certain providers of health care for certain services; prohibited acts.

NRS 689B.0313 Required coverage for certain tests and vaccines relating to human papillomavirus; prohibited acts.

NRS 689B.0314 Required provision concerning coverage for screening, genetic counseling and testing related to BRCA gene in certain circumstances.

NRS 689B.0315 Required provision concerning coverage for examination of person who is pregnant for certain diseases.

NRS 689B.0316 Required provision concerning coverage for testing, treatment and prevention of sexually transmitted diseases; required provision concerning coverage for condoms for certain insureds.

NRS 689B.0317 Required provision in policy covering treatment of prostate cancer concerning coverage for prostate cancer screening; prohibited act.

NRS 689B.0319 Required provision concerning coverage for certain drugs and services related to substance use disorder and opioid use disorder; reimbursement of pharmacists and pharmacies for certain services; prohibited acts.

NRS 689B.033 Certain policies covering family members required to include certain coverage for insured’s newly born and adopted children and children placed with insured for adoption.

NRS 689B.0334 Required provision concerning coverage for medically necessary treatment of conditions relating to gender dysphoria and gender incongruence; restriction on refusal to cover certain treatments; authority of insurer to prescribe requirements for covering surgical treatments for minors; determination of medical necessity.

NRS 689B.0335 Required provision concerning coverage for autism spectrum disorders for certain persons; prohibited acts.

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

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

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

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

NRS 689B.0357 Required provision in policy covering hospital, medical or surgical expenses concerning coverage for management and treatment of diabetes.

NRS 689B.0358 Required provision concerning coverage for management and treatment of sickle cell disease and its variants; required provision in policy covering prescription drugs concerning coverage for medically necessary prescription drugs to treat sickle cell disease and its variants.

NRS 689B.0361 Required provision concerning coverage for biomarker testing for diagnosis, treatment, management and monitoring of cancer in certain circumstances; establishment of process to request exception or appeal denial of coverage; time for responding to request for prior authorization.

NRS 689B.0362 Policy covering treatment of cancer through use of chemotherapy: Prohibited acts related to orally administered chemotherapy.

NRS 689B.0365 Required provision in certain policies concerning coverage for use of certain drugs and related services for treatment of cancer.

NRS 689B.0367 Required provision in policy covering treatment of colorectal cancer concerning coverage for colorectal cancer screening.

NRS 689B.0368 Policy covering prescription drugs prohibited from limiting or excluding coverage for certain prescription drugs previously approved for medical condition of insured; exceptions.

NRS 689B.0369 Required provision concerning coverage for services provided through telehealth to same extent as though provided in person or by other means; required provision concerning reimbursement for certain services provided through telehealth in same amount as though provided in person or by other means; prohibited acts.

NRS 689B.0374 Required provision concerning coverage for certain screenings and tests for breast cancer; prohibited acts.

NRS 689B.0375 Required provision in policy covering mastectomies concerning coverage relating to mastectomy; prohibited acts.

NRS 689B.0376 Required provision in policy covering prescription drugs or devices concerning coverage of hormone replacement therapy in certain circumstances; prohibited acts; exception.

NRS 689B.03762 Required provision in policy covering prescription drugs concerning coverage for drugs irregularly dispensed for purpose of synchronization of chronic medications; prohibited acts; exception.

NRS 689B.03764 Policy covering prescription drugs: Denial of coverage for early refills of otherwise covered topical ophthalmic products prohibited.

NRS 689B.03765 Policy covering prescription drugs: Submission to step therapy protocol for drug to treat psychiatric condition prohibited in certain circumstances.

NRS 689B.03766 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 689B.0377 Required provision in policy covering outpatient care concerning coverage for health care services related to hormone replacement therapy; prohibited acts.

NRS 689B.0378 Required provision concerning coverage for drug or device for contraception and related health services; prohibited acts; exceptions.

NRS 689B.03785 Required provisions concerning coverage for certain services, screenings and tests relating to wellness; prohibited acts.

NRS 689B.0379 Policy prohibited from excluding coverage for treatment of temporomandibular joint; exception.

Reimbursement and Payment

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

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

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

NRS 689B.039 Reimbursement for treatments by chiropractic physician.

NRS 689B.0393 Reimbursement for treatments by podiatrist.

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

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

NRS 689B.045 Reimbursement for services provided by certain nurses.

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

NRS 689B.049 Reimbursement for acupuncture.

Miscellaneous Provisions

NRS 689B.050 Extended disability benefit.

NRS 689B.060 Readjustment of premiums; dividends.

NRS 689B.061 Limitations on deductibles and copayments charged under policy which offers difference of payment between preferred providers of health care and providers who are not preferred.

NRS 689B.063 Primary and secondary policies: Determination of benefits.

