NRS: CHAPTER 695C - HEALTH MAINTENANCE ORGANIZATIONS

[Rev. 6/29/2024 5:02:25 PM--2023]

CHAPTER 695C - HEALTH MAINTENANCE ORGANIZATIONS

GENERAL PROVISIONS

NRS 695C.010 Short title.

NRS 695C.020 Legislative declaration.

NRS 695C.030 Definitions.

NRS 695C.050 Applicability of certain provisions.

NRS 695C.055 Applicability of certain other provisions.

NRS 695C.057 Applicability of certain provisions concerning portability and availability of health insurance.

NRS 695C.060 Establishment of health maintenance organization.

NRS 695C.070 Certificate of authority: Application.

NRS 695C.080 Certificate of authority: Evaluation of application.

NRS 695C.090 Certificate of authority: Issuance.

NRS 695C.100 Certificate of authority: Denial.

NRS 695C.110 Governing body: Composition; participation by enrollees.

NRS 695C.120 Powers of health maintenance organization.

NRS 695C.123 Contracts with certain federally qualified health centers.

NRS 695C.125 Contract between health maintenance organization and provider of health care: Organization required to use form to obtain information on provider of health care; modification; submission by organization of schedule of payments to provider.

NRS 695C.128 Contracts to provide services pursuant to certain state programs: Payment of interest on claims.

NRS 695C.130 Notice and approval required for exercise of powers; rules or regulations.

NRS 695C.140 Notice and approval required for modification of operations; regulations.

NRS 695C.145 Accounting principles required for certain reports and transactions; health maintenance organization subject to requirements for certain insurers.

NRS 695C.150 Fiduciary responsibilities.

NRS 695C.160 Investments.

ELIGIBILITY FOR COVERAGE

NRS 695C.161 Definitions.

NRS 695C.163 Effect of eligibility for medical assistance under Medicaid; assignment of rights to state agency.

NRS 695C.165 Health maintenance organization prohibited from asserting certain grounds to deny enrollment of child pursuant to order if parent is enrolled in health care plan.

NRS 695C.167 Certain accommodations required to be made when child is covered under health care plan of noncustodial parent.

COVERAGE GENERALLY

NRS 695C.1691 Required provision in certain plans concerning coverage for continued medical treatment; exceptions; regulations.

NRS 695C.1693 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 health maintenance organization to require certain information; immunity from liability.

NRS 695C.16932 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 695C.16934 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 health maintenance organization to prescribe requirements for covering surgical treatments for minors; determination of medical necessity.

NRS 695C.1694 Required provision in plan covering prescription drugs or devices concerning coverage of hormone replacement therapy in certain circumstances; prohibited acts; exception.

NRS 695C.16945 Plan covering prescription drugs: Required actions by health maintenance organization related to acquisition of prescription drugs for certain insureds residing in area for which emergency or disaster has been declared.

NRS 695C.16947 Plan covering prescription drugs: Submission to step therapy for drug to treat psychiatric condition prohibited in certain circumstances.

NRS 695C.1695 Required provision in plan covering outpatient care concerning coverage of health care services related to hormone replacement therapy; prohibited acts.

NRS 695C.1696 Required provision concerning coverage for drug or device for contraception and related health services; prohibited acts; exceptions.

NRS 695C.1698 Required provision concerning coverage for certain services, screenings and tests relating to wellness; prohibited acts.

NRS 695C.1699 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 695C.170 Evidence of coverage: Issuance; form and contents.

NRS 695C.1701 Health maintenance organization required to offer and issue plan regardless of health status of persons; prohibited acts; authority to include wellness program in plan that offers discounts based on health status under certain circumstances.

NRS 695C.1703 Evidence of coverage covering prescription drugs: Provision of notice and information regarding use of formulary.

NRS 695C.1705 Group health care plan issued to replace discontinued policy or coverage: Requirements; notice of reduction of benefits; statement of benefits; applicability to self-insured employer.

NRS 695C.1708 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; requirements for certain health maintenance organizations concerning teledentistry.

NRS 695C.1709 Required provision in group insurance policy concerning continuing coverage for enrollee on leave without pay as result of total disability.

NRS 695C.17095 Plan 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 695C.171 Required provision in plan covering mastectomies concerning coverage relating to mastectomy; prohibited acts.

NRS 695C.1712 Health care plan covering maternity care: Prohibited acts by organization if enrollee is acting as gestational carrier; child deemed child of intended parent for purposes of plan.

NRS 695C.1713 Required provision concerning coverage of certain gynecological and obstetrical services without authorization or referral from primary care physician.

NRS 695C.1717 Required provision concerning coverage for autism spectrum disorders for certain persons; prohibited acts.

NRS 695C.172 Evidence of coverage containing exclusion, reduction or limitation of coverage relating to complications of pregnancy; prohibited acts; exception.

NRS 695C.1723 Required provision concerning coverage for treatment of certain inherited metabolic diseases.

NRS 695C.1727 Required provision in evidence of coverage covering hospital, medical or surgical expenses concerning coverage for management and treatment of diabetes.

NRS 695C.1728 Required provision concerning coverage for management and treatment of sickle cell disease and its variants; plan covering prescription drugs required to provide coverage for medically necessary prescription drugs to treat sickle cell disease and its variants.

NRS 695C.173 Plan covering family member of enrollee required to include certain coverage for enrollee’s newly born and adopted children and children placed with enrollee for adoption.

NRS 695C.1731 Required provision in plan covering treatment of colorectal cancer concerning coverage for colorectal cancer screening.

NRS 695C.1733 Required provision in certain evidences of coverage concerning coverage for certain drugs and related services for treatment of cancer.

NRS 695C.17333 Plan covering prescription drug for treatment of cancer or cancer symptom that is part of step therapy protocol: Health maintenance organization required to allow enrollee or attending practitioner to apply for exemption from step therapy protocol in certain circumstances; procedure for applying for and granting exemption.

NRS 695C.17335 Plan covering treatment of cancer through use of chemotherapy: Prohibited acts related to orally administered chemotherapy.

NRS 695C.1734 Evidence of coverage covering prescription drugs prohibited from limiting or excluding coverage for certain prescription drugs previously approved for medical condition of enrollee; exceptions.

NRS 695C.17345 Required provision in plan covering prescription drugs concerning coverage for prescription drugs irregularly dispensed for purpose of synchronization of chronic medications; prohibited acts; exception.

NRS 695C.17347 Required provision concerning coverage for screening, genetic counseling and testing related to BRCA gene in certain circumstances.

NRS 695C.1735 Required provision concerning coverage for certain screenings and tests for breast cancer; prohibited acts.

NRS 695C.1736 Required provision concerning coverage for testing, treatment and prevention of sexually transmitted diseases; required provision concerning coverage for condoms for certain insureds.

NRS 695C.1737 Required provision concerning coverage for examination of person who is pregnant for certain diseases.

NRS 695C.1743 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 695C.1745 Required provision concerning coverage for certain tests and vaccines relating to human papillomavirus; prohibited acts.

NRS 695C.1751 Required provision in plan covering treatment of prostate cancer concerning coverage for prostate cancer screening; prohibited act.

NRS 695C.1755 Evidence of coverage prohibited from excluding coverage for treatment of temporomandibular joint; exception.

NRS 695C.1757 Plan covering prescription drugs: Denial of coverage prohibited for early refills of otherwise covered topical ophthalmic products.

NRS 695C.1759 Plan covering anatomical gifts, organ transplants or treatments or services related to organ transplants: Prohibited acts by health maintenance organization if insured is person with disability.

NRS 695C.176 Required provision concerning coverage for hospice care.

REIMBURSEMENT

NRS 695C.1765 Reimbursement for acupuncture.

NRS 695C.177 Reimbursement for treatments by licensed psychologist.

NRS 695C.1773 Reimbursement for treatment by licensed marriage and family therapist or licensed clinical professional counselor.

NRS 695C.1775 Reimbursement for treatment by licensed associate in social work, social worker, master social worker, independent social worker or clinical social worker.

NRS 695C.178 Reimbursement for treatment by chiropractic physician.

NRS 695C.1783 Reimbursement for treatment by podiatrist.

NRS 695C.1789 Reimbursement for treatment by licensed clinical alcohol and drug counselor.

NRS 695C.179 Reimbursement for services provided by certain nurses.

NRS 695C.1795 Reimbursement to provider of medical transportation.

MISCELLANEOUS PROVISIONS

NRS 695C.185 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 695C.187 Schedule for payment of claims: Mandatory inclusion in arrangements for provision of health care.

NRS 695C.190 Commissioner authorized to require submission of information necessary to determine approval or disapproval of filing.

NRS 695C.200 Approval of forms and schedules.

NRS 695C.201 Offering policy of health insurance for purposes of establishing health savings account.

NRS 695C.204 Health maintenance organization prohibited from discriminating against person with respect to participation or coverage on basis of gender identity or expression.

NRS 695C.205 Health maintenance organization prohibited from denying coverage solely because applicant or insured was intoxicated or under the influence of controlled substance; exceptions.

NRS 695C.207 Health maintenance organization prohibited from requiring or using information concerning genetic testing.

NRS 695C.210 Annual report of financial condition and financial statement; quarterly statement; administrative penalty for failure to file timely report or statement; extension of time.

NRS 695C.215 Financial statement required to include report of net worth.

NRS 695C.220 Applications, filings and reports open to public inspection; exception.

NRS 695C.230 Fees; forwarding of premium tax.

NRS 695C.240 Information required to be available for inspection.

NRS 695C.260 Establishment of system for resolving complaints and system for conducting external review of adverse determinations required.

NRS 695C.265 Required procedure for arbitration of disputes concerning independent medical, dental or chiropractic evaluations.

NRS 695C.267 Provision requiring binding arbitration authorized; procedures for arbitration; declaratory relief.

NRS 695C.270 Surety bond or deposit required; waiver.

NRS 695C.275 Commissioner required to adopt regulations for licensing of provider-sponsored organizations to extent authorized by federal law.

NRS 695C.280 Commissioner authorized to adopt regulations for licensing of agents or brokers.

NRS 695C.290 Insurance company authorized to establish or contract with health maintenance organization.

NRS 695C.300 Prohibited practices.

NRS 695C.310 Examinations by Commissioner: Affairs of and compliance program used by health maintenance organization; submission of books and records; assessment of expenses; exception.

NRS 695C.311 Examinations by Commissioner: Financial condition of health maintenance organization; application for initial certificate of authority; exception.

NRS 695C.313 Financial examination: Procedure; appointment of examiner; maintenance and use of records; penalty for obstruction or interference.

NRS 695C.315 Financial examination: Payment of expense.

NRS 695C.317 Procedures required for examination and hearing.

NRS 695C.318 Insolvency; determination of financial condition; actions by Commissioner; review; regulations.

NRS 695C.319 Power of Commissioner to order corrective action for hazardous operation or violation of law; regulations.

NRS 695C.3195 Conservation, rehabilitation or liquidation of health maintenance organization: Powers of Commissioner; claims of enrollees; distribution of general assets.

NRS 695C.320 Rehabilitation, liquidation or conservation: Conduct.

NRS 695C.325 Offering health care plan to certain small employers for purposes of establishing medical savings accounts.

NRS 695C.326 Health maintenance organization required to provide data relating to claims and costs to person responsible for overseeing health care plan upon request; annual report; format.

NRS 695C.328 Disclosure of data relating to claims and costs prohibited; exceptions; penalties for unauthorized disclosure.

NRS 695C.329 Penalty for failure of health maintenance organization to comply with certain requirements for electronic maintenance, transmittal and exchange of health information. [Effective July 1, 2024.]

NRS 695C.330 Disciplinary proceedings: Grounds; effect of suspension or revocation.

NRS 695C.340 Disciplinary proceedings: Notice; hearing; judicial review.

NRS 695C.350 Violations: Remedies; penalties.

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GENERAL PROVISIONS

NRS 695C.010 Short title. This chapter may be cited as the Nevada Health Maintenance Organization Act.

(Added to NRS by 1973, 1246)

NRS 695C.020 Legislative declaration. The Legislature hereby declares that the rising cost of health services in recent years has led government agencies, private organizations, and legislative bodies to seek alternatives to the traditional medical delivery system which would provide improved health care and would provide such health care at a lower cost. The health maintenance organization is a concept which has received much attention as one means through which an improvement in delivery might be achieved. The Legislature therefore enacts this chapter to carry out this objective.

(Added to NRS by 1973, 1246)

NRS 695C.030 Definitions. As used in this chapter, unless the context otherwise requires:

1. “Comprehensive health care services” means medical services, dentistry, drugs, psychiatric and optometric and all other care necessary for the delivery of services to the consumer.

2. “Enrollee” means a natural person who has been voluntarily enrolled in a health care plan.

3. “Evidence of coverage” means any certificate, agreement or contract issued to an enrollee setting forth the coverage to which the enrollee is entitled.

4. “Health care plan” means any arrangement whereby any person undertakes to provide, arrange for, pay for or reimburse any part of the cost of any health care services and at least part of the arrangement consists of arranging for or the provision of health care services paid for by or on behalf of the enrollee on a periodic prepaid basis.

5. “Health care services” means any services included in the furnishing to any natural person of medical or dental care or hospitalization or incident to the furnishing of such care or hospitalization, as well as the furnishing to any person of any other services for the purpose of preventing, alleviating, curing or healing human illness or injury.

