NRS: CHAPTER 695G - MANAGED CARE

[Rev. 6/29/2024 5:02:58 PM--2023]

CHAPTER 695G - MANAGED CARE

GENERAL PROVISIONS

NRS 695G.010 Definitions.

NRS 695G.012 “Adverse determination” defined.

NRS 695G.014 “Authorized representative” defined.

NRS 695G.015 “Benefits” defined.

NRS 695G.016 “Clinical peer” defined.

NRS 695G.017 “Covered person” defined.

NRS 695G.019 “Health benefit plan” defined.

NRS 695G.020 “Health care plan” defined.

NRS 695G.022 “Health care services” defined.

NRS 695G.024 “Health carrier” defined.

NRS 695G.026 “Independent review organization” defined.

NRS 695G.030 “Insured” defined.

NRS 695G.040 “Managed care” defined.

NRS 695G.050 “Managed care organization” defined.

NRS 695G.053 “Medical or scientific evidence” defined.

NRS 695G.055 “Medically necessary” defined.

NRS 695G.060 “Primary care physician” defined.

NRS 695G.070 “Provider of health care” defined.

NRS 695G.080 “Utilization review” defined.

NRS 695G.085 “Utilization review organization” defined.

NRS 695G.090 Applicability of chapter and other provisions.

NRS 695G.095 Offering policy of health insurance for purposes of establishing health savings account.

NRS 695G.100 Documents filed with Commissioner treated as public record; exception.

ADMINISTRATION OF MANAGED CARE ORGANIZATIONS

NRS 695G.110 Medical director required to be physician licensed in this State.

NRS 695G.120 Utilization review: Development and maintenance of written policies and procedures for use by managed care organization and subcontractors.

NRS 695G.125 Contracts with certain federally qualified health centers.

NRS 695G.127 Contracts between managed care organization and provider of health care: Managed care organization required to use form to obtain information on provider of health care; modification; submission by managed care organization of schedule of payments to provider.

NRS 695G.130 Report regarding methods for reviewing quality of health care services: Form of report; availability for public inspection.

NRS 695G.140 Certain persons in managed care organization in fiduciary relationship to insured.

COVERAGE BY MANAGED CARE ORGANIZATIONS

NRS 695G.150 Authorization of recommended and covered health care services required.

NRS 695G.155 Managed care 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 695G.160 Written criteria concerning coverage of health care services and standards for quality of health care services.

NRS 695G.162 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 managed care organizations concerning teledentistry.

NRS 695G.163 Plan covering prescription drugs: Provision of notice and information regarding use of formulary.

NRS 695G.1635 Plan covering prescription drugs: Required actions by managed care organization related to acquisition of prescription drugs for certain insureds residing in area for which emergency or disaster has been declared.

NRS 695G.1639 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 695G.164 Required provision in certain plans concerning coverage for continued medical treatment; exceptions; regulations.

NRS 695G.1645 Required provision in plan for group coverage concerning coverage for autism spectrum disorders for certain persons; prohibited acts.

NRS 695G.166 Plan covering prescription drugs prohibited from limiting or excluding coverage for prescription drug previously approved for medical condition of insured; exceptions.

NRS 695G.1665 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 695G.167 Plan covering treatment of cancer through use of chemotherapy: Prohibited acts related to orally administered chemotherapy.

NRS 695G.1675 Plan covering prescription drug for treatment of cancer or cancer symptom that is part of step therapy protocol: Managed care organization required to allow insured or attending practitioner to apply for exemption from step therapy protocol in certain circumstances; procedure for applying for and granting exemption.

NRS 695G.168 Required provision in plan covering treatment of colorectal cancer concerning coverage for colorectal cancer screening.

NRS 695G.170 Required provision concerning coverage for medically necessary emergency services at any hospital; prohibited acts.

NRS 695G.1702 Plan covering prescription drugs: Submission to step therapy protocol for drug to treat psychiatric condition prohibited in certain circumstances.

NRS 695G.1703 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 695G.1705 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 695G.1707 Required provision concerning coverage for testing, treatment and prevention of sexually transmitted diseases; required provision concerning coverage for condoms for certain insureds.

NRS 695G.171 Required provision concerning coverage for certain tests and vaccines relating to human papillomavirus; prohibited acts.

NRS 695G.1712 Required provision concerning coverage for screening, genetic counseling and testing related to BRCA gene in certain circumstances.

NRS 695G.1713 Required provision concerning coverage for certain screenings and tests for breast cancer; prohibited acts.

NRS 695G.1714 Required provision concerning coverage for examination of person who is pregnant for certain diseases.

NRS 695G.1715 Required provision concerning coverage for drug or device for contraception and related health services; prohibited acts; exceptions.

NRS 695G.1716 Health care plan covering maternity care: Prohibited acts by managed care organization if insured is acting as gestational carrier; child deemed child of intended parent for purposes of plan.

NRS 695G.1717 Required provision concerning coverage for certain services, screenings and tests relating to wellness; prohibited acts.

NRS 695G.1718 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 managed care organization to prescribe requirements for covering surgical treatments for minors; determination of medical necessity.

NRS 695G.1719 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 695G.172 Plan covering prescription drugs: Denial of coverage prohibited for early refills of otherwise covered topical ophthalmic products.

NRS 695G.173 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 managed care organization to require certain information; immunity from liability.

NRS 695G.174 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 695G.175 Contracts for provision of emergency medical services, outpatient services or inpatient services with hospital or other facility that provides acute care in smaller city or county: Prohibited acts.

NRS 695G.176 Plan covering anatomical gifts, organ transplants or treatments or services related to organ transplants: Prohibited acts by managed care organization if insured is person with disability.

NRS 695G.177 Required provision in plans covering treatment of prostate cancer concerning coverage for prostate cancer screening; prohibited acts.

QUALITY ASSURANCE PROGRAM

NRS 695G.180 Quality assurance program: Requirements; written description; informing providers; necessary staff; review; responsibility for activities.

NRS 695G.190 Quality improvement committee: Administration; duties.

SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS

NRS 695G.200 Establishment; approval; requirements; assistance for persons filing complaints; examination.

NRS 695G.210 Review board; appeal; right to expedited review of complaint; notice to insured.

NRS 695G.220 Annual report; managed care organization required to maintain records of and report complaints concerning something other than health care services.

NRS 695G.230 Written notice required by carrier to insured explaining rights of insureds regarding decision to deny coverage; written notice to insured when health carrier denies coverage of health care service.

EXTERNAL REVIEW OF ADVERSE DETERMINATION

NRS 695G.241 Circumstances under which adverse determination may be subject to external review; exceptions.

NRS 695G.243 Applicability.

NRS 695G.245 Written notice of right to request external review; form; contents.

NRS 695G.247 Requests for external review to be in writing; exception; form and content.

NRS 695G.251 Request for review; assignment of independent review organization; provision of documents relating to adverse determination to independent review organization.

NRS 695G.261 Review of documents by independent review organization; decision of independent review organization.

NRS 695G.271 Expedited approval or denial of request.

NRS 695G.275 Experimental or investigational health care service or treatment: Request for external review; request for expedited external review.

NRS 695G.280 Basis for decision of independent review organization.

NRS 695G.290 Decision in favor of covered person binding on health carrier; limitation of liability; cost for independent review organization.

NRS 695G.300 Submission of complaint of covered person to independent review organization.

NRS 695G.303 Independent review organization and health carrier required to maintain written records; submission of report upon request.

NRS 695G.307 Health carrier required to provide description of external review procedures; format; contents.

NRS 695G.310 Annual report; requirements.

MISCELLANEOUS PROVISIONS

PROHIBITED ACTS

NRS 695G.400 Managed care organization prohibited from restricting or interfering with certain communications between provider of health care and patient.

NRS 695G.405 Managed care organization prohibited from denying coverage solely because applicant or insured was intoxicated or under the influence of controlled substance; exceptions.

NRS 695G.410 Managed care organization prohibited from taking certain actions against provider solely because provider advocates on behalf of patient, assists patient or reports violation of law.

NRS 695G.415 Managed care organization prohibited from discriminating against person with respect to participation or coverage on basis of gender identity or expression.

NRS 695G.420 Managed care organization prohibited from offering or paying financial incentive to provider to deny, reduce, withhold, limit or delay medically necessary services.

NRS 695G.430 Contracts between managed care organization and provider of health care: Form for obtaining information on provider of health care; modification; schedule of fees. [Replaced in revision by NRS 695G.127.]

_________

GENERAL PROVISIONS

NRS 695G.010 Definitions. As used in this chapter, unless the context otherwise requires, the words and terms defined in NRS 695G.012 to 695G.085, inclusive, have the meanings ascribed to them in those sections.

(Added to NRS by 1997, 301; A 2003, 783; 2011, 3410)

NRS 695G.012 “Adverse determination” defined. “Adverse determination” means a determination by a health carrier or utilization review organization that an admission, availability of care, continued stay or other health care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier’s requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, and the requested service or payment for the service is therefore denied, reduced or terminated.

(Added to NRS by 2003, 779; A 2011, 3410)

NRS 695G.014 “Authorized representative” defined. “Authorized representative” means:

1. A person to whom a covered person has given express written consent to represent the covered person in an external review of an adverse determination conducted pursuant to NRS 695G.241 to 695G.310, inclusive;

2. A person authorized by law to provide substituted consent for a covered person; or

3. A family member of a covered person or the covered person’s treating provider only when the covered person is unable to provide consent.

(Added to NRS by 2003, 779; A 2011, 3410)

NRS 695G.015 “Benefits” defined. “Benefits” means those health care services to which a covered person is entitled under the terms of a health benefit plan.