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

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

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

NRS 689B.0675 Insurer prohibited from discriminating against person with respect to participation or coverage on basis of gender identity or expression.

NRS 689B.068 Insurer prohibited from denying coverage solely because claim involves act that constitutes domestic violence or applicant or insured was victim of domestic violence.

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

BLANKET POLICIES

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

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

NRS 689B.090 Application and certificates.

NRS 689B.100 Payment of benefits.

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

MISCELLANEOUS PROVISIONS

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

NRS 689B.255 Approval or denial of claims; payment of claims and interest; requests for additional information; award of costs and attorney’s fees; compliance with requirements; imposition of administrative fine or suspension or revocation of certificate of authority for failure to comply.

NRS 689B.260 Group health or blanket health policy containing exclusion, reduction or limitation of coverage relating to complications of pregnancy prohibited; exception.

NRS 689B.265 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 689B.270 Required procedure for arbitration of disputes concerning independent medical, dental or chiropractic evaluations.

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

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

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

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

ELIGIBILITY FOR COVERAGE UNDER GROUP POLICY

NRS 689B.290 Definitions.

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

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

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

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

PORTABILITY AND ACCOUNTABILITY

NRS 689B.340 Definitions.

NRS 689B.350 “Affiliation period” defined.

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

NRS 689B.360 “Carrier” defined.

NRS 689B.370 “Contribution” defined.

NRS 689B.380 “Creditable coverage” defined.

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

NRS 689B.400 “Group participation” defined.

NRS 689B.430 “Open enrollment” defined.

NRS 689B.440 “Plan sponsor” defined.

NRS 689B.460 “Waiting period” defined.

NRS 689B.480 Determination of applicable creditable coverage of person; determination of period of creditable coverage of person; required statement.

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

NRS 689B.500 Carrier required to offer and issue plan regardless of health status of members; prohibited acts; authority to include wellness program in plan that offers discounts based on health status under certain circumstances.

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

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

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

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

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

NRS 689B.560 Carrier required to renew coverage at option of plan sponsor; exceptions; discontinuation of product; discontinuation of group health insurance through bona fide association.

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

NRS 689B.580 Plan sponsor of governmental plan authorized to elect to exclude governmental plan from compliance with certain statutes; duties of plan sponsor.

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GENERAL PROVISIONS

NRS 689B.010 Short title; scope.

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

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

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

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

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

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

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

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

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

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

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

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

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

GROUP POLICIES

General Provisions

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

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

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

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

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

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

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

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

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

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

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

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

NRS 689B.0265 Policy to guaranteed association.

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

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

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

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

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

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

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

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

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

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

7. As used in this section:

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

(1) Has a constitution and bylaws;

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

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

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

(Added to NRS by 2007, 2457)

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

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

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

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

(1) An explanation of:

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

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

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

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

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

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

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

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

(Added to NRS by 2001, 857)

NRS 689B.0285 System for resolving complaints of insureds: Establishment; approval; requirements; examination; exception.

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

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

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

(Added to NRS by 1997, 309; A 2003, 775; 2011, 3382; 2017, 2365)

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

1. Each insurer that issues a policy of group health insurance in this State shall submit to the Commissioner an annual report regarding its system for resolving complaints established pursuant to subsection 1 of NRS 689B.0285 on a form prescribed by the Commissioner 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, 309; A 2003, 775; 2017, 2366)

NRS 689B.0295 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 group health insurance in this State shall provide written notice to an insured, in clear and comprehensible language that is understandable to an ordinary layperson, explaining the right of the insured to file a written complaint. Such notice must be provided to an insured:

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

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

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

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

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

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

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

Coverage

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

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

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

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

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

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

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

NRS 689B.0303 Required provision in certain policies concerning coverage for continued medical treatment; exceptions; regulations.

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

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

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

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

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

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

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

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

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

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

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

(1) The date of delivery; or

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

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

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

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

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

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

(Added to NRS by 2003, 3356)

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 group 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 requests a refill pursuant to paragraph (a).

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, 824)

1. An insurer that offers or issues a policy of group 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 group 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 group 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, 2661)

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

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

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

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

(2) A cooperative group;

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

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

(5) The United States Department of Defense;

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

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

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

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

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

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

(1) The procedure to be undertaken;

(2) Alternative methods of treatment; and

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(a) Any injury to the insured caused by:

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

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

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

9. As used in this section:

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

(1) The Clinical Trials Cooperative Group Program; and

(2) The Community Clinical Oncology Program.

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

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

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

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

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

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

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

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

(1) A hospital; or

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

(Added to NRS by 2003, 3522; A 2005, 2012; 2017, 2366)

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 group 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 group 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 group 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 group 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 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:

(a) Any prescription drug to which the provisions of NRS 689B.0305 apply.