6. “Health maintenance organization” means any person which provides or arranges for provision of a health care service or services and is responsible for the availability and accessibility of such service or services to its enrollees, which services are paid for or on behalf of the enrollees on a periodic prepaid basis without regard to the dates health services are rendered and without regard to the extent of services actually furnished to the enrollees, except that supplementing the fixed prepayments by nominal additional payments for services in accordance with regulations adopted by the Commissioner shall not be deemed to render the arrangement not to be on a prepaid basis. A health maintenance organization, in addition to offering health care services, may offer indemnity or service benefits provided through insurers or otherwise.

7. “Provider” means any physician, hospital or other person who is licensed or otherwise authorized in this state to furnish health care services.

(Added to NRS by 1973, 1246; A 1985, 538; 1997, 1629)

NRS 695C.050 Applicability of certain provisions.

1. Except as otherwise provided in this chapter or in specific provisions of this title, the provisions of this title are not applicable to any health maintenance organization granted a certificate of authority under this chapter. This provision does not apply to an insurer licensed and regulated pursuant to this title except with respect to its activities as a health maintenance organization authorized and regulated pursuant to this chapter.

2. Solicitation of enrollees by a health maintenance organization granted a certificate of authority, or its representatives, must not be construed to violate any provision of law relating to solicitation or advertising by practitioners of a healing art.

3. Any health maintenance organization authorized under this chapter shall not be deemed to be practicing medicine and is exempt from the provisions of chapter 630 of NRS.

4. The provisions of NRS 695C.110, 695C.125, 695C.1691, 695C.1693, 695C.170, 695C.1703, 695C.1705, 695C.1709 to 695C.173, inclusive, 695C.1733, 695C.17335, 695C.1734, 695C.1751, 695C.1755, 695C.1759, 695C.176 to 695C.200, inclusive, and 695C.265 do not apply to a health maintenance organization that provides health care services through managed care to recipients of Medicaid under the State Plan for Medicaid or insurance pursuant to the Children’s Health Insurance Program pursuant to a contract with the Division of Health Care Financing and Policy of the Department of Health and Human Services. This subsection does not exempt a health maintenance organization from any provision of this chapter for services provided pursuant to any other contract.

5. The provisions of NRS 695C.16932 to 695C.1699, inclusive, 695C.1701, 695C.1708, 695C.1728, 695C.1731, 695C.17333, 695C.17345, 695C.17347, 695C.1736 to 695C.1745, inclusive, 695C.1757 and 695C.204 apply to a health maintenance organization that provides health care services through managed care to recipients of Medicaid under the State Plan for Medicaid.

6. The provisions of NRS 695C.17095 do not apply to a health maintenance organization that provides health care services to members of the Public Employees’ Benefits Program. This subsection does not exempt a health maintenance organization from any provision of this chapter for services provided pursuant to any other contract.

7. The provisions of NRS 695C.1735 do not apply to a health maintenance organization that provides health care services to:

(a) The officers and employees, and the dependents of officers and employees, of the governing body of any county, school district, municipal corporation, political subdivision, public corporation or other local governmental agency of this State; or

(b) Members of the Public Employees’ Benefits Program.

Ê This subsection does not exempt a health maintenance organization from any provision of this chapter for services provided pursuant to any other contract.

(Added to NRS by 1973, 1258; A 1983, 2030; 1995, 2720; 1997, 311, 1528; 1999, 418, 420, 1945, 2004, 2241; 2001, 141, 144, 864, 2734; 2003, 1335, 3366, 3531; 2007, 3240; 2009, 1473; 2013, 1999, 3638; 2015, 208, 644, 2127; 2017, 1846, 3953; 2019, 309, 1007, 2173; 2021, 783, 826, 1173, 2581, 2671, 3211; 2023, 816, 1351, 1787, 2044, 2223, 2377, 3525)

NRS 695C.055 Applicability of certain other provisions.

1. The provisions of NRS 449.465, 679A.200, 679B.700, subsections 7 and 8 of NRS 680A.270, subsections 2, 4, 17, 18 and 30 of NRS 680B.010, NRS 680B.020 to 680B.060, inclusive, chapters 681B and 686A of NRS, NRS 686B.010 to 686B.175, inclusive, 687B.122 to 687B.128, inclusive, 687B.310 to 687B.420, inclusive, and 687B.500 and chapters 692C and 695G of NRS apply to a health maintenance organization.

2. For the purposes of subsection 1, unless the context requires that a provision apply only to insurers, any reference in those sections to “insurer” must be replaced by “health maintenance organization.”

(Added to NRS by 1987, 469; A 1995, 472, 988; 1997, 299, 311, 2958, 2962; 2001, 2735; 2003, 3333, 3367; 2013, 3458, 3639; 2017, 2394; 2019, 1718, 3038; 2021, 2995; 2023, 2643)

NRS 695C.057 Applicability of certain provisions concerning portability and availability of health insurance.

1. A health maintenance organization is subject to the provisions of NRS 689A.470 to 689A.740, inclusive, 689B.340 to 689B.580, inclusive, and chapter 689C of NRS relating to the portability and availability of health insurance offered by such organizations. If there is a conflict between the provisions of this chapter and the provisions of NRS 689A.470 to 689A.740, inclusive, 689B.340 to 689B.580, inclusive, and chapter 689C of NRS, the provisions of NRS 689A.470 to 689A.740, inclusive, 689B.340 to 689B.580, inclusive, and chapter 689C of NRS control.

2. For the purposes of subsection 1, unless the context requires that a provision apply only to a group health plan or a carrier that provides coverage under a group health plan, any reference in those sections to “group health plan” or “carrier” must be replaced by “health maintenance organization.”

(Added to NRS by 1997, 2957; A 2013, 3639; 2019, 1718)

NRS 695C.060 Establishment of health maintenance organization.

1. Any person may apply to the Commissioner for and obtain a certificate of authority to establish and operate a health maintenance organization in compliance with this chapter. No person shall operate a health maintenance organization without obtaining a certificate of authority under this chapter. A foreign corporation may qualify under this chapter, subject to its qualification to do business in this state as a foreign corporation.

2. No person shall be certified to establish or operate a health maintenance organization in this state, nor sell or offer to sell, or solicit offers to purchase or receive advance or periodic consideration in conjunction with health care plans unless such health maintenance organization provides or arranges for the provision of comprehensive health care services.

3. Every health maintenance organization or person operating a health maintenance organization shall submit an application for a certificate of authority under NRS 695C.070 within 30 days after July 1, 1973. Each such applicant may continue to operate until the Commissioner acts upon the application. In the event that an application is denied under NRS 695C.090 and 695C.100, the applicant shall thereafter be treated as a health maintenance organization whose certificate of authority has been revoked. For purposes of this subsection, a health maintenance organization shall be deemed to be in operation only if health care services are being provided to the public generally or to some group or groups thereof.

(Added to NRS by 1973, 1247)

NRS 695C.070 Certificate of authority: Application. Each application for a certificate of authority must be verified by an officer or authorized representative of the applicant, must be in a form prescribed by the Commissioner, and must set forth or be accompanied by the following:

1. A copy of the basic organizational document, if any, of the applicant, and all amendments thereto;

2. A copy of the bylaws, rules or regulations, or a similar document, if any, regulating the conduct of the internal affairs of the applicant;

3. A list of the names, addresses and official positions of the persons who will be responsible for the conduct of the affairs of the applicant, including all members of the board of directors, board of trustees, executive committee, or other governing board or committee, the officers in the case of a corporation, and the partners or members in the case of a partnership or association;

4. A copy of any contract made or to be made between any providers or persons listed in subsection 3 and the applicant;

5. A statement generally describing the health maintenance organization, its health care plan or plans, the location of facilities at which health care services will be regularly available to enrollees and the type of health care personnel who will provide the health care services;

6. A copy of the form of evidence of coverage to be issued to the enrollees;

7. A copy of the form of the group contract, if any, which is to be issued to employers, unions, trustees or other organizations;

8. Certified financial statements showing the applicant’s assets, liabilities and sources of financial support;

9. The proposed method of marketing the plan, a financial plan which includes a 3-year projection of the initial operating results anticipated and the sources of working capital and any other sources of funding;

10. A power of attorney, executed by the applicant, appointing the Commissioner and the authorized deputies of the Commissioner as the true and lawful attorney of such applicant in and for this State upon whom all lawful process in any legal action or proceeding against the health maintenance organization on a cause of action arising in this State may be served;

11. A statement reasonably describing the geographic area to be served;

12. A description of the procedures for resolving complaints and procedures for external reviews to be used as required under NRS 695C.260;

13. A description of the procedures and programs to be implemented to meet the quality of health care requirements in NRS 695C.080;

14. A description of the mechanism by which enrollees will be afforded an opportunity to participate in matters of program content under subsection 2 of NRS 695C.110; and

15. Such other information as the Commissioner may require to make the determinations required in NRS 695C.080.

(Added to NRS by 1973, 1247; A 2003, 777)

NRS 695C.080 Certificate of authority: Evaluation of application.

1. The Commissioner shall determine whether the applicant for a certificate of authority, with respect to health care services to be furnished:

(a) Has demonstrated the willingness and ability to ensure that such health care services will be provided in a manner to ensure both availability and accessibility of adequate personnel and facilities and in a manner enhancing availability, accessibility and continuity of service;

(b) Has organizational arrangements, established in accordance with regulations promulgated by the Commissioner; and

(c) Has a procedure established in accordance with regulations of the Commissioner to develop, compile, evaluate and report statistics relating to the cost of its operations, the pattern of utilization of its services, the availability and accessibility of its services and such other matters as may be reasonably required by the Commissioner.

2. Within 90 days of receipt of the application for issuance of a certificate of authority, the Commissioner shall certify whether the proposed health maintenance organization meets the requirements of subsection 1. If the Commissioner certifies that the health maintenance organization does not meet such requirements, it shall specify in what respects it is deficient.

(Added to NRS by 1973, 1249; A 2013, 3639; 2017, 2394)

NRS 695C.090 Certificate of authority: Issuance. The Commissioner shall issue or deny a certificate of authority to any person filing an application pursuant to NRS 695C.060 within 90 days after certification. Issuance of a certificate of authority must be granted upon payment of the fees prescribed in NRS 695C.230 if the Commissioner is satisfied that the following conditions are met:

1. The persons responsible for the conduct of the affairs of the applicant are competent, trustworthy and possess good reputations.

2. The Commissioner certifies, in accordance with NRS 695C.080, that the health maintenance organization’s proposed plan of operation meets the requirements of subsection 1 of NRS 695C.080.

3. The health care plan furnishes comprehensive health care services.

4. The health maintenance organization is financially responsible and may reasonably be expected to meet its obligations to enrollees and prospective enrollees. In making this determination, the Commissioner may consider:

(a) The financial soundness of the health care plan’s arrangements for health care services and the schedule of charges used in connection therewith;

(b) The adequacy of working capital;

(c) Any agreement with an insurer, a government, or any other organization for insuring the payment of the cost of health care services;

(d) Any agreement with providers for the provision of health care services; and

(e) Any surety bond or deposit of cash or securities submitted in accordance with NRS 695C.270 as a guarantee that the obligations will be duly performed.

5. The enrollees will be afforded an opportunity to participate in matters of program content pursuant to NRS 695C.110.

6. Nothing in the proposed method of operation, as shown by the information submitted pursuant to NRS 695C.060, 695C.070 and 695C.140, or by independent investigation is contrary to the public interest.

(Added to NRS by 1973, 1249; A 1987, 469; 1993, 2400; 2013, 3640)

NRS 695C.100 Certificate of authority: Denial. A certificate of authority shall be denied only after compliance with the requirements of NRS 695C.340.

(Added to NRS by 1973, 1250)

NRS 695C.110 Governing body: Composition; participation by enrollees.

1. The governing body of any health maintenance organization may include providers, other individuals or both.

2. Such governing body shall establish a mechanism to afford the enrollees an opportunity to participate in matters of program content through the establishment of advisory panels, by the use of advisory referenda on major policy decisions or through the use of other mechanisms. In addition there shall be a provider advisory board to advise the health plan in the matter of quality of care. There shall be a joint board of consumers and providers to advise on consumer satisfaction.

(Added to NRS by 1973, 1250)

NRS 695C.120 Powers of health maintenance organization. The powers of a health maintenance organization include, but are not limited to, the following:

1. The purchase, lease, construction, renovation, operation or maintenance of hospitals, medical facilities, or both, and their ancillary equipment, and such property as may reasonably be required for its principal office or for such other purposes as may be necessary in the transaction of the business of the organization;

2. The making of loans to a medical group under contract with it in furtherance of its program or the making of loans to a corporation under its control for the purpose of acquiring or constructing medical facilities and hospitals or in furtherance of a program providing health care services to enrollees;

3. The furnishing of health care service through providers which are under contract with or employed by the health maintenance organization;

4. The contracting with any person for the performance on its behalf of certain functions such as marketing, enrollment and administration; and

5. The contracting with an insurance company licensed in this state or authorized to do business in this state for the provision of such insurance, indemnity, or reimbursement against the cost of health care services provided by the health maintenance organization.

(Added to NRS by 1973, 1250; A 1995, 2166; 1999, 1834)

NRS 695C.123 Contracts with certain federally qualified health centers.

1. Except as otherwise provided in NRS 422.273, a health maintenance organization that furnishes health care services through providers which are under contract with the organization shall use its best efforts to contract with at least one health center in each geographic area served by the organization to provide such services to enrollees if the health center:

(a) Meets all conditions imposed by the organization on similarly situated providers of health care that are under contract with the organization, including, without limitation:

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

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

(b) Agrees to reasonable reimbursement rates that are generally consistent with those offered by the organization to similarly situated providers of health care that are under contract with the organization.