(Added to NRS by 2011, 3398)

NRS 695G.016 “Clinical peer” defined. “Clinical peer” means a physician who is:

1. Engaged in the practice of medicine; and

2. Certified or is eligible for certification by a member board of the American Board of Medical Specialties in the same or similar area of practice as is the health care service that is the subject of a final adverse determination.

(Added to NRS by 2003, 779)

NRS 695G.017 “Covered person” defined. “Covered person” means a policyholder, subscriber, enrollee or other person participating in a health benefit plan.

(Added to NRS by 2011, 3398)

NRS 695G.019 “Health benefit plan” defined. “Health benefit plan” means a policy, contract, certificate or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services.

(Added to NRS by 2011, 3398)

NRS 695G.020 “Health care plan” defined. “Health care plan” means a policy, contract, certificate or agreement offered or issued by a managed care organization to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services.

(Added to NRS by 1997, 301)

NRS 695G.022 “Health care services” defined. “Health care services” means services for the diagnosis, prevention, treatment, care or relief of a health condition, illness, injury or disease.

(Added to NRS by 2011, 3398)

NRS 695G.024 “Health carrier” defined. “Health carrier” means an entity subject to the insurance laws and regulations of this State, or subject to the jurisdiction of the Commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services, including, without limitation, a sickness and accident health insurance company, a health maintenance organization, a nonprofit hospital and health service corporation or any other entity providing a plan of health insurance, health benefits or health care services.

(Added to NRS by 2011, 3398)

NRS 695G.026 “Independent review organization” defined. “Independent review organization” means an entity that:

1. Conducts an independent external review of an adverse determination; and

2. Is certified by the Commissioner in accordance with NRS 683A.3715 and 683A.372.

(Added to NRS by 2003, 779; A 2011, 3410)

NRS 695G.030 “Insured” defined. “Insured” means a person who receives benefits under a health care plan.

(Added to NRS by 1997, 301)

NRS 695G.040 “Managed care” defined. “Managed care” means a system for delivering health care services that encourages the efficient use of health care services by using employed or independently contracted providers of health care and by using various techniques which may include, without limitation:

1. Managing the health care services of an insured who has a serious, complicated, protracted or other health-related condition that requires the use of numerous providers of health care or other costly services;

2. Providing utilization review;

3. Offering financial incentives for the effective use of health care services; or

4. Any combination of those techniques.

(Added to NRS by 1997, 301)

NRS 695G.050 “Managed care organization” defined. “Managed care organization” means any insurer or organization authorized pursuant to this title to conduct business in this State that provides or arranges for the provision of health care services through managed care.

(Added to NRS by 1997, 302)

NRS 695G.053 “Medical or scientific evidence” defined. “Medical or scientific evidence” means evidence found in the following sources:

1. Peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff;

2. Peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia and other medical literature that meet the criteria of the National Library of Medicine of the National Institutes of Health for indexing in Index Medicus (MEDLINE) and Elsevier for indexing in Excerpta Medica (EMBASE);

3. Medical journals recognized by the Secretary of Health and Human Services pursuant to section 1861(t)(2) of the Social Security Act, 42 U.S.C. § 1395x;

4. The following standard reference compendia:

(a) AHFS Drug Information published by the American Society of Health-System Pharmacists;

(b) Drug Facts and Comparisons published by Wolter Kluwers Health;

(d) The United States Pharmacopoeia’s Drug Quality and Information Program;

5. Findings, studies or research conducted by or under the auspices of the Federal Government and nationally recognized federal research institutes, including, without limitation:

(a) The Agency for Healthcare Research and Quality;

(b) The National Institutes of Health;

(d) The National Academy of Sciences of the National Academies;

(e) The Centers for Medicare and Medicaid Services;

(f) The Food and Drug Administration; and

(g) Any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health care services; or

6. Any other source of medical or scientific evidence that is comparable to the sources listed in subsections 1 to 5, inclusive.

(Added to NRS by 2011, 3398)

NRS 695G.055 “Medically necessary” defined. “Medically necessary” means health care services or products that a prudent physician 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 primarily provided for the convenience of the patient, physician or other provider of health care;

4. Required to improve a specific health condition of an insured or to preserve the existing state of health of the insured; and

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

(Added to NRS by 2003, 779)

NRS 695G.060 “Primary care physician” defined. “Primary care physician” means a physician or group of physicians who:

1. Provides initial and primary health care services to an insured;

2. Maintains the continuity of care for the insured; and

3. May refer the insured to a specialized provider of health care.

(Added to NRS by 1997, 302)

NRS 695G.070 “Provider of health care” defined. “Provider of health care” means:

1. A physician or other health care practitioner who is licensed or otherwise authorized in this State to furnish any health care service; and

2. An institution providing health care services or other setting in which health care services are provided, including, without limitation, a hospital, surgical center for ambulatory patients, facility for skilled nursing, residential facility for groups, laboratory and any other such licensed facility.

(Added to NRS by 1997, 302; A 2011, 3411)

NRS 695G.080 “Utilization review” defined.

1. “Utilization review” means the various methods that may be used to review the amount and appropriateness of the provision of a specific health care service.

2. The term does not include an external review of an adverse determination conducted pursuant to NRS 695G.241 to 695G.310, inclusive.

(Added to NRS by 1997, 302; A 2003, 783; 2011, 3411)

NRS 695G.085 “Utilization review organization” defined. “Utilization review organization” means an entity designated by a health carrier to conduct utilization reviews.

(Added to NRS by 2011, 3399)

NRS 695G.090 Applicability of chapter and other provisions.

1. Except as otherwise provided in subsection 3, the provisions of this chapter apply to each organization and insurer that operates as a managed care organization and may include, without limitation, an insurer that issues a policy of health insurance, an insurer that issues a policy of individual or group health insurance, a carrier serving small employers, a fraternal benefit society, a hospital or medical service corporation and a health maintenance organization.

2. In addition to the provisions of this chapter, each managed care organization shall comply with:

(a) The provisions of chapter 686A of NRS, including all obligations and remedies set forth therein; and

(b) Any other applicable provision of this title.

3. The provisions of NRS 695G.127, 695G.1639, 695G.164, 695G.1645, 695G.167 and 695G.200 to 695G.230, inclusive, do not apply to a managed care 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.

4. The provisions of NRS 695C.1735 and 695G.1639 do not apply to a managed care organization that provides health care services to members of the Public Employees’ Benefits Program.

5. Subsections 3 and 4 do not exempt a managed care organization from any provision of this chapter for services provided pursuant to any other contract.

(Added to NRS by 1997, 302; A 2003, 783, 3371; 2009, 1477; 2013, 2001; 2023, 820, 1353)

NRS 695G.095 Offering policy of health insurance for purposes of establishing health savings account. A managed care 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, 2159)

NRS 695G.100 Documents filed with Commissioner treated as public record; exception. Any document required to be filed with the Commissioner pursuant to this chapter, other than medical records and other information relating to a specific insured, must be treated as a public record.

(Added to NRS by 1997, 307)

ADMINISTRATION OF MANAGED CARE ORGANIZATIONS

NRS 695G.110 Medical director required to be physician licensed in this State. Each managed care organization shall employ or contract with a physician who is licensed to practice medicine in the State of Nevada pursuant to chapter 630 or 633 of NRS to serve as its medical director.

(Added to NRS by 1997, 305; A 2003, 1181)

NRS 695G.120 Utilization review: Development and maintenance of written policies and procedures for use by managed care organization and subcontractors. Each managed care organization shall:

1. Develop and maintain written policies and procedures setting forth the manner in which it conducts utilization review; and

2. Require any person with whom it subcontracts to provide utilization review to use the same policies and procedures developed pursuant to subsection 1.

(Added to NRS by 1997, 303)

NRS 695G.125 Contracts with certain federally qualified health centers.

1. A managed care organization that delivers health care services by using independently contracted providers of health care 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 insureds 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, 1925)

1. A managed care organization shall not contract with a provider of health care to provide health care to an insured unless the managed care 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 managed care 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 managed care organization upon giving to the provider 45 days’ written notice of the modification of the managed care 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 managed care organization contracts with a provider of health care to provide health care services pursuant to chapter 689A, 689B, 689C, 695A, 695B or 695C of NRS, the managed care 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 2001, 2736; A 2003, 3371; 2011, 2536)—(Substituted in revision for NRS 695G.430)

NRS 695G.130 Report regarding methods for reviewing quality of health care services: Form of report; availability for public inspection.

1. In addition to any other report which is required to be filed with the Commissioner, each managed care organization shall file with the Commissioner, with its annual filing made pursuant to NRS 686B.070 of forms and rates relating to policies of insurance for individuals and small employer groups, a report regarding its methods for reviewing the quality of health care services provided to its insureds. The report must be submitted on a form prescribed by the Commissioner.

2. A report filed pursuant to this section must be made available for public inspection within a reasonable time after it is received by the Commissioner.

3. As used in this section, “small employer” has the meaning ascribed to it in NRS 689C.095.

(Added to NRS by 1997, 305; A 1997, 3041; 2013, 3650; 2017, 2401)

NRS 695G.140 Certain persons in managed care organization in fiduciary relationship to insured. Any person who receives, collects, disburses or invests money for a managed care organization is responsible for such money in a fiduciary relationship to the insured.

(Added to NRS by 1997, 305)

COVERAGE BY MANAGED CARE ORGANIZATIONS

NRS 695G.150 Authorization of recommended and covered health care services required. Each managed care organization shall authorize coverage of a health care service that has been recommended for the insured by a provider of health care acting within the scope of his or her practice if that service is covered by the health care plan of the insured, unless:

1. The decision not to authorize coverage is made by a physician who:

(a) Is licensed to practice medicine in the State of Nevada pursuant to chapter 630 or 633 of NRS;

(b) Possesses the education, training and expertise to evaluate the medical condition of the insured; and

(c) Has reviewed the available medical documentation, notes of the attending physician, test results and other relevant medical records of the insured.