(b) Any policy of group health insurance purchased or provided pursuant to NRS 287.010.

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, 809)

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

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

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

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

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

(Added to NRS by 1999, 1944)

1. An insurer that offers or issues a policy of group 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 group 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 group 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.

(b) “Network plan” means a policy of group 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.

(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, 3207; A 2023, 3514)

NRS 689B.0313 Required coverage for certain tests and vaccines relating to human papillomavirus; prohibited acts.

1. A policy of group 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 group 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 group health insurance pursuant to subsection 1;

(b) Refuse to issue a policy of group health insurance or cancel a policy of group health insurance solely because the person applying for or covered by the policy uses or may use 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, 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.

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. 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.

(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 group 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 of health care” has the meaning ascribed to it in NRS 629.031.

(Added to NRS by 2007, 3237; A 2013, 3618; 2017, 1817)

NRS 689B.0314 Required provision concerning coverage for screening, genetic counseling and testing related to BRCA gene in certain circumstances.

1. An insurer that issues a policy of group 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 group 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 group 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, 781)

NRS 689B.0315 Required provision concerning coverage for examination of person who is pregnant for certain diseases.

1. An insurer that issues a policy of group 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, 2578)

NRS 689B.0316 Required provision concerning coverage for testing, treatment and prevention of sexually transmitted diseases; required provision concerning coverage for condoms for certain insureds.

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

(a) Coverage of testing for and the treatment of 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 689B.0312 and 689B.0315.

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

2. A policy of group health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after 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, 3513)

NRS 689B.0317 Required provision in policy covering treatment of prostate cancer concerning coverage for prostate cancer screening; prohibited act.

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

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

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

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

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

(Added to NRS by 2007, 3238)

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:

(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.

(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, 2372, 3512)

NRS 689B.033 Certain policies covering family members required to include certain coverage for insured’s newly born and adopted children and children placed with insured for adoption.

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

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

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

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

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

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

(a) The birth of a newly born child;

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

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

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

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

1. Except as otherwise provided in this section, an insurer that issues a policy of group 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 group 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 group 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 group 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 group 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 renewal which is in conflict with the provisions of 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 group 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, 2030)

NRS 689B.0335 Required provision concerning coverage for autism spectrum disorders for certain persons; prohibited acts.

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

2. Coverage provided under this section is subject to:

(a) A maximum benefit of the actuarial equivalent of $72,000 per year for applied behavior analysis treatment; and

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

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

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

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

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

5. Treatment of autism spectrum disorders must be identified in a treatment plan and may include medically necessary habilitative or rehabilitative care, prescription care, psychiatric care, psychological care, 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. A policy subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2011, has the legal effect of including the coverage required by subsection 1, and any provision of the policy or the renewal which is in conflict with subsection 1 or 2 is void.

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

8. As used in this section:

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

(b) “Autism spectrum 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, 1467; A 2015, 681, 683; 2017, 1498, 4254; 2019, 2559; 2021, 1649)

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

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

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

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

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

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

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

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

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

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

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

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

Ê whichever occurs first.

(Added to NRS by 1989, 1249)

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

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

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

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

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

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

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

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

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

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

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

3. A policy subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after 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 689B.0357 Required provision in policy covering hospital, medical or surgical expenses concerning coverage for management and treatment of diabetes.

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

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

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

4. As used in this section:

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

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

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

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

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

(Added to NRS by 1997, 743; A 2017, 2369)

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

(a) Necessary case management services for an insured who has been 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 group 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, 2170)

1. Subject to the limitations prescribed by subsection 4, an insurer that issues a policy of group 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 group 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 group 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, 2214)

NRS 689B.0362 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 group health insurance which provides coverage for the treatment of cancer through the use of chemotherapy shall not:

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

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

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

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

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

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

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

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

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

(1) The United States Pharmacopoeia Drug Information; or

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

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

2. The coverage required pursuant to this section:

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

(b) Does not include coverage for any:

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

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

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

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

NRS 689B.0367 Required provision in policy covering treatment of colorectal cancer concerning coverage for colorectal cancer screening.

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

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

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

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

(Added to NRS by 2003, 1335)

NRS 689B.0368 Policy covering prescription drugs prohibited from limiting or excluding coverage for certain prescription drugs previously approved for medical condition of insured; exceptions.

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

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

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

2. The provisions of subsection 1 do not:

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

(b) Prohibit:

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

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

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

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

(Added to NRS by 2001, 858; A 2003, 2298; 2017, 637)

1. A policy of group or blanket 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 group or blanket 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 group or blanket health insurance must not require an insured to obtain prior authorization for any service provided through telehealth that is not required for that service when provided in person. A policy of group or blanket 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 group or blanket 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, 638; A 2021, 3020, 3021, 3022, 3023; 2023, 226, 237)

NRS 689B.0374 Required provision concerning coverage for certain screenings and tests for breast cancer; prohibited acts.