2. As used in this section, “health center” has the meaning ascribed to it in 42 U.S.C. § 254b.

(Added to NRS by 2001, 1924)

1. A health maintenance organization shall not contract with a provider of health care to provide health care to an insured unless the health maintenance organization 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.

2. A contract between a health maintenance organization 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 health maintenance organization upon giving to the provider 45 days’ written notice of the modification of the health maintenance organization’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).

3. If a health maintenance organization contracts with a provider of health care to provide health care to an enrollee, the health maintenance organization 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.

4. 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, 1651; A 2001, 2735; 2003, 3367; 2011, 2535)

NRS 695C.128 Contracts to provide services pursuant to certain state programs: Payment of interest on claims. Any contract or other agreement entered into or renewed by a health maintenance organization on or after October 1, 2001:

1. To provide health care services through managed care to recipients of Medicaid under the state plan for Medicaid; or

2. With the Division of Health Care Financing and Policy of the Department of Health and Human Services to provide insurance pursuant to the Children’s Health Insurance Program,

Ê must require the health maintenance organization to pay interest to a provider of health care services on a claim that is not paid within the time provided in the contract or agreement 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.

(Added to NRS by 2001, 2734)

NRS 695C.130 Notice and approval required for exercise of powers; rules or regulations.

1. A health maintenance organization shall file notice, with adequate supporting information, with the Commissioner prior to the exercise of any power granted in subsections 1 and 2 of NRS 695C.120. The Commissioner shall disapprove such exercise of power if in the opinion of the Commissioner it would substantially and adversely affect the financial soundness of the health maintenance organization and endanger its ability to meet its obligations. If the Commissioner does not disapprove within 60 days of the filing, it is deemed approved.

2. The Commissioner may promulgate rules or regulations.

(Added to NRS by 1973, 1250)

NRS 695C.140 Notice and approval required for modification of operations; regulations.

1. A health maintenance organization shall, unless otherwise provided for in this chapter, file notice with the Commissioner before any material modification of the operations described in the information required by NRS 695C.070. If the Commissioner does not disapprove within 90 days after filing of the notice, the modification is deemed approved.

2. The Commissioner may adopt regulations to carry out the provisions of this section.

(Added to NRS by 1973, 1248; A 1995, 1632; 2013, 3640)

NRS 695C.145 Accounting principles required for certain reports and transactions; health maintenance organization subject to requirements for certain insurers.

1. A health maintenance organization shall use accounting principles that are recognized by the laws of this state or approved by the Commissioner for:

(a) All financial reports;

(b) The accounting of investments and deposits; and

2. A health maintenance organization is subject to the requirements for insurers for:

(a) Administrators, agents, brokers and solicitors, pursuant to chapter 683A of NRS;

(b) Borrowing, pursuant to NRS 693A.180;

(d) Management and agency contracts executed on or after January 1, 1992; and

(e) Officers, pursuant to NRS 693A.120 and 693A.130.

3. A domestic health maintenance organization is subject to the requirements for insurers for corporations pursuant to NRS 693A.040 to 693A.070, inclusive.

(Added to NRS by 1991, 2036)

NRS 695C.150 Fiduciary responsibilities. Any director, officer, partner, member or employee of a health maintenance organization who receives, collects, disburses or invests funds in connection with the activities of such organization shall be responsible for such funds in a fiduciary relationship to the enrollees.

(Added to NRS by 1973, 1250)

NRS 695C.160 Investments. With the exception of investments made in accordance with subsections 1 and 2 of NRS 695C.120 and NRS 695C.130, the investable funds of a health maintenance organization shall be invested only in securities or other investments permitted by the laws of this state for the investment of assets constituting the legal reserves of life insurance companies or such other securities or investments as the Commissioner may permit.

(Added to NRS by 1973, 1253)

ELIGIBILITY FOR COVERAGE

NRS 695C.161 Definitions. As used in NRS 695C.161 to 695C.169, 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 health care plan to a child pursuant to the provisions of 42 U.S.C. § 1396g-1.

(Added to NRS by 1995, 2435)

NRS 695C.163 Effect of eligibility for medical assistance under Medicaid; assignment of rights to state agency.

1. A health maintenance organization shall not, when considering eligibility for coverage or making payments under a health care plan, 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, a health maintenance organization:

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

(b) May, as otherwise allowed by its plan, 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 enrollee.

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 health care plan,

Ê the organization responsible for the health care plan shall not impose any requirements upon the state agency except requirements it imposes upon the agents or assignees of other persons covered by the same plan.

4. If a state agency is assigned any rights of an enrollee who is eligible for medical assistance under Medicaid, a health maintenance organization shall:

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

(1) Any period during which the enrollee, the spouse or a dependent of the enrollee may be or may have been covered by the health care plan; and

(2) The nature of the coverage that is or was provided by the organization, including, without limitation, the name and address of the enrollee and the identifying number of the health care plan;

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

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

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

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

(Added to NRS by 1995, 2435; A 2007, 2406)

NRS 695C.165 Health maintenance organization prohibited from asserting certain grounds to deny enrollment of child pursuant to order if parent is enrolled in health care plan. An organization shall not deny the enrollment of a child pursuant to an order for medical coverage under a health care plan in which a parent of the child is enrolled, 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 organization’s geographic area of service.

(Added to NRS by 1995, 2436)

NRS 695C.167 Certain accommodations required to be made when child is covered under health care plan of noncustodial parent. If a child has coverage under a health care plan in which a noncustodial parent of the child is enrolled, the organization responsible for that plan 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 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 or an agency of this or another state responsible for the administration of Medicaid.

(Added to NRS by 1995, 2436)

NRS 695C.169 Health maintenance organization required to authorize enrollment of child of parent who is required by order to provide medical coverage under certain circumstances; termination of coverage of child. If a parent is required by an order for medical coverage to provide coverage for a child and the parent is eligible for coverage of members of the parent’s family under a health care plan, the organization responsible for that plan:

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 organization 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, 2436)

COVERAGE GENERALLY

NRS 695C.1691 Required provision in certain plans concerning coverage for continued medical treatment; exceptions; regulations.

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

2. Except as otherwise provided in this section, if an insured who is covered by a health care plan described in subsection 1 is receiving medical treatment for a medical condition from a provider of health care whose contract with the health maintenance organization is terminated during the course of the medical treatment, the health care plan 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 health maintenance organization 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 health maintenance organization 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 health maintenance organization; 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 health maintenance organization.

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 health maintenance organization and the health maintenance organization terminated that contract because of the medical incompetence or professional misconduct of the provider of health care; and

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

5. An evidence of coverage for a health care plan 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 evidence of coverage 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, 3365)

1. Except as otherwise provided in NRS 695C.050, a health care plan issued by a health maintenance organization must provide coverage for medical treatment which an enrollee 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 enrollee has signed, before participating in the clinical trial or study, a statement of consent indicating that the enrollee 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 enrollee.

(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 health care plan.

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

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

(e) Health care services required for the clinically appropriate monitoring of the enrollee 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 enrollee 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 695C.1691, 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 health maintenance organization has contracted for such services. If the health maintenance organization has not contracted for the provision of such services, the health maintenance organization shall pay the provider the rate of reimbursement that is paid to other providers with whom the health maintenance organization 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 an enrollee 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 enrollee.

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 enrollee’s health care plan, 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 enrollee 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 enrollee.

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

5. A health maintenance organization that delivers or issues for delivery a health care plan 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 enrollee, protocols for the clinical trial or study and any other materials related to the scope of the clinical trial or study relevant to the coverage of medical treatment pursuant to this section.

6. A health maintenance organization that delivers or issues for delivery a health care plan specified in subsection 1 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 plan.

7. A health care plan 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 plan that conflicts with this section is void.

8. A health maintenance organization that delivers or issues for delivery a health care plan specified in subsection 1 is immune from liability for:

(a) Any injury to an enrollee caused by:

(1) Any medical treatment provided to the enrollee 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 enrollee 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 enrollee’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, 3528; A 2005, 2018; 2013, 3641)

1. Subject to the limitations prescribed by subsection 4, a health maintenance organization that issues a health care plan shall include in the plan 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. A health maintenance organization 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 enrollee 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

(c) Make the process described in paragraph (b) available on an Internet website maintained by the health maintenance organization.

3. If a health maintenance organization requires an enrollee to obtain prior authorization for a biomarker test described in subsection 1, the health maintenance organization 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 a health maintenance organization 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 health maintenance organization; 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 health care plan 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 plan 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 health care plan offered by a health maintenance organization 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 health maintenance organization. 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, 2221)

1. Except as otherwise provided in this section, a health maintenance organization that issues a health care plan shall include in the health care plan 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 health care plan to include coverage for cosmetic surgery performed by a plastic surgeon or reconstructive surgeon that is not medically necessary.

3. A health maintenance organization that issues a health care plan shall not categorically refuse to cover medically necessary gender-affirming treatments or procedures or revisions to prior treatments if the plan provides coverage for any such services, procedures or revisions for purposes other than gender transition or affirmation.

4. A health maintenance organization that issues a health care plan may prescribe requirements that must be satisfied before the health maintenance organization covers surgical treatment of conditions relating to gender dysphoria or gender incongruence for an enrollee 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 enrollee unless the enrollee 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, a health maintenance organization must consider the most recent Standards of Care prescribed by the World Professional Association for Transgender Health, or its successor organization.

6. A health maintenance organization shall make a reasonable effort to ensure that the benefits required by subsection 1 are made available to an enrollee through a provider of health care who participates in the network plan of the health maintenance organization. If, after a reasonable effort, the health maintenance organization is unable to make such benefits available through such a provider of health care, the health maintenance organization may treat the treatment that the health maintenance organization 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 health maintenance organization.

7. If an enrollee appeals the denial of a claim or coverage under this section on the grounds that the treatment requested by the enrollee is not medically necessary, the health maintenance organization 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 enrollee when considering the appeal.

8. A health care plan 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 plan 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 health care plan offered by a health maintenance organization 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 health maintenance organization. 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, 2041)

NRS 695C.1694 Required provision in plan covering prescription drugs or devices concerning coverage of hormone replacement therapy in certain circumstances; prohibited acts; exception.

1. A health maintenance organization which offers or issues a health care plan that provides coverage for prescription drugs or devices shall include in the plan 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. A health maintenance organization that offers or issues a health care plan that provides coverage for prescription drugs shall not:

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

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

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

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

3. Evidence of coverage 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 evidence of coverage or the renewal which is in conflict with this section is void.

4. The provisions of this section do not require a health maintenance organization 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, 2001; A 2017, 1847, 3954)

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, a health maintenance organization that has issued a health care plan which provides coverage for prescription drugs shall, notwithstanding any provision of the health care plan to the contrary:

(a) Waive any provision of the health care plan restricting the time within which an enrollee may refill a covered prescription if the enrollee:

(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 enrollee 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, 826)

NRS 695C.16946 Required provision concerning coverage of recipients of Medicaid for antipsychotic or anticonvulsant medication that is not on list of preferred prescription drugs upon failure of drug on list to treat condition. A health maintenance organization that provides health care services to recipients of Medicaid under the State Plan for Medicaid pursuant to a contract with the Division of Health Care Financing and Policy of the Department of Health and Human Services shall automatically cover any typical or atypical antipsychotic medication or anticonvulsant medication that is not on the list of preferred prescription drugs developed pursuant to NRS 422.4025 upon the demonstrated therapeutic failure of one drug on that list to adequately treat the condition of a recipient of Medicaid.

(Added to NRS by 2023, 524)

NRS 695C.16947 Plan covering prescription drugs: Submission to step therapy for drug to treat psychiatric condition prohibited in certain circumstances.

1. A health care plan which provides coverage for prescription drugs must not require an enrollee 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 enrollee, if:

(a) The drug has been approved by the Food and Drug Administration with indications for the psychiatric condition of the enrollee 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 enrollee 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 health maintenance organization is located 60 miles or more from the residence of the enrollee; and

(c) The practitioner listed in paragraph (b) who prescribed the drug knows, based on the medical history of the enrollee, 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 health care plan 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 health care plan offered by a health maintenance organization 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 health maintenance organization. The term does not include an arrangement for the financing of premiums.

(c) “Step therapy protocol” means a procedure that requires an enrollee 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 enrollee before his or her health care plan provides coverage for the recommended drug.

(Added to NRS by 2023, 1786)

NRS 695C.1695 Required provision in plan covering outpatient care concerning coverage of health care services related to hormone replacement therapy; prohibited acts.

1. A health maintenance organization that offers or issues a health care plan which provides coverage for outpatient care shall include in the plan coverage for any health care service related to hormone replacement therapy.

2. A health maintenance organization that offers or issues a health care plan that provides coverage for outpatient care shall not:

(a) Require an enrollee 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;

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

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

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

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, 2002; A 2017, 1848, 3955)

NRS 695C.1696 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, a health maintenance organization that offers or issues a health care plan shall include in the plan 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 enrollee was covered by the same health care plan;

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

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

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

3. A health maintenance organization must ensure that the benefits required by subsection 1 are made available to an enrollee through a provider of health care who participates in the network plan of the health maintenance organization.

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 health maintenance organization.

5. Except as otherwise provided in subsections 10, 11 and 13, a health maintenance organization that offers or issues a health care plan shall not:

(a) Require an enrollee 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 health care plan pursuant to subsection 1;

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

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

(d) Penalize a provider of health care who provides any such benefit to an enrollee, 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 enrollee; or

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

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

7. Except as otherwise provided in subsection 8, a health care plan 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 plan or the renewal which is in conflict with this section is void.