Ê The physician may consult with other providers of health care in determining whether to authorize coverage.

2. The decision not to authorize coverage and the reason for the decision have been transmitted in writing in a timely manner to the insured, the provider of health care who recommended the service and the primary care physician of the insured, if any.

(Added to NRS by 1997, 302; A 2003, 1181)

1. A managed care 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 managed care 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 insured; or

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

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

4. A managed care 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 insured who is eligible to participate in the wellness program is given the opportunity to qualify for the discount at least once each year;

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

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

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

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

(Added to NRS by 2019, 313)

NRS 695G.160 Written criteria concerning coverage of health care services and standards for quality of health care services.

1. Each managed care organization shall establish written criteria:

(a) Setting forth the manner in which it determines whether to authorize coverage of a health care service; and

(b) Setting forth its method for reviewing standards for the quality of health care services provided to an insured.

2. Such written criteria must be:

(a) Developed with the assistance of practicing providers of health care;

(b) Developed using generally recognized and, if appropriate, specialized clinical principles and processes;

(d) Made available to an insured for review upon request of the insured any time that the managed care organization denies coverage of a specific health care service to the insured.

(Added to NRS by 1997, 302)

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

2. A health care plan issued by a managed care organization for group coverage 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 managed care organization shall not:

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

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

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

(2) The technology used to provide the services;

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

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

4. A health care plan of a managed care organization must not require an insured to obtain prior authorization for any service provided through telehealth that is not required for the service when provided in person. 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 managed care 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 managed care 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 managed care 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 managed care organization to:

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

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

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

8. Evidence of coverage 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, 647; A 2021, 3042, 3043, 3044, 3045; 2023, 234, 237, 3337)

NRS 695G.163 Plan covering prescription drugs: Provision of notice and information regarding use of formulary.

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

2. If a managed care organization offers or issues a health care plan which provides coverage for prescription drugs and a formulary is used, the organization shall:

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

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

(2) Access to the most current list of prescription drugs in the formulary, organized by major therapeutic category, with an indication of whether any listed drugs are preferred over other listed drugs. If more than one formulary is maintained, the organization 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, 866)

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 managed care organization who 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 insured may refill a covered prescription if the insured:

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

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

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

(b) Authorize payment for, and may apply a copayment, coinsurance or deductible to, a supply of a covered prescription drug for up to 30 days for an insured who requests a refill pursuant to paragraph (a).

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

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

(Added to NRS by 2021, 829)

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

2. A managed care 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 insured and his or her attending practitioner may:

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

(2) Appeal a decision made by the managed care 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 managed care 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 managed care 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 managed care organization shall grant a request to exempt an insured from a step therapy protocol made in accordance with the process established pursuant to subsection 2 if the attending practitioner for the insured submits to the managed care organization a statement which provides an adequate justification for the exemption and any documentation necessary to support the statement. The managed care 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 insured;

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

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

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

4. If a managed care 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 managed care organization shall immediately authorize coverage for and dispensing of the drug chosen by the attending practitioner for the insured.

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 695G.1675 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, 818)

NRS 695G.164 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 managed care 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 managed care 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 managed care 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 managed care 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 managed care 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 managed care 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 managed care 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 managed care organization and the managed care organization terminated that contract because of the medical incompetence or professional misconduct of the provider of health care; and

(b) The managed care 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, 3370)

NRS 695G.1645 Required provision in plan for group coverage concerning coverage for autism spectrum disorders for certain persons; prohibited acts.

1. A health care plan issued by a managed care organization for group coverage 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. A health care plan issued by a managed care organization for individual coverage must provide an option for 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.

3. 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.

4. A managed care organization that offers or issues a health care plan which provides coverage for outpatient care shall not:

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

5. Except as otherwise provided in subsections 1, 2 and 3, a managed care organization shall not limit the number of visits an insured may make to any person, entity or group for treatment of autism spectrum disorders.

6. 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 managed care organization may request a copy of and review a treatment plan created pursuant to this subsection.

7. An 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 3 is void.

8. Nothing in this section shall be construed as requiring a managed care organization to provide reimbursement to a school for services delivered through school services.

9. 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, 1475; A 2015, 693, 695; 2017, 1504, 4261; 2019, 2565; 2021, 1655)

NRS 695G.166 Plan covering prescription drugs prohibited from limiting or excluding coverage for prescription drug previously approved for medical condition of insured; exceptions.

1. Except as otherwise provided in this section, a health care plan 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 managed care organization for a medical condition of an insured and the insured’s provider of health care determines, after conducting a reasonable investigation, that none of the drugs which are otherwise currently approved for coverage are medically appropriate for the insured; and

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

2. The provisions of subsection 1 do not:

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

(b) Prohibit:

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

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

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

3. Any provision of a health care plan 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, 866; A 2003, 2301; 2017, 640)

1. A managed care 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 insured’s chronic medications:

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

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

(b) May not deny coverage for a prescription described in paragraph (a) which is otherwise approved for coverage by the managed care 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, 2129)

NRS 695G.167 Plan covering treatment of cancer through use of chemotherapy: Prohibited acts related to orally administered chemotherapy.

1. A managed care 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 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. An evidence of coverage for a health care plan 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 renewal which is in conflict with this section is void.

3. Nothing in this section shall be construed as requiring a managed care 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, 2001; A 2013, 3660)

1. A managed care 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 insured who has been diagnosed with stage 3 or 4 cancer or the attending practitioner of the insured to apply for an exemption from the step therapy protocol. The application process for such an exemption must:

(a) Allow the insured or attending practitioner, or a designated advocate for the insured or attending practitioner, to present to the managed care 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 insured demonstrating that the insured has:

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

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

(2) Any other relevant clinical information.

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

3. Except as otherwise provided in subsection 4, a managed care 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 insured, a managed care 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 insured.

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

6. A managed care 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 insured when prescribed in accordance with clinical indications, clinical guidelines or other peer-reviewed evidence;

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

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

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

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

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

7. If a managed care organization approves an application for an exemption from a step therapy protocol pursuant to this section, the managed care organization must cover the prescription drug to which the exemption applies in accordance with the terms of the applicable health care plan. The managed care 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 managed care organization must continue to cover the drug for as long as it is necessary to treat the insured for the cancer or symptom. The managed care 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 insured for the cancer or symptom. The managed care organization shall provide a report of the review to the insured.

8. A managed care organization shall post in an easily accessible location on an Internet website maintained by the managed care 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 insured.

(Added to NRS by 2021, 2673)

NRS 695G.168 Required provision in plan covering treatment of colorectal cancer concerning coverage for colorectal cancer screening.

1. A health care plan issued by a managed care 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, 1337)

NRS 695G.170 Required provision concerning coverage for medically necessary emergency services at any hospital; prohibited acts.

1. Each managed care organization shall provide coverage for medically necessary emergency services provided at any hospital.

2. A managed care organization shall not require prior authorization for medically necessary emergency services.

3. As used in this section, “medically necessary emergency services” means health care services that are provided to an insured by a provider of health care after the sudden onset of a medical condition that manifests itself by symptoms of such sufficient severity that a prudent person would believe that the absence of immediate medical attention could result in:

(a) Serious jeopardy to the health of an insured;

(b) Serious jeopardy to the health of an unborn child;

(d) Serious dysfunction of any bodily organ or part.

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

(Added to NRS by 1997, 304; A 1999, 3097)

NRS 695G.1702 Plan covering prescription drugs: Submission to step therapy protocol 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 insured to submit to a step therapy protocol before covering a drug approved by the Food and Drug Administration that is prescribed to treat a psychiatric condition of the insured, if:

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

(b) The drug is prescribed by:

(1) A psychiatrist;

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

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

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

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

2. Any provision of a 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 managed care 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 managed care organization. The term does not include an arrangement for the financing of premiums.

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

(Added to NRS by 2023, 1789)

1. Subject to the limitations prescribed by subsection 4, a managed care 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 managed care 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 insured or provider of health care to:

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

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

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

3. If a managed care organization requires an insured to obtain prior authorization for a biomarker test described in subsection 1, the managed care 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 managed care 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 managed care 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 managed care 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 managed care 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, 2225)

1. A managed care 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 managed care 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 managed care organization.

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

(a) A pharmacist who participates in the network plan of the managed care 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 managed care 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 managed care 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 insured is diagnosed.

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

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

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

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

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

(Added to NRS by 2021, 3213; A 2023, 3529)

NRS 695G.1707 Required provision concerning coverage for testing, treatment and prevention of sexually transmitted diseases; required provision concerning coverage for condoms for certain insureds.

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

(a) Coverage of testing for, treatment of and prevention of sexually transmitted diseases, including, without limitation, Chlamydia trachomatis, gonorrhea, syphilis, human immunodeficiency virus and hepatitis B and C, for all insureds, regardless of age. Such coverage must include, without limitation, the coverage required by NRS 695G.1705 and 695G.1714.

(b) Unrestricted coverage of condoms for insureds 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, 3529)

NRS 695G.171 Required provision concerning coverage for certain tests and vaccines relating to human papillomavirus; prohibited acts.

1. A health care plan issued by a managed care 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.

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

3. Except as otherwise provided in subsection 5, a managed care organization that offers or issues a health care plan which provides coverage for prescription drugs shall not:

(a) Require an insured to pay a higher deductible, any copayment or coinsurance or require a longer waiting period or other condition to obtain any benefit provided in a 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 insured to discourage the insured from obtaining any such benefit;

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

(e) Offer or pay any type of material inducement, bonus or other financial incentive to a provider of health care to deny, reduce, withhold, limit or delay access to any such benefit to an insured; or

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

4. An evidence of coverage for a health care plan 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 thereof which is in conflict with this section is void.