1. A policy of group 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 group 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 group health insurance pursuant to subsection 1;

(b) Refuse to issue a policy of group health insurance or cancel a policy of group health insurance solely because the person applying for or covered by the policy uses or may use 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, 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.

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 group health insurance with respect to the deductible of such a policy of group 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.

(d) “Qualified policy of group health insurance” means a policy of group 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, 1889; A 1997, 1730; 2017, 1818; 2023, 1345; 2023, 1345)

NRS 689B.0375 Required provision in policy covering mastectomies concerning coverage relating to mastectomy; prohibited acts.

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

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

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

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

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

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

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

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

Ê whichever is earlier.

5. A plan or issuer may not:

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

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

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

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

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

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

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

NRS 689B.0376 Required provision in policy covering prescription drugs or devices concerning coverage of hormone replacement therapy in certain circumstances; prohibited acts; exception.

1. An insurer that offers or issues a policy of group health insurance which provides coverage for prescription drugs or devices shall include in the policy coverage for 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 group 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;

(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, 1997; A 2017, 1819, 3939)

1. An insurer who offers or issues a policy of group 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, 2124)

NRS 689B.03764 Policy covering prescription drugs: Denial of coverage for early refills of otherwise covered topical ophthalmic products prohibited.

1. An insurer who offers or issues a policy of group 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 group health insurance.

3. A policy of group 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 689B.03765 Policy covering prescription drugs: Submission to step therapy protocol for drug to treat psychiatric condition prohibited in certain circumstances.

1. A policy of group 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 group 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 group 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 group health insurance provides coverage for the recommended drug.

(Added to NRS by 2023, 1783)

NRS 689B.03766 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 group 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 group 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, 1006)

NRS 689B.0377 Required provision in policy covering outpatient care concerning coverage for health care services related to hormone replacement therapy; prohibited acts.

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

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

(a) Require an insured to pay a higher deductible, 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, 1998; A 2017, 1821, 3940)

NRS 689B.0378 Required provision concerning coverage for drug or device for contraception and related health services; prohibited acts; exceptions.

1. Except as otherwise provided in subsection 8, an insurer that offers or issues a policy of group 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 12; 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 12;

(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 group 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 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 10, 11 and 13, an insurer that offers or issues a policy of group 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 included in the policy pursuant to subsection 1;

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

(f) Impose any other restrictions or delays on the access of an insured to 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 group 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 group health insurance and before the renewal of such a policy, provide to the group policyholder or prospective insured, as applicable, written notice of the coverage that the insurer refuses to provide pursuant to this subsection.

9. If an insurer refuses, pursuant to subsection 8, to provide the coverage required by subsection 1, an employer may otherwise provide for the coverage for the employees of the employer.

10. 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.

11. For each of the 18 methods of contraception listed in subsection 12 that have been approved by the Food and Drug Administration, a policy of group 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.

12. 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.

13. 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.

14. 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 12 at a hospital immediately after an insured gives birth.

15. 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.

16. 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.

(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, 1813, 3936; A 2021, 3276; 2023, 917, 2115)

NRS 689B.03785 Required provisions concerning coverage for certain services, screenings and tests relating to wellness; prohibited acts.

1. An insurer that offers or issues a policy of group 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 initial 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 group health insurance shall not:

(b) Refuse to issue a policy of group health insurance or cancel a policy of group health insurance solely because the person applying for or covered by the policy uses or may use 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 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, 1815)

NRS 689B.0379 Policy prohibited from excluding coverage for treatment of temporomandibular joint; exception.

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

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

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

(b) Treatment which is medically necessary.

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

(Added to NRS by 1989, 2138)

Reimbursement and Payment

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

(Added to NRS by 1981, 575; A 1989, 1553; 2017, 935)

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

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

NRS 689B.0385 Reimbursement for treatments by licensed associate in social work, social worker, master social worker, independent social worker or clinical social worker. If any policy of group health insurance provides coverage for treatment of an illness which is within the authorized scope of the practice of a licensed associate in social work, 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 689B.039 Reimbursement for treatments by chiropractic physician.

1. If any group policy of health insurance provides coverage for treatment of an illness which is within the authorized scope of practice of a qualified 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 charged for similar treatments by other physicians.

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

NRS 689B.0393 Reimbursement for treatments by podiatrist.