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

9. If a health maintenance organization 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. A health maintenance organization may require an enrollee to pay a higher deductible, copayment or coinsurance for a drug for contraception if the enrollee 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 health care plan 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 enrollee, but the health maintenance organization may charge a deductible, copayment or coinsurance for any other drug or device that provides the same method of contraception. If the health maintenance organization charges a copayment or coinsurance for a drug for contraception, the health maintenance organization may only require an enrollee 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, a health maintenance organization 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. A health maintenance organization shall not:

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

(b) Require an enrollee 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 enrollee gives birth.

15. A health maintenance organization must provide an accessible, transparent and expedited process which is not unduly burdensome by which an enrollee, or the authorized representative of the enrollee, may request an exception relating to any medical management technique used by the health maintenance organization 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 a health maintenance organization to provide services to enrollees through a network plan offered or issued by the health maintenance organization.

(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 health care plan offered by a health maintenance organization 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 health maintenance organization. The term does not include an arrangement for the financing of premiums.

(d) “Provider network contract” means a contract between a health maintenance organization and a provider of health care or pharmacy specifying the rights and responsibilities of the health maintenance organization 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, 1842, 3951; A 2021, 3286; 2023, 927, 2127)

NRS 695C.1698 Required provision concerning coverage for certain services, screenings and tests relating to wellness; prohibited acts.

1. A health maintenance organization that offers or issues a health care plan shall include in the plan 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 enrollee or as ordered by a provider of health care;

(i) Smoking cessation programs for an enrollee who is 18 years of age or older 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. A health maintenance organization must ensure that the benefits required by subsection 1 are made available to an enrollee through a provider of health care who participates in the network plan of the health maintenance organization.

3. Except as otherwise provided in subsection 5, a health maintenance organization that offers or issues a health care plan shall not:

(a) Require an enrollee 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 health care plan pursuant to subsection 1;

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

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

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

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

4. A health care plan 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 plan or the renewal which is in conflict with this section is void.

5. Except as otherwise provided in this section and federal law, a health maintenance organization 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) “Medical management technique” means a practice which is used to control the cost or utilization of health care services or prescription drug use. The term includes, without limitation, the use of step therapy, prior authorization or categorizing drugs and devices based on cost, type or method of administration.

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

(Added to NRS by 2017, 1845)

1. A health maintenance organization that offers or issues a health care plan shall include in the plan 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 health maintenance organization. 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. A health maintenance organization that offers or issues a health care plan shall reimburse a pharmacist or pharmacy that participates in the network plan of the health maintenance organization 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. A health maintenance organization 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 health maintenance organization.

4. Except as otherwise provided in this subsection, a health maintenance organization shall not subject the benefits required by paragraphs (a), (b) and (c) of subsection 1 to medical management techniques, other than step therapy. A health maintenance organization 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. A health maintenance organization 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. A health maintenance organization shall ensure that the benefits required by subsection 1 are made available to an enrollee through a provider of health care who participates in the network plan of the health maintenance organization.

7. A health care plan 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 plan that conflicts with the provisions of this section is void.

8. As used in this section:

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

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

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

(Added to NRS by 2023, 2376, 3523)

NRS 695C.170 Evidence of coverage: Issuance; form and contents.

1. Every enrollee residing in this state is entitled to evidence of coverage under a health care plan. If the enrollee obtains coverage under a health care plan through an insurance policy, whether by option or otherwise, the insurer shall issue the evidence of coverage. Otherwise, the health maintenance organization shall issue the evidence of coverage.

2. Evidence of coverage or amendment thereto must not be issued or delivered to any person in this state until a copy of the form of the evidence of coverage or amendment thereto has been filed with and approved by the Commissioner.

3. An evidence of coverage:

(a) Must not contain any provisions or statements which are unjust, unfair, inequitable, misleading, deceptive, which encourage misrepresentation or which are untrue, misleading or deceptive as defined in subsection 1 of NRS 695C.300; and

(b) Must contain a clear and complete statement, if a contract, or a reasonably complete summary if a certificate, of:

(1) The health care services and the insurance or other benefits, if any, to which the enrollee is entitled under the health care plan;

(2) Any limitations on the services, kind of services, benefits, or kind of benefits, to be provided, including any deductible or copayment feature;

(3) Where and in what manner the services may be obtained; and

(4) The total amount of payment for health care services and the indemnity or service benefits, if any, which the enrollee is obligated to pay.

Ê Any subsequent change may be evidenced in a separate document issued to the enrollee.

4. A copy of the form of the evidence of coverage to be used in this state and any amendment thereto is subject to the requirements for filing and approval of subsection 2 unless it is subject to the jurisdiction of the Commissioner under the laws governing health insurance, in which event the provisions for filing and approval of those laws apply. To the extent that such provisions do not apply to the requirements in subsection 3, such provisions are amended to incorporate the requirements of subsection 3 in approving or disapproving an evidence of coverage required by subsection 2.

(Added to NRS by 1973, 1251; A 1975, 1852; 1979, 1182; 1983, 2041; 2009, 1817)

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

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

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

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

2. A health maintenance organization 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 enrollee; or

(b) Require an enrollee, 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 enrollee who does not have such a health status.

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

4. A health maintenance organization 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 enrollee 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 enrollee or an enrollee and his or her dependents, as applicable, under the plan;

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

(e) The plan discloses in all plan materials describing the terms of the wellness program, and in any disclosure that an enrollee 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 2019, 308)

NRS 695C.1703 Evidence of coverage covering prescription drugs: Provision of notice and information regarding use of formulary.

1. A health maintenance organization or insurer that offers or issues evidence of coverage which provides coverage for prescription drugs shall include with any evidence of that coverage provided to an enrollee, notice of whether a formulary is used and, if so, of the opportunity to secure information regarding the formulary from the organization or 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 organization or insurer for making a request for information regarding the formulary pursuant to subsection 2.

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

(a) Provide to any enrollee 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 organization or 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, 863)

NRS 695C.1705 Group health care plan issued to replace discontinued policy or coverage: Requirements; notice of reduction of benefits; statement of benefits; applicability to self-insured employer. Except as otherwise provided in the provisions of NRS 689B.340 to 689B.580, inclusive, and chapter 689C of NRS relating to the portability and accountability of health insurance:

1. A group health care plan issued by a health maintenance organization 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 plan is issued within 60 days after the date on which the previous policy or coverage was discontinued.

2. If an employer obtains a replacement plan 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 pursuant to NRS 608.1577.

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

4. If an employee or enrollee was a recipient of benefits under the coverage provided pursuant to NRS 695C.1709, the employee or enrollee is not entitled to have issued to him or her by a health maintenance organization a replacement plan unless the employee or enrollee has reported for his or her normal employment for a period of 90 consecutive days after last being eligible to receive any benefits under the coverage provided pursuant to NRS 695C.1709.

5. The provisions of this section apply to a self-insured employer who provides health benefits to the employees of the self-insured employer and replaces those benefits with a group health care plan issued by a health maintenance organization.

(Added to NRS by 1987, 850; A 1989, 1253; 1997, 2958; 2013, 3644)

1. A health care plan of a health maintenance organization must include coverage for services provided to an enrollee through telehealth to the same extent as though provided in person or by other means.

2. A health care plan of a health maintenance organization 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. A health maintenance organization shall not:

(a) Require an enrollee 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 enrollee 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 enrollee 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 health care plan of a health maintenance organization must not require an enrollee to obtain prior authorization for any service provided through telehealth that is not required for the service when provided in person. Such a health care plan 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. A health maintenance organization that provides medical services to recipients of Medicaid under the State Plan for Medicaid or insurance pursuant to the Children’s Health Insurance Program pursuant to a contract with the Division of Health Care Financing and Policy of the Department of Health and Human Services shall provide referrals to providers of dental services who provide services through teledentistry.

6. A health maintenance organization that provides dental services to recipients of Medicaid under the State Plan for Medicaid or insurance pursuant to the Children’s Health Insurance Program pursuant to a contract with the Division of Health Care Financing and Policy of the Department of Health and Human Services shall:

(a) Maintain a list of providers of dental services included in the network of the health maintenance organization who offer services through teledentistry;

(b) At least quarterly, update the list and submit a copy of the updated list to the emergency department of each hospital located in this State; and

(c) Allow such providers of dental services to include on claim forms codes for teledentistry services provided through both real-time interactions and asynchronous transmissions of medical and dental information.

7. The provisions of this section do not require a health maintenance organization to:

(a) Ensure that covered services are available to an enrollee 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 health maintenance organization is not otherwise required by law to do so.

8. Evidence of coverage 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 plan or the renewal which is in conflict with this section is void.

9. 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) “Teledentistry” has the meaning ascribed to it in NRS 631.107.

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

(Added to NRS by 2015, 643; A 2021, 3036, 3037, 3038, 3039; 2023, 231, 237, 3336)

NRS 695C.1709 Required provision in group insurance policy concerning continuing coverage for enrollee 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 enrollee, because of an injury or illness, to perform substantially the duties related to his or her employment for which the enrollee is otherwise qualified.

2. No policy of group insurance to which an enrollee is entitled under a health care plan provided by a health maintenance organization may be delivered or issued for delivery in this state unless it provides continuing coverage for an enrollee and dependents of the enrollee who are otherwise covered by the policy while the enrollee is on leave without pay as a result of a total disability. The coverage must be for any injury or illness suffered by the enrollee which is not related to the total disability or for any injury or illness suffered by a dependent of the enrollee. The coverage 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 enrollee is terminated;

(b) The date on which the enrollee obtains another policy of health insurance;

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

Ê whichever occurs first.

(Added to NRS by 1989, 1253)

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

2. A health maintenance organization that offers or issues a health care plan 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 enrollee and his or her attending practitioner may:

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

(2) Appeal a decision made by the health maintenance organization 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 health maintenance organization; 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 health maintenance organization shall respond to the request or appeal within 24 hours after the request is made or the appeal is submitted, as applicable.

3. A health maintenance organization shall grant a request to exempt an enrollee from a step therapy protocol made in accordance with the process established pursuant to subsection 2 if the attending practitioner for the enrollee submits to the health maintenance organization a statement which provides an adequate justification for the exemption and any documentation necessary to support the statement. The health maintenance organization 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 enrollee;

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

(3) Has been tried by the enrollee, regardless of whether the enrollee was covered by the current health care plan 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 enrollee, based on medical necessity; or

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

4. If a health maintenance organization 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 health maintenance organization shall immediately authorize coverage for and dispensing of the drug chosen by the attending practitioner for the enrollee.

6. A health care plan 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 any prescription drug to which the provisions of NRS 695C.17333 apply.

8. As used in this section:

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

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

(Added to NRS by 2023, 815)

NRS 695C.171 Required provision in plan covering mastectomies concerning coverage relating to mastectomy; prohibited acts.

1. A health maintenance plan 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, but is not limited to, augmentation mammoplasty, reduction mammoplasty and mastopexy.

(Added to NRS by 1983, 615; A 1989, 1891; 2001, 2250)

NRS 695C.1712 Health care plan covering maternity care: Prohibited acts by organization if enrollee is acting as gestational carrier; child deemed child of intended parent for purposes of plan.

1. A health maintenance organization that offers or issues a health care plan that includes coverage for maternity care shall not deny, limit or seek reimbursement for maternity care because the enrollee is acting as a gestational carrier.

2. If an enrollee 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 health care plan.

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

(Added to NRS by 2019, 1007)

NRS 695C.1713 Required provision concerning coverage of certain gynecological and obstetrical services without authorization or referral from primary care physician.

1. A health care plan must include a provision authorizing a woman covered by the plan 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 health care plan to designate an obstetrician or gynecologist as her primary care physician.

3. An evidence of coverage 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 evidence of coverage or the renewal which is in conflict with this section is void.

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

(Added to NRS by 1999, 1944)

NRS 695C.1717 Required provision concerning coverage for autism spectrum disorders for certain persons; prohibited acts.

1. A health care plan issued by a health maintenance organization must provide coverage for screening for and diagnosis of autism spectrum disorders and for treatment of autism spectrum disorders to persons covered by the health care plan 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 health care plan to the same extent as other medical services or prescription drugs covered by the plan.

3. A health care plan issued by a health maintenance organization that provides coverage for outpatient care shall not:

(a) Require an enrollee 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 plan; or

(b) Refuse to issue a health care plan or cancel a health care plan solely because the person applying for or covered by the plan 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, a health maintenance organization shall not limit the number of visits an enrollee 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 A health maintenance organization may request a copy of and review a treatment plan created pursuant to this subsection.

6. Evidence of coverage 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 evidence of coverage or the renewal which is in conflict with subsection 1 or 2 is void.

7. Nothing in this section shall be construed as requiring a health maintenance organization 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, 1471; A 2015, 689, 691; 2017, 1502, 4259; 2019, 2563; 2021, 1653)

NRS 695C.172 Evidence of coverage containing exclusion, reduction or limitation of coverage relating to complications of pregnancy; prohibited acts; exception.

1. No health maintenance organization may issue evidence of coverage under a health care plan to any enrollee 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 and complies with the provisions of NRS 689B.340 to 689B.580, inclusive, and chapter 689C of NRS relating to the portability and accountability of health insurance.