5. Except as otherwise provided in this section and federal law, a managed care 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) “Human papillomavirus vaccine” means the Quadrivalent Human Papillomavirus Recombinant Vaccine or its successor which is approved by the Food and Drug Administration for the prevention of human papillomavirus infection and cervical cancer.

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

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

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

(Added to NRS by 2007, 3241; A 2013, 3651; 2017, 1858)

NRS 695G.1712 Required provision concerning coverage for screening, genetic counseling and testing related to BRCA gene in certain circumstances.

1. A managed care 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 managed care organization shall ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the managed care 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 managed care 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 managed care 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, 785)

NRS 695G.1713 Required provision concerning coverage for certain screenings and tests for breast cancer; prohibited acts.

1. A health care plan issued by a managed care organization must provide coverage for benefits payable for expenses incurred for:

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

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

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

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

(2) Detected by other means of examination.

3. Except as otherwise provided in subsection 5, a managed care organization that offers or issues a health care plan which provides coverage for prescription drugs shall not:

(a) Except as otherwise provided in subsection 6, require an insured to pay a deductible, copayment, coinsurance or any other form of cost-sharing or require a longer waiting period or other condition to obtain any benefit provided in the 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 insured to discourage the insured from obtaining any such benefit;

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

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

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

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

7. As used in this section:

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

(d) “Qualified health care plan” means a health care plan issued by a managed care 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 2017, 1857; A 2023, 1354)

NRS 695G.1714 Required provision concerning coverage for examination of person who is pregnant for certain diseases.

1. A managed care 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 insured by a provider of health care, facility or medical laboratory that participates in the network plan of the managed care 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, 2583)

NRS 695G.1715 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 managed care 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 11; and

(4) Dispensed in accordance with NRS 639.28075;

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

(1) Lawfully prescribed or ordered;

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

(3) Listed in subsection 11;

(d) Insertion of a device for contraception or removal of such a device if the device was inserted while the insured was covered by the same 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 managed care 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 managed care organization must ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the managed care 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 managed care organization.

5. Except as otherwise provided in subsections 9, 10 and 12, a managed care organization that offers or issues a health care plan shall not:

(a) Require an insured to pay a higher deductible, any copayment or coinsurance or require a longer waiting period or other condition to obtain any benefit included in the 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 benefits;

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

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

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

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

7. Except as otherwise provided in subsection 8, a 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 managed care 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 managed care 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 insured written notice of the coverage that the managed care organization refuses to provide pursuant to this subsection.

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

10. For each of the 18 methods of contraception listed in subsection 11 that have been approved by the Food and Drug Administration, a 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 insured, but the managed care organization may charge a deductible, copayment or coinsurance for any other drug or device that provides the same method of contraception. If the managed care organization charges a copayment or coinsurance for a drug for contraception, the managed care 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.

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

(a) Voluntary sterilization for women;

(b) Surgical sterilization implants for women;

(d) Copper-based intrauterine devices;

(e) Progesterone-based intrauterine devices;

(f) Injections;

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

(h) Progestin-based drugs;

(i) Extended- or continuous-regimen drugs;

(j) Estrogen- and progestin-based patches;

(k) Vaginal contraceptive rings;

(l) Diaphragms with spermicide;

(m) Sponges with spermicide;

(n) Cervical caps with spermicide;

(o) Female condoms;

(p) Spermicide;

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

(r) Ulipristal acetate for emergency contraception.

12. Except as otherwise provided in this section and federal law, a managed care 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.

13. A managed care organization shall not:

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

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

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

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

15. As used in this section:

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

(d) “Provider network contract” means a contract between a managed care organization and a provider of health care or pharmacy specifying the rights and responsibilities of the managed care 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, 1853, 3958; A 2021, 3288; 2023, 930, 2131)

1. A managed care 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 insured is acting as a gestational carrier.

2. If an insured acts as a gestational carrier, the child shall be deemed to be a child of the intended parent, as defined in NRS 126.590, for purposes related to the 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, 1008)

NRS 695G.1717 Required provision concerning coverage for certain services, screenings and tests relating to wellness; prohibited acts.

1. A managed care 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) Hormone replacement therapy;

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

(f) 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;

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

(h) Screening for depression;

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

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

(k) 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

(l) 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.

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

(a) Require an insured to pay a higher deductible, any copayment or coinsurance or require a longer waiting period or other condition to obtain any benefit provided in the 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 insured to discourage the insured from obtaining any such benefit;

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

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

4. A 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.

6. As used in this section:

(Added to NRS by 2017, 1855)

1. Except as otherwise provided in this section, a managed care 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 managed care 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 managed care organization that issues a health care plan may prescribe requirements that must be satisfied before the managed care organization covers surgical treatment of conditions relating to gender dysphoria or gender incongruence for an insured who is less than 18 years of age. Such requirements may include, without limitation, requirements that:

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

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

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

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

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

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

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

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 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 managed care 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 managed care 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, 2046)

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

4. Except as otherwise provided in this subsection, a managed care 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 managed care 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 managed care 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 managed care organization shall ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the managed care 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:

(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, 2379, 3528)

NRS 695G.172 Plan covering prescription drugs: Denial of coverage prohibited for early refills of otherwise covered topical ophthalmic products.

1. A managed care 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 managed care organization when the insured, pursuant to NRS 639.2395, receives a refill of the product:

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

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

2. The provisions of this section do not affect any deductibles, copayments or coinsurance authorized or required pursuant to the 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, 210)

1. A health care plan issued by a managed care organization must provide coverage for medical treatment which a person insured under the plan receives as part of a clinical trial or study if:

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

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

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

(2) A cooperative group;

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

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

(5) The United States Department of Defense;

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

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

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

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

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

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

(1) The procedure to be undertaken;

(2) Alternative methods of treatment; and

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

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

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

(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 insured in a Phase I clinical trial or study.

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

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

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

Ê Except as otherwise provided in NRS 695G.164, 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 managed care organization has contracted for such services. If the managed care organization has not contracted for the provision of such services, the managed care organization shall pay the provider the rate of reimbursement that is paid to other providers with whom the managed care 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 a person insured under the plan is not required to be covered pursuant to this section if that particular medical treatment is provided by the sponsor of the clinical trial or study free of charge to the person insured under the plan.

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

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

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

(c) Health care services that are specifically excluded from coverage under the insured’s 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 insured during the clinical trial or study.

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

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

5. A managed care 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 insured, protocols for the clinical trial or study and any other materials related to the scope of the clinical trial or study relevant to the coverage of medical treatment pursuant to this section.

6. A managed care 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 managed care 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 insured caused by:

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

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

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

9. As used in this section:

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

(1) The Clinical Trials Cooperative Group Program; and

(2) The Community Clinical Oncology Program.

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

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

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

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

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

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

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

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

(1) A hospital; or

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

(Added to NRS by 2003, 3533; A 2005, 2022; 2013, 3651)

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

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

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

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

4. A managed care 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.

(Added to NRS by 2019, 2175)

1. If a managed care organization contracts for the provision of emergency medical services, outpatient services or inpatient services with a hospital or other licensed health care facility that provides acute care and is located in a city whose population is less than 60,000 or a county whose population is less than 100,000, the managed care organization shall not:

(a) Prohibit an insured from receiving services covered by the health care plan of the insured at that hospital or licensed health care facility if the services are provided by a provider of health care with whom the managed care organization has contracted for the provision of the services;

(b) Refuse to provide coverage for services covered by the health care plan of an insured that are provided to the insured at that hospital or licensed health care facility if the services were provided by a provider of health care with whom the managed care organization has contracted for the provision of the services;

(c) Refuse to pay a provider of health care with whom the managed care organization has contracted for the provision of services for providing services to an insured at that hospital or licensed health care facility if the services are covered by the health care plan of the insured;

(d) Discourage a provider of health care with whom the managed care organization has contracted for the provision of services from providing services to an insured at that hospital or licensed health care facility that are covered by the health care plan of the insured; or

(e) Offer or pay any type of material inducement, bonus or other financial incentive to a provider of health care:

(1) To provide services to an insured that are covered by the health care plan of the insured at another hospital or licensed health care facility; or

(2) Not to provide services to an insured at that hospital or licensed health care facility that are covered by the health care plan of the insured.

2. Nothing in this section prohibits a managed care organization from informing an insured that enhanced health care services are available at a hospital or licensed health care facility other than the hospital or licensed health care facility described in subsection 1 with which the managed care organization contracts for the provision of emergency medical services, outpatient services or inpatient services.

(Added to NRS by 1999, 1945; A 2001, 1998)

1. A managed care 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 insured for care related to an organ transplant because the insured is a person with a disability;

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

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

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

2. As used in this section:

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

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

(Added to NRS by 2021, 1175)

NRS 695G.177 Required provision in plans covering treatment of prostate cancer concerning coverage for prostate cancer screening; prohibited acts.

1. A health care plan issued by a managed care 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 issued by a managed care 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 issued by a managed care 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, 3242)

QUALITY ASSURANCE PROGRAM

NRS 695G.180 Quality assurance program: Requirements; written description; informing providers; necessary staff; review; responsibility for activities.

1. Each managed care organization shall establish a quality assurance program designed to direct, evaluate and monitor the effectiveness of health care services provided to its insureds. The program must include, without limitation:

(a) A method for analyzing the outcomes of health care services;

(b) Peer review;

(d) Recommendations for remedial action; and

(e) Written guidelines that set forth the procedures for remedial action when problems related to quality of care are identified.