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

2. The terms of the policy must not limit:

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

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

(Added to NRS by 2007, 1046)

NRS 689B.0397 Reimbursement for treatment by licensed clinical alcohol and drug counselor. If any policy of group health insurance provides coverage for treatment of an illness which is within the authorized scope of practice of a licensed clinical alcohol and drug 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 689B.040 Direct payment for hospital and medical services and home health care; payment to assignee.

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

(a) May, at the insurer’s option; or

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

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

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

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

NRS 689B.045 Reimbursement for services provided by certain nurses.

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

2. The terms of the policy must not limit:

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

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

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

(Added to NRS by 1985, 1447)

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

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

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

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

(Added to NRS by 1989, 1273)

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

(Added to NRS by 1991, 1134)

Miscellaneous Provisions

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

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

NRS 689B.060 Readjustment of premiums; dividends.

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

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

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

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

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

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

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

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

(Added to NRS by 1987, 1781; A 1991, 1329; 1995, 1629; 2013, 3619; 2017, 2370)

NRS 689B.063 Primary and secondary policies: Determination of benefits.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(Added to NRS by 1987, 848)

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

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

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

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

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

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

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

4. The provisions of this section:

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

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

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

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

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

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

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

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

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

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

(Added to NRS by 1995, 2557)

NRS 689B.0675 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 group 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 group 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, 2032)

NRS 689B.068 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 group health insurance or cancel a policy of group health insurance solely because the claim involves an act that constitutes domestic violence pursuant to NRS 33.018, or because the person applying for or covered by the policy of group health insurance was the victim of such an act of domestic violence, regardless of whether the insured or applicant contributed to any loss or injury.

(Added to NRS by 1997, 1096)

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

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

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

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

(c) Determine the rates or any other aspect of the coverage or benefits for health care provided to an insured person based on 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 group health insurance that provides coverage for long-term care or disability income.

3. As used in this section:

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

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

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

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

(Added to NRS by 1997, 1460; A 2019, 299)

BLANKET POLICIES

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

NRS 689B.090 Application and certificates.

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

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

(Added to NRS by 1971, 1770)

NRS 689B.100 Payment of benefits.

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

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

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

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

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

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

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

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

(Added to NRS by 1971, 1771)

MISCELLANEOUS PROVISIONS

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

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

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

(Added to NRS by 1975, 897; A 2001, 2224; 2021, 1651)

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

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

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

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

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

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

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

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

(Added to NRS by 1991, 1328; A 1999, 1648; 2001, 2730; 2003, 3358; 2019, 330)

NRS 689B.260 Group health or blanket health policy containing exclusion, reduction or limitation of coverage relating to complications of pregnancy prohibited; exception.

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

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

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

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

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

(Added to NRS by 1977, 415)

NRS 689B.265 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 group 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, 1171)

NRS 689B.270 Required procedure for arbitration of disputes concerning independent medical, dental or chiropractic evaluations.

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

2. If an insurer, for any final determination of benefits or care, requires an independent evaluation of the medical, dental or chiropractic care of any person for whom such care is covered under the terms of a policy of group or blanket health insurance, only a physician, 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 receiving 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, 196)

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

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

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

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

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

(d) Provisions relating to renewability; and

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

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

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

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

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

(Added to NRS by 2001, 2219; A 2019, 300)

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

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

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

(b) The identity of that drug or medicine.

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

(Added to NRS by 1989, 1978)

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

(Added to NRS by 2005, 2137)

NRS 689B.287 Insurer prohibited from denying coverage solely because 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 group health insurance solely because the claim involves an injury sustained by an insured as a consequence of being intoxicated or under the influence of a controlled substance.

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

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

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

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

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

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

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

ELIGIBILITY FOR COVERAGE UNDER GROUP POLICY

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

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

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

(Added to NRS by 1995, 2428)

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

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

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

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

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

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

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

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

(a) Eligible for medical assistance under Medicaid; and

(b) Covered by a group health policy,

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

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

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

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

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

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

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

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

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

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 group health policy 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, 2429; A 2007, 2403; 2015, 285)

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

1. Was born out of wedlock;

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

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

(Added to NRS by 1995, 2429)

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

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

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

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

(Added to NRS by 1995, 2429)

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

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

2. Shall, if:

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

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

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

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

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

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

(Added to NRS by 1995, 2429)

PORTABILITY AND ACCOUNTABILITY

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

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

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

(Added to NRS by 1997, 2900)

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

(Added to NRS by 2001, 2219)

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

(Added to NRS by 1997, 2900)

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

(Added to NRS by 1997, 2900)

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

1. A group health plan;

2. A health benefit plan;

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

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

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

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

7. A state health benefit risk pool;

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

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

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

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

12. A short-term health insurance policy; or

13. A blanket accident and health insurance policy.

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

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

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

2. The term does not include:

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

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

(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, 2900)

NRS 689B.400 “Group participation” defined. “Group participation” means the minimum number of participants or beneficiaries that must be enrolled in a health benefit plan in relation to a specified percentage or number of eligible persons or employees of the employer.