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

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

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

3. Evidence of coverage under a health care plan subject to the provisions of this chapter which is issued on or after July 1, 1977, has the legal effect of including the coverage required by this section, and any provision which is in conflict with this section is void.

(Added to NRS by 1977, 416; A 1997, 2959; 2013, 3644)

NRS 695C.1723 Required provision concerning coverage for treatment of certain inherited metabolic diseases.

1. A health maintenance plan 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 health maintenance plan was purchased.

3. Any evidence of coverage 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 evidence of coverage 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, 1527; A 2021, 3624)

NRS 695C.1727 Required provision in evidence of coverage covering hospital, medical or surgical expenses concerning coverage for management and treatment of diabetes.

1. No evidence of coverage that provides coverage for hospital, medical or surgical expenses may be delivered or issued for delivery in this state unless the evidence of coverage 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 an evidence of coverage specified in subsection 1 shall provide the coverage required by this section subject to the same deductible, copayment, coinsurance and other such conditions for the evidence of coverage that are required under the evidence of coverage.

3. Evidence of coverage 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 evidence of coverage 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 enrollee after the enrollee 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 enrollee and which requires modification of the enrollee’s program of self-management of diabetes; and

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

(Added to NRS by 1997, 745; A 2013, 3645)

1. A health maintenance organization that issues a health care plan shall include in the plan coverage for:

(a) Necessary case management services for an enrollee who has been diagnosed with sickle cell disease and its variants; and

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

2. A health maintenance organization that issues a health care plan which provides coverage for prescription drugs shall include in the plan coverage for medically necessary prescription drugs to treat sickle cell disease and its variants.

3. A health maintenance organization shall establish a plan for each enrollee under 18 years of age who has been diagnosed with sickle cell disease and its variants to transition the enrollee from pediatric care to adult care when the enrollee reaches 18 years of age.

4. A health maintenance organization 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.

5. 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, 2172)

NRS 695C.173 Plan covering family member of enrollee required to include certain coverage for enrollee’s newly born and adopted children and children placed with enrollee for adoption.

1. All individual and group health care plans which provide coverage for a family member of the enrollee must as to such coverage provide that the health care services applicable for children are payable with respect to:

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

2. The evidence of coverage 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 charge, if any, must be furnished to the health maintenance organization 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 preventive health care services as well as coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities and, within the limits of the policy, necessary transportation costs from place of birth to the nearest specialized treatment center under major medical policies, and with respect to basic policies to the extent such costs are charged by the treatment center.

4. For covered services provided to the child, the health maintenance organization shall reimburse noncontracted providers of health care to an amount equal to the average amount of payment for which the organization has agreements, contracts or arrangements for those covered services.

(Added to NRS by 1975, 1110; A 1989, 741; 1995, 2436; 1997, 2959; 2019, 309)

NRS 695C.1731 Required provision in plan covering treatment of colorectal cancer concerning coverage for colorectal cancer screening.

1. A health care plan issued by a health maintenance organization 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. An evidence of coverage for a health care plan 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 evidence of coverage that conflicts with the provisions of this section is void.

(Added to NRS by 2003, 1335)

NRS 695C.1733 Required provision in certain evidences of coverage concerning coverage for certain drugs and related services for treatment of cancer. Except as otherwise provided in NRS 695C.1693:

1. No evidence of coverage 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 evidence of coverage 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 enrollee.

(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. Any evidence of coverage 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 evidence of coverage that conflicts with the provisions of this section is void.

(Added to NRS by 1999, 761; A 2003, 3531)

1. A health maintenance organization that offers or issues a health care plan 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 enrollee who has been diagnosed with stage 3 or 4 cancer or the attending practitioner of the enrollee to apply for an exemption from the step therapy protocol. The application process for such an exemption must:

(a) Allow the enrollee or attending practitioner, or a designated advocate for the enrollee or attending practitioner, to present to the health maintenance organization 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 enrollee demonstrating that the enrollee 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, a health maintenance organization 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 enrollee, a health maintenance organization 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 enrollee.

5. A health maintenance organization shall disclose to the enrollee 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. A health maintenance organization 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 enrollee 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 enrollee 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 enrollee and the known characteristics of the treatment;

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

(2) Has prevented or is likely to prevent the enrollee 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 enrollee is stable while being treated with the prescription drug for which the exemption is requested and the enrollee 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 a health maintenance organization approves an application for an exemption from a step therapy protocol pursuant to this section, the health maintenance organization must cover the prescription drug to which the exemption applies in accordance with the terms of the applicable health care plan. The health maintenance organization 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 health maintenance organization must continue to cover the drug for as long as it is necessary to treat the enrollee for the cancer or symptom. The health maintenance organization 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 enrollee for the cancer or symptom. The health maintenance organization shall provide a report of the review to the enrollee.

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

9. A health care plan 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 health care plan 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 enrollee.

(Added to NRS by 2021, 2669)

NRS 695C.17335 Plan covering treatment of cancer through use of chemotherapy: Prohibited acts related to orally administered chemotherapy.

1. A health maintenance organization that offers or issues a health care plan 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 such 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. Evidence of coverage 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 evidence of coverage or the renewal which is in conflict with this section is void.

3. Nothing in this section shall be construed as requiring a health maintenance organization 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, 1999; A 2013, 3659)

1. Except as otherwise provided in this section, evidence of coverage 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 health maintenance organization or insurer for a medical condition of an enrollee and the enrollee’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 enrollee; and

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

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 health maintenance organization or insurer from charging a deductible, copayment or coinsurance for the provision of benefits for prescription drugs to the enrollee 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 evidence of coverage that is medically appropriate for the enrollee; or

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

3. Any provision of an evidence of coverage 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, 863; A 2003, 2300; 2017, 639)

1. A health maintenance organization that offers or issues a health care plan 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 enrollee’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 enrollee; and

(2) The enrollee 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 health maintenance organization.

(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. An evidence of coverage 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 evidence of coverage 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, 2126)

NRS 695C.17347 Required provision concerning coverage for screening, genetic counseling and testing related to BRCA gene in certain circumstances.

1. A health maintenance organization that issues a health care plan 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. A health maintenance organization shall ensure that the benefits required by subsection 1 are made available to an enrollee through a provider of health care who participates in the network plan of the health maintenance organization.

3. A health care plan 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 plan that conflicts with the provisions of this section is void.

4. As used in this section:

(a) “Network plan” means a health care plan offered by a health maintenance organization 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 health maintenance organization. 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, 783)

NRS 695C.1735 Required provision concerning coverage for certain screenings and tests for breast cancer; prohibited acts.

1. A health care plan of a health maintenance organization must provide coverage for benefits payable for expenses incurred for:

(a) A mammogram to screen for breast cancer annually for enrollees 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 enrollee’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 enrollee.

(c) A diagnostic imaging test for breast cancer at the age deemed most appropriate, when medically necessary, as recommended by the enrollee’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.

3. Except as otherwise provided in subsection 5, a health maintenance organization that offers or issues a health care plan shall not:

(a) Except as otherwise provided in subsection 6, require an enrollee 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 health care plan pursuant to subsection 1;

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

(c) Offer or pay any type of material inducement or financial incentive to an enrollee to discourage the enrollee from obtaining any benefit provided in the health care plan pursuant to subsection 1;

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

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

4. A health care plan 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 plan 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 enrollee pursuant to 26 U.S.C. § 223, the prohibitions of paragraph (a) of subsection 3 shall apply only for a qualified health care plan with respect to the deductible of such a health care plan after the enrollee 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:

(d) “Qualified health care plan” means a health care plan of a health maintenance organization 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, 1891; A 1997, 1730; 2017, 1849; 2023, 1352)

NRS 695C.1736 Required provision concerning coverage for testing, treatment and prevention of sexually transmitted diseases; required provision concerning coverage for condoms for certain insureds.

1. A health maintenance organization that offers or issues a health care plan shall include in the plan:

(a) Coverage of testing for and the treatment and prevention of sexually transmitted diseases, including, without limitation, Chlamydia trachomatis, gonorrhea, syphilis, human immunodeficiency virus and hepatitis B and C, for all enrollees, regardless of age. Such coverage must include, without limitation, the coverage required by NRS 695C.1737 and 695C.1743.

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

2. A health care plan 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 plan that conflicts with the provisions of this section is void.

(Added to NRS by 2023, 3524)

NRS 695C.1737 Required provision concerning coverage for examination of person who is pregnant for certain diseases.

1. A health maintenance organization that issues a health care plan 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 enrollee by a provider of health care, facility or medical laboratory that participates in the network plan of the health maintenance organization; and

(b) Without prior authorization.

3. A health care plan 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 plan 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, 2580)

1. A health maintenance organization that offers or issues a health care plan shall include in the plan 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 health maintenance organization;

(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 health maintenance organization.

2. A health maintenance organization that offers or issues a health care plan shall reimburse:

(a) A pharmacist who participates in the network plan of the health maintenance organization 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 health maintenance organization 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. A health maintenance organization 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 enrollee is diagnosed.

4. A health maintenance organization shall ensure that the benefits required by subsection 1 are made available to an enrollee through a provider of health care who participates in the network plan of the health maintenance organization.

5. A health care plan 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 plan that conflicts with the provisions of this section is void.

6. As used in this section:

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

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

(Added to NRS by 2021, 3211; A 2023, 3525)

NRS 695C.1745 Required provision concerning coverage for certain tests and vaccines relating to human papillomavirus; prohibited acts.

1. A health care plan of a health maintenance organization 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 and 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.

3. Except as otherwise provided in subsection 5, a health maintenance organization that offers or issues a health care plan shall not:

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

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

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

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

4. Any evidence of coverage 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 evidence of coverage or the renewal which is in conflict with this section is void.

6. As used in this section:

(a) “Human papillomavirus vaccine” means the Quadrivalent Human Papillomavirus Recombinant Vaccine or its successor which is approved by the Food and Drug Administration for the prevention of human papillomavirus infection and cervical cancer.

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

(Added to NRS by 2007, 3239; A 2013, 3645; 2017, 1850)

NRS 695C.1751 Required provision in plan covering treatment of prostate cancer concerning coverage for prostate cancer screening; prohibited act.

1. A health care plan of a health maintenance organization 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 health care plan of a health maintenance organization 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. Any evidence of coverage for a health care plan of a health maintenance organization 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 evidence of coverage or the renewal which is in conflict with subsection 1 is void.

(Added to NRS by 2007, 3239)

NRS 695C.1755 Evidence of coverage prohibited from excluding coverage for treatment of temporomandibular joint; exception.

1. Except as otherwise provided in this section, no evidence of coverage 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 evidence of coverage or by a claims settlement practice. An evidence of coverage 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 health maintenance organization 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 enrollee, but in no case more than 50 percent of the maximum benefits provided by the evidence of coverage for such treatment; and

(b) Treatment which is medically necessary.

3. Any provision of an evidence of coverage 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, 2139)

NRS 695C.1757 Plan covering prescription drugs: Denial of coverage prohibited for early refills of otherwise covered topical ophthalmic products.

1. A health maintenance organization which offers or issues a health care plan that provides coverage for prescription drugs shall not deny coverage for a topical ophthalmic product which is otherwise approved for coverage by the health maintenance organization when the enrollee, 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 established by the health care plan.

3. An evidence of coverage 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 evidence of coverage 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, 208)

1. A health maintenance organization that offers or issues a health care plan 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 enrollee for care related to an organ transplant because the enrollee 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 enrollee 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, 1173)

NRS 695C.176 Required provision concerning coverage for hospice care. Each health care plan must provide benefits for hospice care.

(Added to NRS by 1983, 1936; A 1985, 1779; 1989, 1033)

REIMBURSEMENT

NRS 695C.1765 Reimbursement for acupuncture. If any evidence of coverage provides coverage for acupuncture performed by a physician, the insured is entitled to reimbursement for acupuncture performed by a person who is licensed pursuant to chapter 634A of NRS.

(Added to NRS by 1991, 1134)

NRS 695C.177 Reimbursement for treatments by licensed psychologist. If any evidence of coverage provides coverage for treatment of an illness which is within the authorized scope of the practice of a qualified psychologist, the insured is entitled to reimbursement for treatments by a licensed psychologist.

(Added to NRS by 1981, 576; A 1989, 1553; 2017, 935)

NRS 695C.1773 Reimbursement for treatment by licensed marriage and family therapist or licensed clinical professional counselor. If any evidence of coverage 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, 2134; A 2007, 3094)

NRS 695C.1775 Reimbursement for treatment by licensed associate in social work, social worker, master social worker, independent social worker or clinical social worker. If any evidence of coverage 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, 3508)

NRS 695C.178 Reimbursement for treatment by chiropractic physician.

1. If any evidence of coverage 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, 328)

NRS 695C.1783 Reimbursement for treatment by podiatrist.

1. If any evidence of coverage 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 695C.1789 Reimbursement for treatment by licensed clinical alcohol and drug counselor. If any evidence of coverage 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, 3094; A 2017, 2211)

NRS 695C.179 Reimbursement for services provided by certain nurses.

1. If any evidence of coverage 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 evidence of coverage 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, 1448)

NRS 695C.1795 Reimbursement to provider of medical transportation.

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

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

(Added to NRS by 1989, 1274)

MISCELLANEOUS PROVISIONS

1. Except as otherwise provided in subsection 2 and NRS 439B.754, a health maintenance organization shall approve or deny a claim relating to a health care plan within 30 days after the health maintenance organization receives the claim. If the claim is approved, the health maintenance organization 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 health maintenance organization 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 health maintenance organization 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 health maintenance organization shall notify the provider of health care services of all the specific reasons for the delay in approving or denying the claim. The health maintenance organization shall approve or deny the claim within 30 days after receiving the additional information. If the claim is approved, the health maintenance organization shall pay the claim within 30 days after it receives the additional information. If the approved claim is not paid within that period, the health maintenance organization shall pay interest on the claim in the manner prescribed in subsection 1.