2. Each managed care organization shall:

(a) Maintain a written description of the quality assurance program established pursuant to subsection 1, including, without limitation, the specific actions used by the managed care organization to promote adequate quality of health care services provided to insureds and the persons responsible for such actions;

(b) Provide information to each provider of health care whom it employs or with whom it contracts to provide health care services to insureds regarding the manner in which the quality assurance program functions;

(c) Provide the necessary staff to implement the quality assurance program and to evaluate the effectiveness of the program; and

(d) At least one time each year, review the continuity and effectiveness of the quality assurance program, review any findings of the quality improvement committee established pursuant to NRS 695G.190 and take any reasonable actions to improve the program.

3. Each managed care organization is responsible for an activity conducted pursuant to its quality assurance program, regardless of whether the managed care organization or another entity performs the activity.

(Added to NRS by 1997, 303)

NRS 695G.190 Quality improvement committee: Administration; duties.

1. As part of a quality assurance program established pursuant to NRS 695G.180, each managed care organization shall create a quality improvement committee directed by a physician who is licensed to practice medicine in the State of Nevada pursuant to chapter 630 or 633 of NRS.

2. Each managed care organization shall:

(a) Establish written guidelines setting forth the procedure for selecting the members of the committee;

(b) Select members pursuant to such guidelines; and

3. The committee shall:

(a) Select and review appropriate medical records of insureds and other data related to the quality of health care provided to insureds by providers of health care;

(b) Review the clinical processes used by providers of health care in providing services;

(d) Advise providers of health care regarding issues related to quality of care.

(Added to NRS by 1997, 303; A 2003, 1182)

SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS

NRS 695G.200 Establishment; approval; requirements; assistance for persons filing complaints; examination.

1. Each managed care organization shall establish a system for resolving complaints of an insured concerning:

(a) Payment or reimbursement for covered health care services;

(b) Availability, delivery or quality of covered health care services, including, without limitation, an adverse determination made pursuant to utilization review; or

Ê The system must be approved by the Commissioner.

2. If an insured makes an oral complaint, a managed care organization shall inform the insured that if the insured is not satisfied with the resolution of the complaint, the insured must file the complaint in writing to receive further review of the complaint.

3. Each managed care organization shall:

(a) Upon request, assign an employee of the managed care organization to assist an insured or other person in filing a complaint or appealing a decision of the review board;

(b) Authorize an insured who appeals a decision of the review board to appear before the review board to present testimony at a hearing concerning the appeal; and

(c) Authorize an insured to introduce any documentation into evidence at a hearing of a review board and require an insured to provide the documentation required by the health care plan of the insured to the review board not later than 5 business days before a hearing of the review board.

4. The Commissioner may examine the system for resolving complaints established pursuant to this section at such times as the Commissioner deems necessary or appropriate.

(Added to NRS by 1997, 305; A 2013, 3654; 2017, 2401)

NRS 695G.210 Review board; appeal; right to expedited review of complaint; notice to insured.

1. Except as otherwise provided in NRS 695G.300, a system for resolving complaints created pursuant to NRS 695G.200 must include, without limitation, an initial investigation, a review of the complaint by a review board and a procedure for appealing a determination regarding the complaint. The majority of the members of the review board must be insureds who receive health care services from the managed care organization.

2. Except as otherwise provided in subsection 3, a review board shall complete its review regarding a complaint or appeal and notify the insured of its determination not later than 30 days after the complaint or appeal is filed, unless the insured and the review board have agreed to a longer period.

3. If a complaint involves an imminent and serious threat to the health of the insured, the managed care organization shall inform the insured immediately of the right of the insured to an expedited review of the insured’s complaint. If an expedited review is required, the review board shall notify the insured in writing of its determination within 72 hours after the complaint is filed.

4. Notice provided to an insured by a review board regarding a complaint must include, without limitation, an explanation of any further rights of the insured regarding the complaint that are available under the health care plan of the insured.

(Added to NRS by 1997, 306; A 2003, 783)

NRS 695G.220 Annual report; managed care organization required to maintain records of and report complaints concerning something other than health care services.

1. Each managed care organization shall submit to the Commissioner an annual report regarding its system for resolving complaints established pursuant to NRS 695G.200 on a form prescribed by the Commissioner which includes, without limitation:

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

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

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

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

(Added to NRS by 1997, 306; A 2013, 3655; 2017, 2402)

1. After approval by the Commissioner, each health carrier shall provide a written notice to an insured, in clear and comprehensible language that is understandable to an ordinary layperson, explaining the right of the insured to file a written complaint and to obtain an expedited review pursuant to NRS 695G.210. Such a notice must be provided to an insured:

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

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

2. If a health carrier denies coverage of a health care service to an insured, including, without limitation, a health maintenance organization that denies a claim related to a health care plan pursuant to NRS 695C.185, it shall notify the insured in writing within 10 working days after it denies coverage of the health care service of:

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

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

(1) File a written complaint and the procedure for filing such a complaint;

(2) Appeal an adverse determination pursuant to NRS 695G.241 to 695G.310, inclusive;

(3) Receive an expedited external review of an adverse determination if the health carrier receives proof from the insured’s provider of health care that failure to proceed in an expedited manner may jeopardize the life or health of the insured, including notification of the procedure for requesting the expedited external review; and

(4) Receive assistance from any person, including an attorney, for an external review of an adverse determination; and

(d) The telephone number of the Office for Consumer Health Assistance.

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

(Added to NRS by 1997, 307; A 1999, 3097; 2003, 784; 2011, 3411)

EXTERNAL REVIEW OF ADVERSE DETERMINATION

NRS 695G.241 Circumstances under which adverse determination may be subject to external review; exceptions. Except as otherwise required for an expedited external review pursuant to NRS 695G.271 or 695G.275, for the purposes of NRS 695G.200 to 695G.310, inclusive, an adverse determination may be subject to an external review:

1. If a covered person exhausts all procedures set forth in the health care plan for reviewing the adverse determination within the health carrier and the health carrier fails to render a decision within the period required to render that decision set forth in the health care plan; or

2. If the health carrier allows the covered person to submit the adverse determination to the independent review organization without requiring the covered person to exhaust all procedures set forth in the health care plan for reviewing the adverse determination within the health carrier.

(Added to NRS by 2003, 780; A 2011, 3412)

NRS 695G.243 Applicability.

1. Except as otherwise provided in subsection 2, the provisions of NRS 695G.200 to 695G.310, inclusive, apply to all health carriers.

2. The provisions of subsection 1 do not apply to:

(a) A policy or certificate that provides only coverage for:

(1) A specified disease or accident;

(2) Accidents;

(3) Credit;

(4) Dental;

(5) Disability income;

(6) Hospital indemnity;

(7) Long-term care insurance;

(8) Vision care; or

(9) Any other limited supplemental benefit;

(b) A Medicare supplement policy of insurance, as defined in regulations adopted by the Commissioner;

(c) Coverage under a plan through Medicare, Medicaid or the Federal Employees Health Benefits Program, FEHBP, 5 U.S.C. §§ 8901 et seq.;

(d) Any coverage issued under the Civilian Health and Medical Program of the Uniformed Services, CHAMPUS, 10 U.S.C. §§ 1071 et seq., and any coverage issued as supplemental to that coverage;

(e) Any coverage issued as supplemental to liability insurance;

(f) Workers’ compensation or similar insurance;

(g) Automobile medical payment insurance; or

(h) Any insurance under which benefits are payable with or without regard to fault, whether written on a group, blanket or individual basis.

(Added to NRS by 2011, 3399)

NRS 695G.245 Written notice of right to request external review; form; contents.

1. A health carrier shall notify the covered person in writing of the covered person’s right to request an external review to be conducted pursuant to NRS 695G.241 to 695G.310, inclusive, and include the appropriate statements and information set forth in subsection 2 at the same time the health carrier sends written notice of an adverse determination upon completion of the health carrier’s utilization review process set forth in NRS 683A.375 to 683A.379, inclusive, and the regulations adopted pursuant thereto.

2. As part of the written notice required pursuant to subsection 1, a health carrier shall include the following, or substantially equivalent, language:

We have denied your request for the provision of or payment for a health care service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care or effectiveness of the health care service or treatment you requested by submitting a request for external review to the Office for Consumer Health Assistance.

3. The Commissioner may prescribe by regulation the form and content of the notice required pursuant to this section.

4. The health carrier shall include in the notice required pursuant to subsection 1 a statement informing the covered person that:

(a) If the covered person has a medical condition where the time frame for completion of an expedited review of a grievance involving an adverse determination set forth in NRS 695G.200 to 695G.230, inclusive, would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function, the covered person or the covered person’s authorized representative may, at the same time the covered person or the covered person’s authorized representative files a request for an expedited review of a grievance involving an adverse determination as set forth in NRS 695G.210, file a request for an expedited external review to be conducted pursuant to NRS 695G.271 and 695G.275 if the adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person’s treating physician certifies in writing that the recommended or requested health care service or treatment that is the subject of the adverse determination would be significantly less effective if not promptly initiated, and the independent review organization assigned to conduct the expedited external review will determine whether the covered person will be required to complete the expedited review of the grievance before conducting the expedited external review; and

(b) The covered person or the covered person’s authorized representative may file a grievance under the health carrier’s internal grievance process as set forth in NRS 695G.200 to 695G.230, inclusive, but if the health carrier has not issued a written decision to the covered person or the covered person’s authorized representative within 30 days after the date on which the covered person or the covered person’s authorized representative filed the grievance with the health carrier and the covered person or the covered person’s authorized representative has not requested or agreed to a delay, the covered person or the covered person’s authorized representative may file a request for external review pursuant to NRS 695G.251 and shall be considered to have exhausted the health carrier’s internal grievance process.