(Added to NRS by 1997, 2901)

NRS 689B.430 “Open enrollment” defined. “Open enrollment” means the period designated for enrollment in a health benefit plan.

(Added to NRS by 1997, 2903)

NRS 689B.440 “Plan sponsor” defined. “Plan sponsor” has the meaning ascribed to it in section 3(16)(B) of the Employee Retirement Income Security Act of 1974, as that section existed on July 16, 1997.

(Added to NRS by 1997, 2903)

NRS 689B.460 “Waiting period” defined. “Waiting period” means the period established by a plan of health insurance that must pass before a person who is an eligible participant or beneficiary in a plan is covered for benefits under the terms of the plan. The term includes the period from the date a person submits an application to an individual carrier for coverage under a health benefit plan until the first day of coverage under that health benefit plan.

(Added to NRS by 1997, 2903; A 1999, 2808)

NRS 689B.480 Determination of applicable creditable coverage of person; determination of period of creditable coverage of person; required statement.

1. In determining the applicable creditable coverage of a person for the purposes of NRS 689B.340 to 689B.580, inclusive, a period of creditable coverage must not be included if, after the expiration of that period but before the enrollment date, there was a 63-day period during all of which the person was not covered under any creditable coverage. To establish a period of creditable coverage, a person must present any certificates of coverage provided to the person in accordance with NRS 689B.490 and such other evidence of coverage as required by regulations adopted by the Commissioner. For the purposes of this subsection, any waiting period for coverage or an affiliation period must not be considered in determining the applicable period of creditable coverage.

2. In determining the period of creditable coverage of a person, a carrier shall include each applicable period of creditable coverage without regard to the specific benefits covered during that period, except that the carrier may elect to include applicable periods of creditable coverage based on coverage of specific benefits as specified in the regulations of the United States Department of Health and Human Services, if such an election is made on a uniform basis for all participants and beneficiaries of the health benefit plan or coverage. Pursuant to such an election, the carrier shall include each applicable period of creditable coverage with respect to any class or category of benefits if any level of benefits is covered within that class or category, as specified by those regulations.

3. Regardless of whether coverage is actually provided, if a carrier elects in accordance with subsection 2 to determine creditable coverage based on specified benefits, a statement that such an election has been made and a description of the effect of the election must be:

(a) Included prominently in any disclosure statement concerning the health benefit plan; and

(b) Provided to each person at the time of enrollment in the health benefit plan.

4. The provisions of this section apply only to grandfathered plans.

(Added to NRS by 1997, 2903; A 2013, 3620)

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

1. For the purpose of determining the period of creditable coverage of a person accumulated under a health benefit plan, blanket accident and health insurance or group health insurance, the insurer shall provide written certification on a form prescribed by the Commissioner of coverage to the person which certifies the length of:

(a) The period of creditable coverage that the person accumulated under the plan and any coverage under any provision of the Consolidated Omnibus Budget Reconciliation Act of 1985, as that act existed on July 16, 1997, relating to the continuation of coverage; and

(b) Any waiting and affiliation period imposed on the person pursuant to that coverage.

2. The certification of coverage must be provided to the person who was insured:

(a) At the time that the person ceases to be covered under the plan, if the person does not otherwise become covered under any provision of the Consolidated Omnibus Budget Reconciliation Act of 1985, as that act existed on July 16, 1997, relating to the continuation of coverage;

(b) If the person becomes covered under such a provision, at the time that the person ceases to be covered by that provision; and

(c) Upon request, if the request is made not later than 24 months after the date on which the person ceased to be covered as described in paragraphs (a) and (b).

(Added to NRS by 1997, 2904; A 2001, 2225)

1. A carrier shall offer and issue a health benefit plan to any group regardless of the health status of the group, any member of the group or any dependent of a member of the group. Such health status includes, without limitation:

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

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

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

2. A carrier 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. A carrier 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. A carrier that offers or issues a health benefit plan may include in the plan a wellness program that reduces a premium, deductible or copayment based on health status if:

(a) An insured who is eligible to participate in the wellness program is given the opportunity to qualify for the discount at least once each year;

(b) The amount of all discounts provided pursuant to such a wellness program does not exceed 30 percent, or if the program is designed to prevent or reduce tobacco use, 50 percent, of the cost of coverage for an insured or an insured and his or her dependents, as applicable, under the plan;

(d) The carrier ensures that the full discount under the wellness program is available to all similarly situated insureds by providing a reasonable alternative standard by which an insured may qualify for the discount which, if based on health status, must accommodate the recommendations of the physician of the insured; and

(e) The plan discloses in all plan materials describing the terms of the wellness program, and in any disclosure that an insured did not satisfy the initial standard to be eligible for the discount, the availability of a reasonable alternative standard described in paragraph (d).