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

4. A health maintenance organization 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 health maintenance organization.

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

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

(Added to NRS by 1991, 1331; A 1999, 1651; 2001, 2735; 2003, 3368; 2019, 333)

NRS 695C.187 Schedule for payment of claims: Mandatory inclusion in arrangements for provision of health care.

1. A health maintenance organization shall not:

(a) Enter into any contract or agreement, or make any other arrangements, with a provider for the provision of health care; or

(b) Employ a provider pursuant to a contract, an agreement or any other arrangement to provide health care,

Ê unless the contract, agreement or other arrangement specifically provides that the health maintenance organization and provider agree to the schedule for the payment of claims set forth in NRS 695C.185.

2. Any contract, agreement or other arrangement between a health maintenance organization and a provider that is entered into or renewed on or after October 1, 2001, that does not specifically include a provision concerning the schedule for the payment of claims as required by subsection 1 shall be deemed to conform with the requirements of subsection 1 by operation of law.

(Added to NRS by 2001, 2734)

NRS 695C.190 Commissioner authorized to require submission of information necessary to determine approval or disapproval of filing. The Commissioner may require the submission of whatever relevant information the Commissioner deems necessary in determining whether to approve or disapprove a filing made pursuant to NRS 695C.170 to 695C.200, inclusive.

(Added to NRS by 1973, 1252; A 1985, 1448; 1989, 1274)

NRS 695C.194 Provision of health care services to recipients of Medicaid or enrollees in Children’s Health Insurance Program: Requirement to contract with hospital with certain endorsement for inclusion in network of providers. A health maintenance organization that provides health care services to recipients of Medicaid under the State Plan for Medicaid or insurance pursuant to the Children’s Health Insurance Program pursuant to a contract with the Division of Health Care Financing and Policy of the Department of Health and Human Services shall negotiate in good faith to enter into a contract with a hospital with an endorsement as a crisis stabilization center pursuant to NRS 449.0915 to include the hospital in the network of providers under contract with the health maintenance organization to provide services to recipients of Medicaid or enrollees in the Children’s Health Insurance Program, as applicable.

(Added to NRS by 2019, 1926; A 2021, 240)

NRS 695C.200 Approval of forms and schedules. The Commissioner shall within a reasonable period approve any form if the requirements of NRS 695C.170 are met. It is unlawful to issue such form or to use such schedule of charges until approved. If the Commissioner disapproves such filing, the Commissioner shall notify the filer. In the notice, the Commissioner shall specify the reasons for disapproval. A hearing will be granted within 90 days after a request in writing by the person filing.

(Added to NRS by 1973, 1251; A 2013, 3646)

NRS 695C.201 Offering policy of health insurance for purposes of establishing health savings account. A health maintenance organization may, subject to regulation by the Commissioner, offer a policy of health insurance that has a high deductible and is in compliance with 26 U.S.C. § 223 for the purposes of establishing a health savings account.

(Added to NRS by 2005, 2158)

NRS 695C.202 Provision of health care services to recipients of Medicaid: Notice to recipients if Department of Health and Human Services obtains waiver to provide dental care to persons with diabetes; coordination to ensure receipt of such care. If the Department of Health and Human Services obtains a waiver to provide the dental care described in NRS 422.27247, a health maintenance organization that provides health care services through managed care to recipients of Medicaid must:

1. Provide written notice to each such recipient who is diagnosed with diabetes and is eligible to receive dental care pursuant to NRS 422.27247 of his or her eligibility to receive such care; and

2. Coordinate with any entity necessary to ensure that eligible recipients of Medicaid receive the benefits prescribed by that section.

(Added to NRS by 2019, 2418)

NRS 695C.203 Health maintenance organization prohibited from denying coverage solely because claim involves act that constitutes domestic violence or applicant or insured was victim of domestic violence. A health maintenance organization shall not deny a claim, refuse to issue a policy or cancel a policy 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 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 695C.204 Health maintenance organization prohibited from discriminating against person with respect to participation or coverage on basis of gender identity or expression. A health maintenance organization that issues a health care plan shall not discriminate against any person with respect to participation or coverage under the plan 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 health care plan 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 enrollee or a family member of the enrollee;

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 plan 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, 2043)

NRS 695C.205 Health maintenance organization prohibited from denying coverage solely because applicant or insured was intoxicated or under the influence of controlled substance; exceptions.

1. Except as otherwise provided in subsection 2, a health maintenance organization shall not:

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

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

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

2. The provisions of subsection 1 do not prohibit a health maintenance organization from enforcing a provision included in a health care plan 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 participation under a health care plan solely because of such a claim; or

3. The provisions of this section do not apply to a health maintenance organization under a health care plan that provides coverage for long-term care or disability income.

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

NRS 695C.207 Health maintenance organization prohibited from requiring or using information concerning genetic testing.

1. A health maintenance organization shall not:

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

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

(c) Determine the rates or any other aspect of the coverage or benefits for health care provided to an enrollee based on whether the enrollee or any member of the family of the enrollee has taken a genetic test.

2. 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 which uses deoxyribonucleic acid extracted from the cells of a person or a diagnostic test, to determine the presence of abnormalities or deficiencies, including carrier status, that:

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

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

(Added to NRS by 1997, 1461; A 2019, 310)

NRS 695C.210 Annual report of financial condition and financial statement; quarterly statement; administrative penalty for failure to file timely report or statement; extension of time.

1. Every health maintenance organization shall file with the Commissioner on or before March 1 of each year a report showing its financial condition on the last day of the preceding calendar year. The report must be verified by at least two principal officers of the organization.

2. The report must be on forms prescribed by the Commissioner and must include:

(a) A financial statement of the organization, including its balance sheet and receipts and disbursements for the preceding calendar year;

(b) Any material changes in the information submitted pursuant to NRS 695C.070;

(c) The number of persons enrolled during the year, the number of enrollees as of the end of the year, the number of enrollments terminated during the year and, if requested by the Commissioner, a compilation of the reasons for such terminations;

(d) The number and amount of malpractice claims initiated against the health maintenance organization and any of the providers used by it during the year broken down into claims with and without form of legal process, and the disposition, if any, of each such claim, if requested by the Commissioner;

(e) A summary of information compiled pursuant to paragraph (c) of subsection 1 of NRS 695C.080 in such form as required by the Commissioner; and

(f) Such other information relating to the performance of the health maintenance organization as is necessary to enable the Commissioner to carry out his or her duties pursuant to this chapter.

3. Every health maintenance organization shall file with the Commissioner annually an audited financial statement of the organization in accordance with the provisions of subsection 1 of NRS 680A.265. Upon written request, the Commissioner may grant a 30-day extension.

4. Every health maintenance organization shall file with the Commissioner and the National Association of Insurance Commissioners a quarterly statement in the form most recently adopted by the National Association of Insurance Commissioners for that type of insurer. The quarterly statement must be:

(a) Prepared in accordance with the instructions which are applicable to that form, including, without limitation, the required date of submission for the form; and

(b) Filed by electronic means.

5. If an organization fails to file timely a report or financial statement required by this section, it shall pay an administrative penalty of $100 per day until the report or statement is filed, except that the total penalty must not exceed $3,000. The Attorney General shall recover the penalty in the name of the State of Nevada.

6. The Commissioner may grant a reasonable extension of time for filing any report or statement required by this section, if the request for an extension is submitted in writing and shows good cause.

(Added to NRS by 1973, 1252; A 1991, 2204; 1995, 1632, 2681; 2013, 3646; 2019, 1718)

NRS 695C.215 Financial statement required to include report of net worth. A health maintenance organization which has been issued a certificate of authority pursuant to this chapter shall maintain and report on each financial statement filed with the Commissioner pursuant to NRS 695C.210 a net worth in an amount which is not less than the greatest of:

1. One million five hundred thousand dollars;

2. Two percent of the first $150,000,000 earned as revenue from premiums collected in the preceding 12-month period, plus 1 percent of the amount in excess of $150,000,000 earned as revenue from premiums collected in that same period; or

3. The amount of risk-based capital required by regulations adopted by the Commissioner pursuant to NRS 681B.550.

(Added to NRS by 2019, 1717)

NRS 695C.220 Applications, filings and reports open to public inspection; exception. All applications, filings and reports required under this chapter shall be treated as public documents except as otherwise provided in this chapter.

(Added to NRS by 1973, 1258)

NRS 695C.230 Fees; forwarding of premium tax.

1. Every health maintenance organization subject to this chapter shall pay to the Commissioner the following fees:

(a) For filing an application for a certificate of authority, $2,450.

(b) For issuance of a certificate of authority, $250.

(d) For the renewal of a certificate of authority, $2,450.

(e) For filing each annual report, $25.

(f) In addition to any other fee or charge, all applicable fees required pursuant to NRS 680C.110.

2. At the time of filing the annual report the health maintenance organization shall forward to the Department of Taxation the tax and any penalty for nonpayment or delinquent payment of the tax in accordance with the provisions of chapter 680B of NRS.

3. All fees paid pursuant to this section shall be deemed earned when paid and may not be refunded.

(Added to NRS by 1973, 1257; A 1987, 470; 1991, 1634; 1993, 1923; 2009, 1818)

NRS 695C.240 Information required to be available for inspection. Every health maintenance organization shall have available for inspection the following information:

1. A current statement of financial condition including a balance sheet and summary of receipts and disbursements;

2. A description of the organizational structure and operation of the health maintenance organization and a summary of any material changes since the issuance of the last report;

3. A description of services and information as to where and how to secure them; and

4. A clear and understandable description of the health maintenance organization’s method for resolving enrollee complaints.

(Added to NRS by 1973, 1252)

NRS 695C.260 Establishment of system for resolving complaints and system for conducting external review of adverse determinations required. Each health maintenance organization shall establish:

1. A system for resolving complaints which complies with the provisions of NRS 695G.200 to 695G.230, inclusive; and

2. A system for conducting external reviews of adverse determinations that complies with the provisions of NRS 695G.241 to 695G.310, inclusive.

(Added to NRS by 1973, 1253; A 1997, 311; 2003, 778; 2011, 3395)

NRS 695C.265 Required procedure for arbitration of disputes concerning independent medical, dental or chiropractic evaluations.

1. If a health maintenance organization, 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 provided under the evidence of coverage:

(a) The evidence of coverage must include a procedure for binding arbitration to resolve disputes concerning independent medical evaluations pursuant to the rules of the American Arbitration Association; and

(b) 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.

2. 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 evidence of coverage within 30 days after the insured person receives the finding of the evaluation. Upon its receipt of an appeal, the insurer shall so notify in writing the primary treating physician, dentist or chiropractic physician.

3. 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 2 concerning the appeal of the insured person.

(Added to NRS by 1989, 2116; A 2015, 197)

NRS 695C.267 Provision requiring binding arbitration authorized; procedures for arbitration; declaratory relief.

1. Except as otherwise provided in NRS 695C.265 and subject to the approval of the Commissioner, a health maintenance organization may include in any evidence of coverage issued by the organization a provision which requires an enrollee to whom the evidence of coverage is issued and the health maintenance organization to submit for binding arbitration any dispute between the enrollee and the organization concerning any matter directly or indirectly related to, or associated with, the evidence of coverage or the health care plan or health care services of the health maintenance organization. If such a provision is included in the evidence of coverage:

(a) An enrollee must be given the opportunity to decline to participate in binding arbitration at the time of his or her enrollment.

(b) It must clearly state that the health maintenance organization and an enrollee 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 health maintenance organization is responsible for any administrative fees and expenses relating to the arbitration, except that the health maintenance organization 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 an enrollee, 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 any evidence of coverage issued by a health maintenance organization, 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, 2559)

NRS 695C.270 Surety bond or deposit required; waiver. Each health maintenance organization shall furnish a surety bond in an amount satisfactory to the Commissioner or deposit with the Commissioner cash or securities acceptable to the Commissioner in at least the same amount as a guarantee that the obligations to the enrollees will be performed. The Commissioner may waive this requirement whenever satisfied that the assets of the organization and its contracts with insurers, governments, or other organizations are sufficient to reasonably assure the performance of its obligations.

(Added to NRS by 1973, 1253)

NRS 695C.275 Commissioner required to adopt regulations for licensing of provider-sponsored organizations to extent authorized by federal law.

1. To the extent authorized by federal law, the Commissioner shall adopt regulations for the licensing of provider-sponsored organizations in this State.

2. As used in this section, “provider-sponsored organization” has the meaning ascribed to it in 42 U.S.C. § 1395w-25(d).

(Added to NRS by 1999, 2817)

NRS 695C.280 Commissioner authorized to adopt regulations for licensing of agents or brokers. The Commissioner may adopt such reasonable regulations as are necessary to provide for the licensing of agents or brokers. An agent is a person directly or indirectly associated with a health care plan who engages in solicitation or enrollment. A broker is a person who is directly involved with the insured in the manner provided in chapter 683A of NRS.

(Added to NRS by 1973, 1254; A 1981, 107; 1993, 2401)

NRS 695C.290 Insurance company authorized to establish or contract with health maintenance organization.