5. In addition to the information required to be provided pursuant to subsection 1, the health carrier shall include a copy of the description of both the standard and expedited external review procedures the health carrier is required to provide pursuant to NRS 695G.307, highlighting the provisions in the external review procedures that give the covered person or the covered person’s authorized representative the opportunity to submit additional information and including any forms used to process an external review.

6. As part of any forms provided pursuant to subsection 3, the health carrier shall include an authorization form, or other document approved by the Commissioner that complies with the requirements of 45 C.F.R. § 164.508, by which the covered person, for purposes of conducting an external review, authorizes the health carrier and the covered person’s treating health care provider to disclose protected health information, including medical records, concerning the covered person that are pertinent to the external review.

7. As used in this section, “protected health information” has the meaning ascribed to it in 45 C.F.R. § 160.103.

(Added to NRS by 2011, 3400)

NRS 695G.247 Requests for external review to be in writing; exception; form and content.

1. Except for a request for an expedited external review as set forth in NRS 695G.271 or 695G.275, all requests for external review must be made in writing to the Office for Consumer Health Assistance.

2. The Commissioner may prescribe by regulation the form and content of requests for external review required to be submitted pursuant to this section.

3. A covered person or the covered person’s authorized representative may submit a request for an external review of an adverse determination.

(Added to NRS by 2011, 3401)

NRS 695G.251 Request for review; assignment of independent review organization; provision of documents relating to adverse determination to independent review organization.

1. If a covered person or a physician of a covered person receives notice of an adverse determination from a health carrier concerning the covered person, the covered person, the physician of the covered person or an authorized representative may, within 4 months after receiving notice of the adverse determination, submit a request to the Office for Consumer Health Assistance for an external review of the adverse determination.

2. Within 5 days after receiving a request pursuant to subsection 1, the Office for Consumer Health Assistance shall notify the covered person, the authorized representative or physician of the covered person, the agent who performed utilization review for the health carrier, if any, and the health carrier that the request has been filed with the Office for Consumer Health Assistance.

3. As soon as practicable after receiving a request pursuant to subsection 1, the Office for Consumer Health Assistance shall assign an independent review organization from the list maintained pursuant to NRS 683A.3715. Each assignment made pursuant to this subsection must be completed on a rotating basis.

4. Within 5 days after receiving notification from the Office for Consumer Health Assistance specifying the independent review organization assigned pursuant to subsection 3, the health carrier shall provide to the independent review organization all documents and materials relating to the adverse determination, including, without limitation:

(a) Any medical records of the insured relating to the external review;

(b) A copy of the provisions of the health benefit plan upon which the adverse determination was based;

(d) The reasons for the adverse determination; and

(e) Insofar as practicable, a list that specifies each provider of health care who has provided health care to the covered person and the medical records of the provider of health care relating to the external review.

(Added to NRS by 2003, 780; A 2011, 3412)

NRS 695G.261 Review of documents by independent review organization; decision of independent review organization.

1. Except as otherwise provided in NRS 695G.271 and 695G.275, upon receipt of a request for an external review pursuant to NRS 695G.251, the independent review organization shall, within 5 days after receiving the request:

(a) Review the request and the documents and materials submitted pursuant to NRS 695G.251; and

(b) Notify the covered person, the physician of the covered person and the health carrier if any additional information is required to conduct a review of the adverse determination. Such additional information must be provided within 5 days after receiving notice that the information is required to conduct a review of the adverse determination. The independent review organization shall forward to the health carrier, within 1 business day after receipt, any information received from a covered person or the physician of a covered person.

2. Except as otherwise provided in NRS 695G.271 and 695G.275, the independent review organization shall approve, modify or reverse the adverse determination within 15 days after it receives the information required to make that determination pursuant to this section. The independent review organization shall submit a copy of its determination, including the reasons therefor, to:

(a) The covered person;

(b) The physician of the covered person;

(d) The health carrier.

(Added to NRS by 2003, 781; A 2011, 3413)

NRS 695G.271 Expedited approval or denial of request.

1. The Office for Consumer Health Assistance shall approve or deny a request for an external review of an adverse determination in an expedited manner not later than 72 hours after it receives proof from the provider of health care of the covered person that:

(a) The adverse determination concerns an admission, availability of care, continued stay or health care service for which the covered person received emergency services but has not been discharged from the facility providing the services or care; or

(b) Failure to proceed in an expedited manner may jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function.

2. If the Office for Consumer Health Assistance approves a request for an external review pursuant to subsection 1, the Office for Consumer Health Assistance shall assign the request to an independent review organization not later than 1 working day after approving the request. Each assignment made by the Office for Consumer Health Assistance pursuant to this section must be completed on a rotating basis.

3. Within 24 hours after receiving notice of the Officer for Consumer Health Assistance assigning the request, the health carrier shall provide to the independent review organization all documents and materials specified in subsection 4 of NRS 695G.251.

4. An independent review organization that is assigned to conduct an external review pursuant to subsection 2 shall, if it accepts the assignment:

(a) Complete its external review not later than 48 hours after receiving the assignment, unless the covered person and the health carrier agree to a longer period;

(b) Not later than 24 hours after completing its external review, notify the covered person, the physician of the covered person, the authorized representative, if any, and the health carrier by telephone of its determination; and

(c) Not later than 48 hours after completing its external review, submit a written decision of its external review to the covered person, the physician of the covered person, the authorized representative, if any, and the health carrier.

(Added to NRS by 2003, 781; A 2011, 3413)

NRS 695G.275 Experimental or investigational health care service or treatment: Request for external review; request for expedited external review.

1. Within 4 months after receipt of a notice of an adverse determination pursuant to NRS 695G.245 that involves a denial of coverage based on a determination that the health care service or treatment recommended or requested is experimental or investigational, a covered person or the covered person’s authorized representative may file a request for external review with the Office for Consumer Health Assistance pursuant to this section.

2. A covered person or the covered person’s authorized representative may make an oral request for an expedited external review of the adverse determination pursuant to NRS 695G.245 that involves a denial of coverage based on a determination that the health care service or treatment recommended or requested is experimental or investigational if the covered person’s treating physician certifies, in writing, that the recommended or requested health care service or treatment that is the subject of the request would be significantly less effective if not promptly initiated.

3. Upon receipt of a request for an expedited external review pursuant to subsection 2, the Office for Consumer Health Assistance shall immediately notify the health carrier.

4. Immediately upon notice of a request for an expedited external review pursuant to subsection 2, the health carrier shall determine whether the request meets the requirements for review set forth in subsection 12. The health carrier shall immediately notify the Office for Consumer Health Assistance and the covered person and, if applicable, the covered person’s authorized representative, of its determination regarding eligibility.

5. The Commissioner may specify the form for the notice of initial determination pursuant to subsection 4 and any supporting information to be included in the notice.

6. The notice of initial determination required by subsection 4 must include a statement that a health carrier’s initial determination that a request which is ineligible for external review may be appealed to the Office for Consumer Health Assistance.

7. The Office for Consumer Health Assistance may determine that a request for an expedited external review is eligible for external review pursuant to subsection 12 and require that it be referred for expedited external review notwithstanding a health carrier’s initial determination that the request is ineligible.

8. In making a determination pursuant to subsection 7, the decision of the Office for Consumer Health Assistance must be made in accordance with the terms of the covered person’s health benefit plan and is subject to all applicable provisions of the external review process.

9. Upon receipt of the notice that the request for expedited external review meets the requirements for review, the Office for Consumer Health Assistance shall immediately assign an independent review organization to conduct the expedited external review from the list of approved independent review organizations compiled and maintained by the Commissioner pursuant to NRS 683A.3715 and notify the health carrier of the name of the assigned independent review organization.

10. Upon receipt of the notice pursuant to subsection 9, the health carrier or utilization review organization shall provide or transmit any documents and information considered in making the adverse determination to the assigned independent review organization electronically or by telephone or facsimile, or any other available expeditious method.

11. Except as otherwise provided in subsection 3, within 1 business day after receipt of a request for external review pursuant to subsection 1, the Office for Consumer Health Assistance shall notify the health carrier.

12. Within 5 business days after receipt of the notice sent pursuant to subsection 11, the health carrier shall conduct and complete a preliminary review of the request to determine whether:

(a) The person is or was a covered person in the health benefit plan at the time the health care service or treatment was recommended or requested or, in the case of a retrospective review, was a covered person in the health benefit plan at the time the health care service or treatment was provided;

(b) The recommended or requested health care service or treatment that is the subject of the adverse determination:

(1) Would be a covered benefit under the covered person’s health benefit plan but for the health carrier’s determination that the health care service or treatment is experimental or investigational for a particular medical condition; and

(2) Is not explicitly listed as an excluded benefit under the covered person’s health benefit plan;

(1) Standard health care services or treatments have not been effective in improving the condition of the covered person;

(2) Standard health care services or treatments are not medically appropriate for the covered person; or

(3) There is no available standard health care service or treatment covered by the health carrier that is more beneficial than the recommended or requested health care service or treatment described in paragraph (d);

(d) The covered person’s treating physician:

(1) Has recommended a health care service or treatment that the physician certifies, in writing, is likely to be more beneficial to the covered person, in the physician’s opinion, than any available standard health care services or treatments; or

(2) Who is a licensed, board certified or board eligible physician qualified to practice in the area of medicine appropriate to treat the covered person’s condition, has certified in writing that scientifically valid studies using accepted protocols demonstrate that the health care service or treatment requested by the covered person that is the subject of the adverse determination is likely to be more beneficial to the covered person than any available standard health care services or treatments;

(e) The covered person has exhausted the health carrier’s internal grievance process as set forth in NRS 695G.200 to 695G.230, inclusive, unless the covered person is not required to exhaust the health carrier’s internal grievance process; and

(f) The covered person has provided all the information and forms required by the Office for Consumer Health Assistance to process an external review, including the release form provided pursuant to subsection 6 of NRS 695G.245.