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

(Added to NRS by 1997, 2904; A 1999, 2808; 2001, 2225; 2013, 3621; 2019, 300)

NRS 689B.510 Carrier authorized to modify coverage for insurance product under certain circumstances. A carrier may modify the health insurance coverage for a product offered pursuant to a group health plan by the carrier at the time of renewal of such coverage if the modification is consistent with the provisions of this chapter.

(Added to NRS by 1997, 2906)

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

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

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

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

Ê If a different length of stay is provided in the guidelines established by the American College of Obstetricians and Gynecologists, or its successor organization, and the American Academy of Pediatrics, or its successor organization, the group health plan or health insurance coverage may follow such guidelines in lieu of following the length of stay set forth above. The provisions of this subsection do not apply to any group health plan or health insurance coverage in any case in which the decision to discharge the 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. A group health plan or coverage under group health insurance that offers coverage for maternity care and pediatric care of newborn infants may not:

(a) Deny a 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 a group health plan or carrier from imposing a deductible, coinsurance or other mechanism for sharing costs relating to benefits for hospital stays in connection with childbirth for a 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 a group health plan or carrier and a provider of health care that uses capitation or other financial incentives, if the arrangement is designed to provide services efficiently and consistently in the best interest of the pregnant or postpartum individual and the newborn infant.

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

(Added to NRS by 1997, 2906; A 2021, 2976)

NRS 689B.530 Carrier required to permit eligible employee or dependent of employee to enroll for coverage under certain circumstances. A carrier offering group health insurance shall permit an employee or a dependent of an employee covered by the group health insurance who is eligible, but not enrolled, for coverage in connection with the group health insurance to enroll for coverage under the terms of the group health insurance if:

1. The employee or dependent was covered under a different group health insurance or had other health insurance coverage at the time coverage was previously offered to the employee or dependent;

2. The employee stated in writing at that time that the other coverage was the reason for declining enrollment, but only if the plan sponsor or carrier required such a written statement and informed the employee of that requirement and the consequences of the requirement; and

3. The employee or dependent:

(a) Was covered under any provision of the Consolidated Omnibus Budget Reconciliation Act of 1985 relating to the continuation of coverage and such continuation of coverage was exhausted; or

(b) Was not covered under such a provision and his or her insurance coverage was lost as a result of cessation of contributions by his or her employer, termination of employment or eligibility, reduction in the number of hours of employment, or the death of, or divorce or legal separation from, a covered spouse.

(Added to NRS by 1997, 2907)

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

1. A carrier that offers group health insurance which makes coverage available to the dependent of an employee covered by the group health plan shall permit the employee to enroll a dependent after the close of a period of open enrollment if:

(a) The employee is a participant in the group health plan, or has met any waiting period applicable to becoming a participant and is eligible to be enrolled under the plan, except for a failure to enroll during a previous period of open enrollment; and

(b) The person to be enrolled became a dependent of the employee through marriage, birth, adoption or placement for adoption.

2. The group health plan or carrier shall provide a period of special enrollment for the enrollment of a dependent of an employee pursuant to this section. Such a period must be not less than 30 days and must begin on:

(a) The date specified by the group health plan or carrier for the period of special enrollment; or

(b) The date of the marriage, birth, adoption or placement for adoption, as appropriate.

3. If an employee seeks to enroll a dependent during the first 30 days of the period for special enrollment provided pursuant to subsection 2, the coverage of the dependent becomes effective:

(a) In the case of a marriage, not later than the first day of the first month beginning after the date on which the completed request for enrollment is received;

(b) In the case of a birth, on the date of the birth; and

4. In the case of a birth, an adoption or a placement for adoption of a child of an employee, the spouse of the employee may be enrolled as a dependent pursuant to this section if the spouse is otherwise eligible for coverage under the group health plan.

(Added to NRS by 1997, 2908)

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

1. A carrier shall not place any restriction on a person or a dependent of the person as a condition of being a participant in or a beneficiary of a policy of blanket accident and health insurance or group health insurance that is inconsistent with the provisions of this chapter.

2. A carrier that offers coverage under a policy of blanket accident and health insurance or group health insurance pursuant to this chapter shall not establish rules of eligibility which conflict with the provisions of NRS 689B.500, including rules which define applicable waiting periods, for the initial or continued enrollment under a group health plan offered by the carrier that are based on the following factors relating to the employee or a dependent of the employee:

(a) Health status.

(b) Medical condition, including physical and mental illnesses, or both.

(d) Receipt of health care.

(e) Medical history.