1. An insurance company licensed in this State may either directly or through a subsidiary or affiliate organize and operate a health maintenance organization under the provisions of this chapter. Notwithstanding any other law which may be inconsistent herewith, any two or more such insurance companies or subsidiaries or affiliates thereof may jointly organize and operate a health maintenance organization. The business of insurance is deemed to include the providing of health care by a health maintenance organization owned or operated by an insurer or a subsidiary thereof.

2. An insurer may contract with a health maintenance organization to provide insurance or similar protection against the cost of care provided through health maintenance organizations and to provide coverage in the event of the failure of the health maintenance organization to meet its obligations. Among other things, under such contracts the insurer may make benefit payments to health maintenance organizations for health care services rendered by providers pursuant to the health care plan.

(Added to NRS by 1973, 1254)

NRS 695C.300 Prohibited practices.

1. No health maintenance organization or representative thereof may cause or knowingly permit the use of advertising which is untrue or misleading, solicitation which is untrue or misleading or any form of evidence of coverage which is deceptive. For purposes of this chapter:

(a) A statement or item of information shall be deemed to be untrue if it does not conform to fact in any respect which is or may be significant to an enrollee of, or person considering enrollment in, a health care plan.

(b) A statement or item of information shall be deemed to be misleading, whether or not it may be literally untrue if, in the total context in which such statement is made or such item of information is communicated, such statement or item of information may be reasonably understood by a reasonable person not possessing special knowledge regarding health care coverage, as indicating any benefit or advantage or the absence of any exclusion, limitation or disadvantage of possible significance to an enrollee of, or person considering enrollment in, a health care plan if such benefit or advantage or absence of limitation, exclusion or disadvantage does not in fact exist.

(c) An evidence of coverage shall be deemed to be deceptive if the evidence of coverage taken as a whole, and with consideration given to typography and format as well as language, shall be such as to cause a reasonable person not possessing special knowledge regarding health care plans and evidences of coverage therefor to expect benefits, services, charges or other advantages which the evidence of coverage does not provide or which the health care plan issuing such evidence of coverage does not regularly make available for enrollees covered under such evidence of coverage.

2. NRS 686A.010 to 686A.310, inclusive, shall be construed to apply to health maintenance organizations, health care plans and evidences of coverage except to the extent that the nature of health maintenance organizations, health care plans and evidences of coverage render the sections therein clearly inappropriate.

3. An enrollee may not be cancelled or not renewed except for the failure to pay the charge for such coverage or for cause as determined in the master contract.

4. No health maintenance organization, unless licensed as an insurer, may use in its name, contracts, or literature any of the words “insurance,” “casualty,” “surety,” “mutual” or any other words descriptive of the insurance, casualty or surety business or deceptively similar to the name or description of any insurance or surety corporation doing business in this State.

5. No person not certificated under this chapter shall use in its name, contracts or literature the phrase “health maintenance organization” or the initials “HMO.”

(Added to NRS by 1973, 1253; A 2021, 901; 2023, 21)

NRS 695C.310 Examinations by Commissioner: Affairs of and compliance program used by health maintenance organization; submission of books and records; assessment of expenses; exception.

1. The Commissioner shall make an examination of the affairs of any health maintenance organization and providers with whom such organization has contracts, agreements or other arrangements pursuant to its health care plan as often as the Commissioner deems it necessary for the protection of the interests of the people of this State, but not less frequently than once every 3 years.

2. The Commissioner shall make an examination concerning any compliance program used by a health maintenance organization and any report, as determined to be appropriate by the Commissioner, regarding the health maintenance organization produced by an organization which examines best practices in the insurance industry. The Commissioner shall make such an examination as often as the Commissioner deems it necessary for the protection of the interests of the people of this State, but not less frequently than once every 3 years.

3. In making an examination pursuant to subsection 1 or 2, the Commissioner:

(a) Shall determine whether the health maintenance organization is in compliance with this Code, including, without limitation, whether any relationship or transaction between the health maintenance organization and any other health maintenance organization is in compliance with this Code; and

(b) May examine any account, record, document or transaction of any health maintenance organization or any provider which relates to:

(1) Compliance with this Code by the health maintenance organization which is the subject of the examination;

(2) Any relationship or transaction between the health maintenance organization which is the subject of the examination and any other health maintenance organization; or

(3) Any relationship or transaction between the health maintenance organization which is the subject of the examination and any provider.

4. Except as otherwise provided in this subsection, for the purposes of an examination pursuant to subsection 1 or 2, each health maintenance organization and provider shall, upon the request of the Commissioner or an examiner designated by the Commissioner, submit its books and records relating to any applicable health care plan to the Commissioner or the examiner, as applicable. Medical records of natural persons and records of physicians providing service pursuant to a contract with a health maintenance organization are not subject to such examination, although the records, except privileged medical information, are subject to subpoena upon a showing of good cause. For the purpose of examinations, the Commissioner may administer oaths to and examine the officers and agents of a health maintenance organization and the principals of providers concerning their business.

5. The expenses of examinations pursuant to this section must be assessed, billed and paid in accordance with the provisions of NRS 679B.290.

6. In lieu of an examination pursuant to this section, the Commissioner may accept the report of an examination made by the insurance commissioner of another state or an applicable regulatory agency of another state.

(Added to NRS by 1973, 1255; A 1991, 2036; 2013, 3647; 2017, 2395; 2019, 1719)

NRS 695C.311 Examinations by Commissioner: Financial condition of health maintenance organization; application for initial certificate of authority; exception.

1. For the purpose of determining its financial condition, fulfillment of its contractual obligations and compliance with law, the Commissioner shall, as often as the Commissioner deems advisable, examine the affairs, transactions, accounts, records and assets of a health maintenance organization and of any person as to any matter relevant to the financial affairs of the health maintenance organization or to the examination. Except as otherwise provided in this Code, the Commissioner shall examine each health maintenance organization at least once every 3 years.

2. The Commissioner shall examine each health maintenance organization applying for an initial certificate of authority.

3. In lieu of making his or her own examination, the Commissioner may, in the discretion of the Commissioner, accept a full report of the last recent examination of a foreign or alien health maintenance organization, certified to by the supervisory officer of insurance of another state.

4. To the extent that it is practical, the examination of a foreign or alien health maintenance organization must be made in cooperation with the insurance supervisory officers of other states in which the organization transacts business.

(Added to NRS by 1991, 2035)

NRS 695C.313 Financial examination: Procedure; appointment of examiner; maintenance and use of records; penalty for obstruction or interference.

1. If the Commissioner determines to examine a health maintenance organization pursuant to NRS 695C.311, the Commissioner shall designate one or more examiners and instruct them as to the scope of the examination. The examiner shall, upon demand, exhibit his or her official credentials to the health maintenance organization being examined.

2. The Commissioner shall conduct each examination in an expeditious, fair and impartial manner.

3. The Commissioner, or the examiner if the examiner is authorized in writing by the Commissioner, may administer oaths and examine under oath any person concerning any matter relevant to the examination.

4. Every health maintenance organization and its officers, attorneys, employees, agents and representatives shall make available to the Commissioner or the examiners of the Commissioner the accounts, records, documents, files, information, assets and matters of the health maintenance organization in his or her possession or control relating to the subject of the examination and shall facilitate the examination.

5. If the Commissioner or examiner finds any accounts or records to be inadequate or inadequately kept or posted, he or she shall so notify the health maintenance organization and give the health maintenance organization a reasonable opportunity to reconstruct, rewrite, post or balance the account or record. If the health maintenance organization fails to maintain, complete or correct the records or accounting after the Commissioner or examiner has given the health maintenance organization written notice and a reasonable opportunity to do so, the Commissioner may employ experts to reconstruct, rewrite, post or balance the account or record at the expense of the health maintenance organization being examined.

6. The Commissioner or an examiner shall not remove any record, account, document, file or other property of the health maintenance organization being examined from the office or place of business of the health maintenance organization unless the Commissioner or examiner has the written consent of an officer of the health maintenance organization before the removal or pursuant to an order of court. This provision does not prohibit the Commissioner or examiner from making or removing copies or abstracts of a record, account, document or file.

7. Any person who, without just cause, refuses to be examined under oath or who willfully obstructs or interferes with an examiner in the exercise of his or her authority is guilty of a misdemeanor.

(Added to NRS by 1991, 2035)

NRS 695C.315 Financial examination: Payment of expense.

1. The health maintenance organization being examined shall pay the expense of an examination. The expenses to be paid include only the reasonable and proper travel and lodging expenses of the Commissioner and the examiners and assistants of the Commissioner, including expert assistance, reasonable compensation to the examiners and assistants and incidental expenses as necessarily incurred in the examination. The Commissioner shall consider the scales and limitations recommended by the National Association of Insurance Commissioners regarding the expense and compensation for an examination.

2. The health maintenance organization shall promptly pay to the Commissioner the expenses of the examination upon presentation by the Commissioner of a reasonably detailed written statement thereof.

(Added to NRS by 1991, 2036)

NRS 695C.317 Procedures required for examination and hearing. The Commissioner shall use the procedures required by:

1. NRS 679B.230 to 679B.290, inclusive, when conducting an examination of a health maintenance organization.

2. NRS 679B.310 to 679B.370, inclusive, when conducting a hearing involving a health maintenance organization.

(Added to NRS by 1991, 2036)

NRS 695C.318 Insolvency; determination of financial condition; actions by Commissioner; review; regulations.

1. A health maintenance organization shall be deemed to be insolvent if:

(a) The health maintenance organization fails to meet its obligations as they mature; and

(b) The assets of the health maintenance organization are less than the sum of its liabilities and the minimum surplus required to be maintained by the health maintenance organization under this Code for authority to transact business in this State.

2. In addition to the provisions of subsection 1, a health maintenance organization shall be deemed to be insolvent as otherwise expressly provided in this Code.

3. A health maintenance organization shall be deemed to be impaired if the assets of the health maintenance organization are less than the sum of its liabilities and the minimum surplus required to be maintained by the health maintenance organization under this Code for authority to transact business in this State.

4. The Commissioner may adopt regulations to define when a health maintenance organization is considered to be in a hazardous financial condition and to set forth the standards to be considered by the Commissioner in determining whether the continued operation of a health maintenance organization transacting business in this State may be considered to be hazardous to its enrollees or creditors or to the general public.

5. If the Commissioner determines after a hearing that any health maintenance organization is in a hazardous financial condition, the Commissioner may, instead of suspending or revoking the certificate of authority of the health maintenance organization, limit the certificate of authority as the Commissioner deems reasonably necessary to correct, eliminate or remedy any conduct, condition or ground that is deemed to be a cause of the hazardous financial condition.

6. An order or decision of the Commissioner under this section is subject to review in accordance with NRS 679B.310 to 679B.370, inclusive, at the request of any party to the proceedings whose interests are substantially affected.

(Added to NRS by 2017, 2392)

NRS 695C.319 Power of Commissioner to order corrective action for hazardous operation or violation of law; regulations.

1. If the Commissioner determines that, because of the financial condition of a health maintenance organization, the continued operation of the health maintenance organization is or may be hazardous to its enrollees or creditors or to the general public, or that the health maintenance organization has violated any law of this State to which the health maintenance organization is subject, the Commissioner may, after notice and a hearing, order the health maintenance organization to take any action the Commissioner deems reasonably necessary to correct, eliminate or remedy the condition or violation, including, without limitation:

(a) Reducing the total amount of the present and potential liability of the health maintenance organization for benefits by reinsurance or any other method acceptable to the Commissioner;

(b) Suspending, limiting or reducing the volume of new business being written or accepted by the health maintenance organization for any period of time specified by the Commissioner;

(d) Increasing the capital and surplus of the health maintenance organization by contribution.

2. The Commissioner may adopt regulations to:

(a) Set standards and criteria for early warning that the continued operation of a health maintenance organization may be hazardous to its enrollees or creditors or to the general public; and

(b) For the purposes of subsection 1, set standards for evaluating the financial condition of a health maintenance organization.

3. The authority conferred upon the Commissioner pursuant to this section is in addition to the authority of the Commissioner pursuant to chapter 696B of NRS. Any order issued by the Commissioner pursuant to this section may, at the discretion of the Commissioner, be in addition to any order issued by the Commissioner pursuant to chapter 696B of NRS.

(Added to NRS by 2017, 2393)

NRS 695C.3195 Conservation, rehabilitation or liquidation of health maintenance organization: Powers of Commissioner; claims of enrollees; distribution of general assets.

1. Any conservation, rehabilitation or liquidation of a health maintenance organization shall be deemed to be the conservation, rehabilitation or liquidation of an insurer and must be conducted under the supervision of the Commissioner pursuant to chapter 696B of NRS.

2. The Commissioner may apply to a court of competent jurisdiction for an order directing the Commissioner to conserve, rehabilitate or liquidate a health maintenance organization:

(a) Upon any ground provided in chapter 696B of NRS; or

(b) If, as determined by the Commissioner, the continued operation of the health maintenance organization is or may be hazardous to its enrollees or creditors or to the general public.

3. In the event of a rehabilitation or liquidation of a health maintenance organization, a claim of an enrollee or of a beneficiary of an enrollee shall be deemed to have the same priority as would be provided to a claim of a policyholder or insured of an insurer, or of a beneficiary of such a policyholder or insured, in the event of the rehabilitation or liquidation of the insurer.

4. In the event of a distribution of the general assets of a health maintenance organization:

(a) If an enrollee is liable to a provider for health care services provided pursuant to and covered by the applicable health care plan, that liability shall be deemed to be a claim of the enrollee for distribution of the general assets of the health maintenance organization.