13. Within 1 business day after completion of the preliminary review, the health carrier shall notify the Office for Consumer Health Assistance and the covered person, and, if applicable, the covered person’s authorized representative, in writing, whether the request is:

(a) Complete;

(b) Eligible for external review;

(c) Not complete, in which case the health carrier shall include in the notice the information or materials that are needed to make the request complete; or

(d) Not eligible for external review, in which case the health carrier shall include in the notice the reasons for its ineligibility.

14. The Commissioner may specify the form for the notice of initial determination pursuant to subsection 13 and any supporting information to be included in the notice.

15. The notice of initial determination must include a statement informing the covered person and, if applicable, the covered person’s authorized representative that a health carrier’s initial determination that a request which is ineligible for external review may be appealed to the Office for Consumer Health Assistance.

16. The Office for Consumer Health Assistance may determine that a request is eligible for external review pursuant to subsection 12 and require that it be referred for external review notwithstanding a health carrier’s initial determination that the request is ineligible.

17. In making a determination pursuant to subsection 16, the decision of the Office for Consumer Health Assistance must be made in accordance with the terms of the covered person’s health benefit plan and is subject to all applicable provisions of the external review process.

18. When a health carrier determines that a request is eligible for external review pursuant to subsection 12, the health carrier shall notify the Office for Consumer Health Assistance and the covered person and, if applicable, the covered person’s authorized representative.

19. Within 1 business day after receipt of the notice from the health carrier that the external review request is eligible for external review pursuant to subsection 18, the Office for Consumer Health Assistance shall:

(a) Assign an independent review organization from the list of approved independent review organizations compiled and maintained by the Commissioner pursuant to NRS 683A.3715 to conduct the external review;

(b) Notify the health carrier of the name of the assigned independent review organization; and

(c) Notify in writing the covered person and, if applicable, the covered person’s authorized representative that the request is eligible for external review and provide the name of the assigned independent review organization.

20. The Office for Consumer Health Assistance shall include in the notice provided to the covered person and, if applicable, the covered person’s authorized representative pursuant to subsection 19 a statement that the covered person or the covered person’s authorized representative may submit in writing to the assigned independent review organization within 5 business days after receipt of the notice provided pursuant to subsection 19 additional information that the independent review organization shall consider when conducting the external review. The independent review organization may accept and consider additional information submitted after the 5 business days have elapsed.

21. Within 1 business day after receipt of the notice of assignment to conduct the external review pursuant to subsection 19, the assigned independent review organization shall:

(a) Select one or more clinical reviewers to conduct the external review, as it determines is appropriate; and

(b) Based on the opinion of the clinical reviewer, or opinions if more than one clinical reviewer has been selected to conduct the external review, make a decision to uphold or reverse the adverse determination.

22. In selecting clinical reviewers pursuant to paragraph (a) of subsection 21, the assigned independent review organization shall select health care professionals who meet the minimum qualifications described in NRS 683A.372 and through clinical experience in the past 3 years, are experts in the treatment of the covered person’s condition and knowledgeable about the recommended or requested health care service or treatment.

23. The covered person, the covered person’s authorized representative, if applicable, and the health carrier may not choose or control the choice of the health care professionals to be selected to conduct the external review.

24. In accordance with subsections 37 to 41, inclusive, each clinical reviewer shall provide a written opinion to the assigned independent review organization regarding whether the recommended or requested health care service or treatment should be covered.

25. In reaching an opinion, clinical reviewers are not bound by any decisions or conclusions reached during the health carrier’s utilization review process as set forth in NRS 683A.375 to 683A.379, inclusive, or the health carrier’s internal grievance process as set forth in NRS 695G.200 to 695G.230, inclusive.

26. Within 5 business days after receipt of the notice pursuant to subsection 19, the health carrier or utilization review organization shall provide to the assigned independent review organization any documents and information considered in making the adverse determination.

27. Except as otherwise provided in subsection 28, failure by the health carrier or utilization review organization to provide the documents and information within the time specified in subsection 26 must not delay the conduct of the external review.

28. If the health carrier or utilization review organization fails to provide the documents and information within the time specified in subsection 26, the assigned independent review organization may terminate the external review and make a decision to reverse the adverse determination.

29. If the independent review organization elects to terminate the external review and reverse the adverse determination pursuant to subsection 28, the independent review organization shall immediately notify the covered person, the covered person’s authorized representative, if applicable, the health carrier and the Office for Consumer Health Assistance.

30. Each clinical reviewer selected pursuant to subsection 21 shall review all the information and documents received pursuant to subsections 20 and 26.

31. The assigned independent review organization shall forward any information submitted by the covered person or the covered person’s authorized representative pursuant to subsection 20 to the health carrier within 1 business day after receipt of the information.

32. Upon receipt of the information required to be forwarded pursuant to subsection 31, the health carrier may reconsider the adverse determination that is the subject of the external review.

33. Reconsideration by the health carrier of its adverse determination pursuant to subsection 32 must not delay or terminate the external review.

34. Except as otherwise provided in subsection 28, the external review may only be terminated before completion if the health carrier decides, upon completion of its reconsideration, to reverse its adverse determination and provide coverage or payment for the recommended or requested health care service or treatment that is the subject of the adverse determination.

35. If the health carrier reverses its adverse determination pursuant to subsection 28, the health carrier shall immediately notify the covered person, the covered person’s authorized representative, if applicable, the assigned independent review organization and the Office for Consumer Health Assistance in writing of its decision.

36. The assigned independent review organization shall terminate the external review upon receipt of the notice from the health carrier pursuant to subsection 35.

37. Except as otherwise provided in subsection 39, within 20 days after being selected in accordance with subsection 21 to conduct the external review, each clinical reviewer shall provide an opinion to the assigned independent review organization pursuant to subsection 41 regarding whether the recommended or requested health care service or treatment should be covered.

38. Except for an opinion provided pursuant to subsection 39, each clinical reviewer’s opinion must be in writing and include the following:

(a) A description of the covered person’s medical condition;

(b) A description of the indicators relevant to determine if there is sufficient evidence to demonstrate that the recommended or requested health care service or treatment is more likely to be beneficial to the covered person than any available standard health care services or treatments and the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services or treatments;

(d) A description and analysis of any evidence-based standards used as a basis for the opinion; and

(e) Information concerning whether the reviewer’s rationale for the opinion is based on the provisions of subsection 41.

39. For an expedited external review, each clinical reviewer shall provide an opinion orally or in writing to the assigned independent review organization as expeditiously as the covered person’s medical condition or circumstances requires, but in no event not more than 5 calendar days after being selected in accordance with subsection 21.

40. If the opinion provided pursuant to subsection 39 was not in writing, within 48 hours after providing that notice, the clinical reviewer shall provide written confirmation of the opinion to the assigned independent review organization and include the information required pursuant to subsection 38.

41. In addition to the documents and information provided pursuant to subsections 10 and 26, each clinical reviewer, to the extent the information or documents are available and the reviewer considers them appropriate, shall consider the following in reaching an opinion:

(a) The covered person’s medical records;

(b) The attending health care professional’s recommendation;

(c) Consulting reports from appropriate health care professionals and other documents submitted by the health carrier, covered person, the covered person’s authorized representative or the covered person’s treating provider;

(d) The terms of coverage under the covered person’s health benefit plan with the health carrier to ensure that, but for the health carrier’s determination that the recommended or requested health care service or treatment that is the subject of the opinion is experimental or investigational, the reviewer’s opinion is not contrary to the terms of coverage under the health benefit plan; and

(e) Whether:

(1) The recommended or requested health care service or treatment has been approved by the Food and Drug Administration, if applicable, for the condition; or

(2) Medical or scientific evidence or evidence-based standards demonstrate that the expected benefits of the recommended or requested health care service or treatment is more likely to be beneficial to the covered person than any available standard health care services or treatments and the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services or treatments.

42. Except as otherwise provided in subsection 43, within 20 days after receipt of the opinion of each clinical reviewer pursuant to subsection 41, the assigned independent review organization, in accordance with subsection 45 or 46, shall make a decision and provide written notice of the decision to the covered person, the covered person’s authorized representative, if applicable, the health carrier and the Office for Consumer Health Assistance and include the information required pursuant to subsection 50.

43. For an expedited external review, within 48 hours after receipt of the opinion of each clinical reviewer pursuant to subsection 41, the assigned independent review organization, in accordance with subsection 45 or 46, shall make a decision and provide notice of the decision orally or in writing to the covered person, the covered person’s authorized representative, if applicable, the health carrier and the Office for Consumer Health Assistance.

44. If the notice provided pursuant to subsection 43 was not in writing, within 48 hours after providing that notice, the assigned independent review organization shall provide written confirmation of the decision to the covered person, the covered person’s authorized representative, if applicable, the health carrier and the Office for Consumer Health Assistance and include the information required pursuant to subsection 50.

45. If a majority of the clinical reviewers recommend that the recommended or requested health care service or treatment should be covered, the independent review organization shall make a decision to reverse the health carrier’s adverse determination.

46. If a majority of the clinical reviewers recommend that the recommended or requested health care service or treatment should not be covered, the independent review organization shall make a decision to uphold the health carrier’s adverse determination.

47. If the clinical reviewers are evenly split as to whether the recommended or requested health care service or treatment should be covered, the independent review organization shall obtain the opinion of an additional clinical reviewer in order for the independent review organization to make a decision based on the opinions of a majority of the clinical reviewers pursuant to subsection 45 or 46.

48. The additional clinical reviewer selected pursuant to subsection 47 shall use the same information to reach an opinion as the clinical reviewers who have already submitted their opinions pursuant to subsection 41.