(f) Genetic information.

(g) Evidence of insurability, including conditions which arise out of acts of domestic violence.

(h) Disability.

3. Except as otherwise provided in NRS 689B.500, the provisions of subsection 1 do not:

(a) Require a carrier to provide particular benefits other than those that would otherwise be provided under the terms of the blanket health and accident insurance or group health insurance or coverage; or

(b) Prevent a carrier from establishing limitations or restrictions on the amount, level, extent or nature of the benefits or coverage for similarly situated persons.

4. This section does not:

(a) Restrict the amount that an employer or employee may be charged for coverage by a carrier;

(b) Prevent a carrier from establishing premium discounts or rebates or from modifying otherwise applicable copayments or deductibles in return for adherence by the insured person to programs of health promotion and disease prevention; or

(c) Preclude a carrier from establishing rules relating to employer contribution or group participation when offering health insurance coverage to small employers in this state.

(Added to NRS by 1997, 2908; A 2001, 2227; 2019, 301)

NRS 689B.560 Carrier required to renew coverage at option of plan sponsor; exceptions; discontinuation of product; discontinuation of group health insurance through bona fide association.

1. Except as otherwise provided in this section, coverage under a policy of group health insurance must be renewed by the carrier at the option of the plan sponsor, unless:

(a) The plan sponsor has failed to pay premiums or contributions in accordance with the terms of the group health insurance or the carrier has not received timely premium payments;

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

(c) The plan sponsor has failed to comply with any material provision of the group health insurance relating to employer contributions and group participation; or

(d) The carrier decides to discontinue offering coverage under group health insurance. If the carrier decides to discontinue offering and renewing such insurance, the carrier shall:

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

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

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

2. A carrier may discontinue a product offered to employers pursuant to this subsection only if:

(a) The carrier notifies the Commissioner of its decision pursuant to this subsection to discontinue the product at least 60 days before the carrier notifies the affected employers and persons covered pursuant to paragraph (b).

(b) The carrier notifies each affected employer and person covered of the decision of the carrier to discontinue the product. The notice must be made at least 90 days before the date on which the carrier will discontinue offering the product.

(c) The carrier offers to each affected employer the option to purchase any other health benefit plan currently offered by the carrier to groups 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 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 person or beneficiary who may become eligible for such coverage.

3. A carrier may discontinue the issuance and renewal of any type of group health insurance offered by the carrier in this state that is made available pursuant to this chapter only to a member of a bona fide association if:

(a) The membership of the person in the bona fide association was the basis for the provision of coverage under the group health insurance;

(b) The membership of the person in the bona fide association ceases; and

(c) Coverage is terminated pursuant to this subsection for all such former members uniformly without regard to any health status-related factor relating to the former member.

4. A carrier that elects not to renew group health insurance pursuant to paragraph (d) of subsection 1 shall not write new business pursuant to this chapter for 5 years after the date on which notice is provided to the Commissioner pursuant to subparagraph (2) of paragraph (d) of subsection 1.

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

6. As used in this section, “bona fide association” has the meaning ascribed to it in NRS 689A.485.

(Added to NRS by 1997, 2909; A 2013, 3623; 2017, 2371)

1. A carrier that offers coverage through a network plan is not required to offer coverage to or accept an application from an employer that does not employ or no longer employs any enrollees who reside or work in the geographic service area of the carrier, provided that such coverage is refused or terminated uniformly without regard to any health status-related factor for any employee of the employer.

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

(Added to NRS by 1997, 2911; A 2013, 3624)

NRS 689B.580 Plan sponsor of governmental plan authorized to elect to exclude governmental plan from compliance with certain statutes; duties of plan sponsor.

1. A plan sponsor of a governmental plan that is a group health plan to which the provisions of NRS 689B.340 to 689B.580, inclusive, otherwise apply may elect to exclude the governmental plan from compliance with those sections. Such an election:

(a) Must be made in such a form and in such a manner as the Commissioner prescribes by regulation.

(b) Is effective for a single specified year of the plan or, if the plan is provided pursuant to a collective bargaining agreement, for the term of that agreement.

(d) Excludes the governmental plan from those provisions in this chapter that apply only to group health plans.

2. If a plan sponsor of a governmental plan makes an election pursuant to this section, the plan sponsor shall:

(a) Annually and at the time of enrollment, notify the enrollees in the plan of the election and the consequences of the election; and

(b) Provide certification and disclosure of creditable coverage under the plan with respect to those enrollees pursuant to NRS 689B.490.

3. As used in this section, “governmental plan” has the meaning ascribed to in section 3(32) of the Employee Retirement Income Security Act of 1974, as that section existed on July 16, 1997.

(Added to NRS by 1997, 2911; A 2013, 3624)