(b) A provider under contract with the health maintenance organization who is obligated by law or contract to hold an enrollee harmless from liability for health care services provided pursuant to and covered by the applicable health care plan shall be deemed to have a priority for distribution of the general assets of the health maintenance organization immediately following that of an enrollee as described in this section and immediately preceding any other priority for distribution which, pursuant to this section and chapter 696B of NRS, would follow that of an enrollee.

(Added to NRS by 2017, 2393)

NRS 695C.320 Rehabilitation, liquidation or conservation: Conduct. Any rehabilitation, liquidation or conservation of a health maintenance organization shall be deemed to be the rehabilitation, liquidation or conservation of an insurance company and shall be conducted under the supervision of the Commissioner pursuant to the law governing the rehabilitation, liquidation, or conservation of insurance companies.

(Added to NRS by 1973, 1256)

NRS 695C.325 Offering health care plan to certain small employers for purposes of establishing medical savings accounts. A health maintenance organization may offer to a small employer who has not less than 2 and not more than 50 employees, a health care plan that has a high deductible and that is in compliance with 26 U.S.C. § 220 for the purposes of establishing medical savings accounts for any person insured by the health care plan.

(Added to NRS by 1997, 2957)

NRS 695C.326 Health maintenance organization required to provide data relating to claims and costs to person responsible for overseeing health care plan upon request; annual report; format.

1. Notwithstanding any other provision of law that provides for the confidentiality of the information described in this section, a health maintenance organization shall, except as otherwise provided in subsection 4, provide to the person responsible for overseeing the health care plan for a group purchaser upon written request from that person not more than once each year:

(a) All claims data relating to the enrollees in a health care plan provided by the health maintenance organization pursuant to a contract with the group purchaser; or

(b) Sufficient data relating to the claims of enrollees in the health care plan to allow the group purchaser to calculate the cost-effectiveness of the benefits provided by the health maintenance organization. Such data must include, without limitation:

(1) Data necessary to calculate the actual cost of obtaining medical services through the health maintenance organization, organized by medical service and category of disease;

(2) Data relating to enrollees in the health care plan who receive care, including, without limitation, demographics of such enrollees, prescriptions, office visits with a provider of health care, inpatient services and outpatient services, as used by the health maintenance organization to make calculations which are required to comply with the risk adjustment, reinsurance and risk corridor requirements of 42 U.S.C. §§ 18061, 18062 and 18063; and

(3) Such data as used to establish an experience rating for the enrollees in the health care plan, including, without limitation, coding relating to diagnostics and procedures, the total cost charged to any person for each drug, device or service made available by the health care plan and all reimbursements made to a provider of health care for such drugs, devices or services.

2. If a written request is made pursuant to subsection 1, the health maintenance organization must also provide an annual report relating to the data required to be made available pursuant to subsection 1, which must include, without limitation, sufficient detail to demonstrate the annual changes in the cost and the percentage of increase or decrease, as applicable, for each category of information made available pursuant to subsection 1.

3. A health maintenance organization shall provide the data required by this section in an aggregated form which complies with federal and state law, including, without limitation, the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, and any applicable regulations.

4. Before providing any data pursuant to subsection 1, a health maintenance organization shall ensure that a professional statistician examines the data to confirm that such data cannot be used to identify and does not provide a reasonable basis upon which to identify a person whose information is included in the report. If the professional statistician is not able to make such a confirmation, the data must not be provided by the health maintenance organization until such confirmation is obtained.

5. A health maintenance organization must provide the data required by this section in a format which is easily searchable electronically or on a secure Internet website. A health maintenance organization may only provide the data described in this section relating to the health care plan of a group purchaser to the person responsible for overseeing the health care plan for the group purchaser and not relating to the health care plan of any other group purchaser.

6. A group purchaser must have policies and procedures in place which are compliant with federal law, including, without limitation, the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, and the regulations adopted pursuant thereto, and the laws of this State to ensure the privacy and security of the data made available to the person responsible for overseeing the health care plan for a group purchaser pursuant to this section.

7. As used in this section, “group purchaser” means:

(a) An employer that employs at least 1,000 employees, at least 300 of whom are enrolled in a health care plan which is offered by a health maintenance organization; or

(b) A group of employers that cumulatively employ at least 500 employees and which has formed a trust for the purpose of funding health care benefits for at least 300 employees who are enrolled in a health care plan which is offered by a health maintenance organization.

(Added to NRS by 2017, 2264)

NRS 695C.328 Disclosure of data relating to claims and costs prohibited; exceptions; penalties for unauthorized disclosure.

1. Except as otherwise provided in subsection 2:

(a) A person responsible for overseeing a health care plan for a group purchaser shall not disclose data made available to the person pursuant to NRS 695C.326 to any other person except for a person responsible for making decisions about the health care plan.

(b) A person responsible for making decisions about a health care plan for a group purchaser shall not further disclose data disclosed to the person pursuant to paragraph (a) to any other person except for another person responsible for making decisions about the health care plan.

2. A person described in subsection 1 may disclose data made available to the person pursuant to that subsection or NRS 695C.326 to another person not described in that subsection if:

(a) The health maintenance organization that provided the data agrees to the disclosure; or

(b) The disclosure is ordered by a court of competent jurisdiction.

3. Except as otherwise provided in subsections 4 to 7, inclusive, the Commissioner shall impose against any person who violates the requirements of this section:

(a) If the person did not know of the violation and would not have known about the violation if he or she had exercised reasonable diligence, an administrative penalty of not less than $100 and not more than $50,000 per violation.

(b) If the person knew of the violation or should have known about the violation if he or she had exercised reasonable diligence but the violation is not due to willful neglect, an administrative penalty of not less than $1,000 and not more than $50,000 per violation.

4. If a person who violates the requirements of this section corrects the violation not later than 30 days after the person knew of the violation or should have known of the violation if he or she had exercised reasonable diligence, or another date determined by the Commissioner, the Commissioner:

(a) Shall not impose an administrative penalty if the violation is not due to willful neglect.

(b) Except as otherwise provided in subsection 5, shall impose an administrative penalty of not less than $10,000 and not more than $50,000 per violation if the violation is due to willful neglect.

5. Administrative penalties imposed pursuant to this section against a person must not exceed $1,500,000 in a calendar year.

6. The Commissioner:

(a) Shall make a determination of the amount of an administrative penalty imposed pursuant to this section based upon the nature and extent of the violation and the harm resulting from the violation; and

(b) May reduce any administrative penalty imposed for a violation of the requirements of this section, other than a violation due to willful neglect, if the Commissioner determines that the amount prescribed by subsection 3 is excessive.

7. The Commissioner shall not impose an administrative penalty for a violation for which a penalty has been imposed pursuant to subsection 8.

8. Any person who knowingly violates the requirements of this section:

(a) Except as otherwise provided in paragraphs (b) and (c), is guilty of a gross misdemeanor and may be fined not more than $50,000.

(b) If the violation is committed under false pretenses, is guilty of a category C felony and shall be punished as provided in NRS 193.130, and may be further punished by a fine of not more than $100,000.

(c) If the violation is committed with intent to sell, transfer or use the data for commercial advantage, personal gain or malicious harm, is guilty of a category B felony and shall be punished by imprisonment in the state prison for a minimum term of not less than 1 year and a maximum term of not more than 10 years, and may be further punished by a fine of not more than $250,000.

(Added to NRS by 2017, 2265)

1. If the Commissioner receives notification from the Department of Health and Human Services pursuant to NRS 439.5895 that a health maintenance organization is not in compliance with the requirements of subsection 4 of NRS 439.589, the Commissioner may, after notice and the opportunity for a hearing in accordance with the provisions of this chapter, require corrective action or impose an administrative fine in the amount prescribed by NRS 695C.350.

2. The Commissioner shall not suspend or revoke the certificate of authority of a health maintenance organization for failure to comply with the requirements of subsection 4 of NRS 439.589.

(Added to NRS by 2023, 1856, effective July 1, 2024)

NRS 695C.330 Disciplinary proceedings: Grounds; effect of suspension or revocation.

1. The Commissioner may suspend or revoke any certificate of authority issued to a health maintenance organization pursuant to the provisions of this chapter if the Commissioner finds that any of the following conditions exist:

(a) The health maintenance organization is operating significantly in contravention of its basic organizational document, its health care plan or in a manner contrary to that described in and reasonably inferred from any other information submitted pursuant to NRS 695C.060, 695C.070 and 695C.140, unless any amendments to those submissions have been filed with and approved by the Commissioner;

(b) The health maintenance organization issues evidence of coverage or uses a schedule of charges for health care services which do not comply with the requirements of NRS 695C.1691 to 695C.200, inclusive, 695C.204 or 695C.207;

(d) The Commissioner certifies that the health maintenance organization:

(1) Does not meet the requirements of subsection 1 of NRS 695C.080; or

(2) Is unable to fulfill its obligations to furnish health care services as required under its health care plan;

(e) The health maintenance organization is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees;

(f) The health maintenance organization has failed to put into effect a mechanism affording the enrollees an opportunity to participate in matters relating to the content of programs pursuant to NRS 695C.110;

(g) The health maintenance organization has failed to put into effect the system required by NRS 695C.260 for:

(1) Resolving complaints in a manner reasonably to dispose of valid complaints; and

(2) Conducting external reviews of adverse determinations that comply with the provisions of NRS 695G.241 to 695G.310, inclusive;

(h) The health maintenance organization or any person on its behalf has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive or unfair manner;

(i) The continued operation of the health maintenance organization would be hazardous to its enrollees or creditors or to the general public;

(j) The health maintenance organization fails to provide the coverage required by NRS 695C.1691; or

(k) The health maintenance organization has otherwise failed to comply substantially with the provisions of this chapter.

2. A certificate of authority must be suspended or revoked only after compliance with the requirements of NRS 695C.340.

3. If the certificate of authority of a health maintenance organization is suspended, the health maintenance organization shall not, during the period of that suspension, enroll any additional groups or new individual contracts, unless those groups or persons were contracted for before the date of suspension.

4. If the certificate of authority of a health maintenance organization is revoked, the organization shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of the organization. It shall engage in no further advertising or solicitation of any kind. The Commissioner may, by written order, permit such further operation of the organization as the Commissioner may find to be in the best interest of enrollees to the end that enrollees are afforded the greatest practical opportunity to obtain continuing coverage for health care.

(Added to NRS by 1973, 1255; A 1985, 1448; 1997, 745, 1462, 1629; 1999, 417, 419, 761, 2004; 2001, 141, 144; 2003, 778, 1336, 3369, 3532; 2007, 3240; 2009, 1474; 2011, 3395; 2013, 2000, 3647; 2015, 209, 644, 2128; 2017, 1852, 2396, 3956; 2019, 311, 1007, 1926, 2173; 2021, 784, 827, 1174, 2581, 2672, 3212; 2023, 524, 817, 1787, 2044, 2224, 2378, 3527)

NRS 695C.340 Disciplinary proceedings: Notice; hearing; judicial review.

1. When the Commissioner has cause to believe that grounds for the denial of an application for a certificate of authority exist, or that grounds for the suspension or revocation of a certificate of authority exist, the Commissioner shall notify the health maintenance organization in writing specifically stating the grounds for denial, suspension or revocation and fixing a time at least 30 days thereafter for a hearing on the matter.

2. After the hearing, or upon the failure of the health maintenance organization to appear at the hearing, the Commissioner shall take action as is deemed advisable on written findings which must be mailed to the health maintenance organization. The action of the Commissioner is subject to review by the First Judicial District Court of the State of Nevada in and for Carson City. The court may, in disposing of the issue before it, modify, affirm or reverse the order of the Commissioner in whole or in part.

(Added to NRS by 1973, 1256; A 1981, 107; 2013, 3649)

NRS 695C.350 Violations: Remedies; penalties.

1. The Commissioner may, in lieu of suspension or revocation of a certificate of authority under NRS 695C.330, levy an administrative penalty in an amount not more than $2,500 for each act or violation, if reasonable notice in writing is given of the intent to levy the penalty.

2. Any person who violates the provisions of this chapter is guilty of a misdemeanor.

3. If the Commissioner for any reason has cause to believe that any violation of this chapter has occurred or is threatened, the Commissioner may give notice to the health maintenance organization and to the representatives, or other persons who appear to be involved in the suspected violation, to arrange a conference with the alleged violators or their authorized representatives to attempt to determine the facts relating to the suspected violation, and, if it appears that any violation has occurred or is threatened, to arrive at an adequate and effective means of correcting or preventing the violation.

4. The proceedings conducted pursuant to the provisions of subsection 3 must not be governed by any formal procedural requirements, and may be conducted in such manner as the Commissioner may deem appropriate under the circumstances.

5. The Commissioner may issue an order directing a health maintenance organization or a representative of a health maintenance organization to cease and desist from engaging in any act or practice in violation of the provisions of this chapter.

6. Within 30 days after service of the order to cease and desist, the respondent may request a hearing on the question of whether acts or practices in violation of this chapter have occurred. The hearing must be conducted pursuant to the provisions of chapter 233B of NRS and judicial review must be available as provided therein.

7. In the case of any violation of the provisions of this chapter, if the Commissioner elects not to issue a cease and desist order, or in the event of noncompliance with a cease and desist order issued pursuant to subsection 5, the Commissioner may institute a proceeding to obtain injunctive relief, or seek other appropriate relief in the district court of the judicial district of the county in which the violator resides.

(Added to NRS by 1973, 1257; A 1999, 2817; 2013, 3649)