49. The selection of an additional clinical reviewer pursuant to subsection 47 must not extend the time within which the assigned independent review organization is required to make a decision based on the opinions of the clinical reviewers pursuant to subsection 42.

50. The independent review organization shall include in the notice provided pursuant to subsection 42 or 44:

(a) A general description of the reason for the request for external review;

(b) The written opinion of each clinical reviewer, including the recommendation of each clinical reviewer as to whether the recommended or requested health care service or treatment should be covered and the rationale for the reviewer’s recommendation;

(c) The date the independent review organization was assigned by the Office for Consumer Health Assistance to conduct the external review;

(d) The date on which the external review was conducted;

(e) The date of the decision;

(f) The principal reason or reasons for the decision; and

(g) The rationale for the decision.

51. Upon receipt of a notice of a decision pursuant to subsection 42 or 44 reversing the adverse determination, the health carrier shall immediately approve coverage of the recommended or requested health care service or treatment that was the subject of the adverse determination.

52. The assignment by the Office for Consumer Health Assistance of an approved independent review organization to conduct an external review in accordance with this section must be done on a random basis among those approved independent review organizations qualified to conduct the particular external review based on the nature of the health care service or treatment that is the subject of the adverse determination and other circumstances, including concerns regarding conflicts of interest pursuant to subsection 4 of NRS 683A.372.

53. As used in this section:

(a) “Best evidence” means evidence based on:

(1) Randomized clinical trials;

(2) If randomized clinical trials are not available, cohort studies or case-control studies;

(3) If the methods described in subparagraphs (1) and (2) are not available, case series; or

(4) If the methods described in subparagraphs (1), (2) and (3) are not available, expert opinion.

(b) “Evidence-based standard” means the conscientious, explicit and judicious use of the current best evidence based on the overall systematic review of research in making decisions about the care of an individual patient.

(c) “Randomized clinical trial” means a controlled, prospective study of patients who have been randomized into an experimental group and a control group at the beginning of the study with only the experimental group of patients receiving a specific intervention, which includes study of the groups for variables and anticipated outcomes over time.

(Added to NRS by 2011, 3401)

NRS 695G.280 Basis for decision of independent review organization. The decision of an independent review organization concerning a request for an external review must be based on:

1. Documentary evidence, including any recommendation of the physician of the insured submitted pursuant to NRS 695G.251;

2. Medical or scientific evidence, including, without limitation:

(a) Professional standards of safety and effectiveness for diagnosis, care and treatment that are generally recognized in the United States;

(b) Any report published in literature that is peer-reviewed;

(c) Evidence-based medicine, including, without limitation, reports and guidelines that are published by professional organizations that are recognized nationally and that include supporting scientific data; and

(d) An opinion of an independent physician who, as determined by the independent review organization, is an expert in the health specialty that is the subject of the independent review; and

3. The terms and conditions for benefits set forth in the evidence of coverage issued to the insured by the health carrier.

(Added to NRS by 2003, 782; A 2011, 3414)

NRS 695G.290 Decision in favor of covered person binding on health carrier; limitation of liability; cost for independent review organization.

1. If the determination of an independent review organization concerning an external review of an adverse determination is in favor of the covered person, the determination is final, conclusive and binding upon the health carrier.

2. An independent review organization or any clinical peer who conducts or participates in an external review of an adverse determination for the independent review organization is not liable in a civil action for damages relating to a determination made by the independent review organization if the determination is made in good faith and without gross negligence.

3. The cost of conducting an external review of an adverse determination pursuant to NRS 695G.241 to 695G.310, inclusive, must be paid by the health carrier that made the adverse determination.

(Added to NRS by 2003, 782; A 2011, 3415)

NRS 695G.300 Submission of complaint of covered person to independent review organization. In lieu of resolving a complaint of a covered person in accordance with a system for resolving complaints established pursuant to the provisions of NRS 695G.200, a health carrier may:

1. Submit the complaint to an independent review organization pursuant to the provisions of NRS 695G.241 to 695G.310, inclusive; or

2. If a federal law or regulation provides a procedure for submitting the complaint for resolution that the Commissioner determines is substantially similar to the procedure for submitting the complaint to an independent review organization pursuant to NRS 695G.241 to 695G.310, inclusive, submit the complaint for resolution in accordance with the federal law or regulation.

(Added to NRS by 2003, 782; A 2011, 3415)

NRS 695G.303 Independent review organization and health carrier required to maintain written records; submission of report upon request.

1. An independent review organization assigned pursuant to NRS 695G.251, 695G.271 or 695G.275 to conduct an external review shall maintain written records, aggregated for each state and for each health carrier, on all requests for which it conducted an external review during a calendar year and, upon request, submit a report to the Office for Consumer Health Assistance in a format specified by the Commissioner.

2. The report must include, aggregated for each state and for each health carrier:

(a) The total number of requests for external review;

(b) The number of requests for external review resolved and, of those resolved, the number upholding the adverse determination and the number reversing the adverse determination;

(d) A summary of the types of coverages or cases for which an external review was sought;

(e) The number of external reviews that were terminated as the result of a reconsideration by the health carrier of its adverse determination after receipt of additional information from the covered person or the covered person’s authorized representative pursuant to subsection 4 of NRS 695G.251 and subsection 32 of NRS 695G.275; and

(f) Any other information the Office for Consumer Health Assistance may request or require.

3. An independent review organization shall retain the written records required pursuant to this section for at least 3 years.

4. Each health carrier shall maintain written records, aggregated for each state and for each type of health benefit plan offered by the health carrier, on all requests for external review for which the health carrier receives notice from the Office for Consumer Health Assistance and, upon request, submit a report to the Office for Consumer Health Assistance in a format specified by the Commissioner.

5. The report must include, aggregated for each state and for each type of health benefit plan:

(a) The total number of requests for external review;

(b) Of the total number of requests for external review, the number of requests determined to be eligible for external review; and

6. A health carrier shall retain the written records required pursuant to this section for at least 3 years.

(Added to NRS by 2011, 3409)

NRS 695G.307 Health carrier required to provide description of external review procedures; format; contents.

1. A health carrier shall include a description of the external review procedures in or attached to the policy, certificate, membership booklet, outline of coverage or other evidence of coverage it provides to covered persons.

2. The description required by subsection 1 must be in a format prescribed by the Commissioner.

3. The description required by subsection 1 must include a statement that informs the covered person of the right of the covered person to file a request for an external review of an adverse determination with the Office for Consumer Health Assistance. The statement may explain that external review is available when the adverse determination involves an issue of medical necessity, appropriateness, health care setting, level of care or effectiveness. The statement must include the telephone number and address of the Office for Consumer Health Assistance.

4. In addition to the requirements of subsection 3, the statement must inform the covered person that, when filing a request for an external review, the covered person will be required to authorize the release of any medical records of the covered person that may be required to be reviewed for the purpose of reaching a decision on the external review.

(Added to NRS by 2011, 3409)

NRS 695G.310 Annual report; requirements. On or before December 31 of each year, each health carrier shall file a written report with the Office for Consumer Health Assistance setting forth the total number of:

1. Requests for an external review of an adverse decision made by the health carrier which were granted by the Office for Consumer Health Assistance during the immediately preceding year; and

2. Adverse determinations of the health carrier that were:

(a) Upheld during the immediately preceding year.

(b) Reversed during the immediately preceding year.

(Added to NRS by 2003, 783; A 2005, 1026; 2011, 3415)

MISCELLANEOUS PROVISIONS

NRS 695G.320 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 managed care 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 managed care organization to provide services to recipients of Medicaid or insureds in the Children’s Health Insurance Program, as applicable.

(Added to NRS by 2019, 1927; A 2021, 240)

NRS 695G.325 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 managed care 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, 2419)

NRS 695G.330 Provision of health care services to recipients of Medicaid: Coverage for antipsychotic or anticonvulsant medication that is not on list of preferred prescription drugs required upon failure of drug on list to treat condition. A managed care 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, 525)

PROHIBITED ACTS

NRS 695G.400 Managed care organization prohibited from restricting or interfering with certain communications between provider of health care and patient. A managed care organization shall not restrict or interfere with any communication between a provider of health care and a patient of the provider of health care regarding any information that the provider of health care determines is relevant to the health care of the patient.

(Added to NRS by 1997, 304)

NRS 695G.405 Managed care 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 managed care organization shall not:

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

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

(c) Refuse 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 managed care 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 managed care organization under a health care plan that provides coverage for long-term care or disability income.

(Added to NRS by 2005, 2347; A 2007, 87)

NRS 695G.410 Managed care organization prohibited from taking certain actions against provider solely because provider advocates on behalf of patient, assists patient or reports violation of law. A managed care organization shall not terminate a contract with, demote, refuse to contract with or refuse to compensate a provider of health care solely because the provider, in good faith:

1. Advocates in private or in public on behalf of a patient;

2. Assists a patient in seeking reconsideration of a decision by the managed care organization to deny coverage for a health care service; or

3. Reports a violation of law to an appropriate authority.

(Added to NRS by 1997, 304)

NRS 695G.415 Managed care organization prohibited from discriminating against person with respect to participation or coverage on basis of gender identity or expression. A managed care 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 insured or a family member of the insured;

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

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

(a) Related to gender transition, provided that there is coverage under the 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, 2048)

NRS 695G.420 Managed care organization prohibited from offering or paying financial incentive to provider to deny, reduce, withhold, limit or delay medically necessary services.

1. A managed care organization shall not 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 specific medically necessary health care services to an insured.

2. Nothing in this section prohibits an arrangement for payment between a managed care organization and a provider of health care that uses capitation or other financial incentives, if the arrangement is designed to provide an incentive to the provider of health care to use health care services effectively and consistently in the best interest of the health care of the insured.

(Added to NRS by 1997, 304)