NAC: CHAPTER 689B - GROUP AND BLANKET HEALTH INSURANCE

[Rev. 5/25/2022 11:36:50 AM]

[NAC-689B Revised Date: 8-18]

CHAPTER 689B - GROUP AND BLANKET HEALTH INSURANCE

GENERAL PROVISIONS

689B.010 Definitions.

689B.011 “Actuarial memorandum” defined.

689B.0115 “Actuarial opinion” defined.

689B.012 “Association” defined.

689B.014 “Commissioner” defined.

689B.016 “Division” defined.

689B.018 “Employer’s group” defined.

689B.019 “Guaranteed association” defined.

GROUPS FORMED TO PURCHASE INSURANCE

689B.020 Request for approval of policy.

689B.030 Certification, filing and approval of policy.

689B.040 Standards for rates.

689B.050 Establishment of program for rating experience.

689B.060 Standards for acceptance or rejection of employer’s group.

689B.070 Coverage of employer’s group; standards for exclusion or limitation.

689B.080 Limiting benefits to certain employer’s groups for preexisting conditions.

689B.090 Notice of cancellation, nonrenewal or renewal with altered terms.

GUARANTEED ASSOCIATIONS

689B.095 Actuarial memorandum: Submission by insurer; contents.

689B.097 Annual approval of actuarial memorandum and applicable rates; submission of additional information.

689B.099 Notice of cancellation of policy when fewer than 200 persons covered.

USE OF PREFERRED PROVIDERS OF HEALTH CARE

689B.110 Disclosure of points at which insured’s payment for coinsurance is no longer required; sample calculation of claim; limitation on approval of policy.

689B.120 Contents of policy: General requirements.

689B.130 Contents of policy: Provisions concerning emergencies and medical necessity.

689B.140 Filing of information with Division.

689B.150 Dissemination of list of preferred providers and any geographic limitations.

689B.160 Agreements with preferred providers: Notice of termination.

PAYMENT OF BENEFITS

689B.180 Subrogation: Right of insurer and insured to recover from third party; lien against recovery; subrogation not basis for denial of payment of benefits.

689B.190 Group benefits payable by more than one insurer to provider; restrictions.

689B.195 Determination of benefits; consideration of benefits payable under another policy not allowed.

SUMMARY OF COVERAGE

689B.205 Disclosures in advertising and sales materials; inclusion of certain information in health benefit plan.

689B.210 “Group policyholder” interpreted; filing, contents and delivery of disclosure.

PREMIUM RATES

689B.230 Limitation on frequency of increases; exceptions.

SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS

689B.250 Requirements for approval.

689B.260 Annual report.

BLANKET POLICIES

689B.280 Compliance with NAC 689B.205 and 689B.230.

PORTABILITY AND ACCOUNTABILITY

689B.295 Definitions.

689B.300 Evidence of creditable coverage.

689B.305 Restrictions on rules of eligibility and on premium and contribution rates.

689B.310 Converted policies.

POLICIES FOR STOP-LOSS INSURANCE

689B.350 General provisions.

GENERAL PROVISIONS

NAC 689B.010 Definitions. (NRS 679B.130) As used in this chapter, unless the context otherwise requires, the words and terms defined in NAC 689B.011 to 689B.019, inclusive, have the meanings ascribed to them in those sections.

(Added to NAC by Comm’r of Insurance, eff. 10-12-88; A 5-27-92; R111-07, 1-30-2008)

NAC 689B.011 “Actuarial memorandum” defined. (NRS 679B.130) “Actuarial memorandum” means a memorandum created and signed by a qualified actuary that justifies the actuarial opinion rendered by the actuary.

(Added to NAC by Comm’r of Insurance by R111-07, eff. 1-30-2008)

NAC 689B.0115 “Actuarial opinion” defined. (NRS 679B.130) “Actuarial opinion” means the conclusion drawn by an actuary from actuarial knowledge or from the application of one or more actuarial methods to a body of data.

(Added to NAC by Comm’r of Insurance by R111-07, eff. 1-30-2008)

NAC 689B.012 “Association” defined. (NRS 679B.130) “Association” means any group formed for the purpose of purchasing insurance which has been approved and marketed pursuant to NRS 688B.030 or 689B.026.

(Added to NAC by Comm’r of Insurance, eff. 10-12-88; A 5-27-92)—(Substituted in revision for part of NAC 689B.010)

NAC 689B.014 “Commissioner” defined. “Commissioner” means the Commissioner of Insurance.

(Supplied in codification)

NAC 689B.016 “Division” defined. (NRS 679B.130) “Division” means the Division of Insurance of the Department of Business and Industry.

(Added to NAC by Comm’r of Insurance, eff. 10-12-88; A 5-27-92)—(Substituted in revision for part of NAC 689B.010)

NAC 689B.018 “Employer’s group” defined. “Employer’s group” means any subgroup within an association consisting of an employer, his or her employees and their dependents, who purchase group health insurance as members of the association.

(Added to NAC by Comm’r of Insurance, eff. 10-12-88; A 5-27-92)—(Substituted in revision for part of NAC 689B.010)

NAC 689B.019 “Guaranteed association” defined. (NRS 679B.130) “Guaranteed association” has the meaning ascribed to it in NRS 689B.0265.

(Added to NAC by Comm’r of Insurance by R111-07, eff. 1-30-2008)

GROUPS FORMED TO PURCHASE INSURANCE

NAC 689B.020 Request for approval of policy. (NRS 679B.130) An insurer requesting approval of a policy for group insurance to be issued and delivered to an association shall submit to the Division:

1. A copy of each insurance policy, certificate, rider, endorsement and application used for the association.

2. A statement illustrating that the benefits payable are reasonable in relation to the premiums charged.

3. The name and address of the administrator if an administrator is to pay the claims or collect the premiums.

4. The name and address of the trustee of the association and the name of the trust.

5. Copies of all agreements or contracts for the administration of claims and collection of premiums as well as any information relating to utilization reviews, quality assurance programs and the marketing of the insurance policy, including copies of any advertising or brochures to be used.

6. For health insurance benefits:

(a) A description of the methodology used to determine the usual and customary fees charged for services rendered by providers; and

(b) A statement verifying that the insurer has adopted at least three practices in administering benefits that control or reduce the cost of health care, and a brief description of those practices. The statement must list those sections of the policy or certificate where the practices are described.

7. The appropriate filing fees and forms prescribed by the Commissioner.

(Added to NAC by Comm’r of Insurance, eff. 10-12-88; A 5-27-92)

NAC 689B.030 Certification, filing and approval of policy. (NRS 679B.130)

1. If an insurer certifies its filing pursuant to this section and mails it to the Division by certified mail, the approval of the filing of the policy shall be deemed to be effective upon the date of the mailing subject to the notice of disapproval provided in NRS 687B.130.

2. An insurer’s filing may be approved if it certifies, on a form provided by the Division, that:

(a) The policy is issued to a group formed to purchase insurance pursuant to NRS 688B.030 or 689B.026;

(b) The policy contains the terms and benefits required by title 57 of NRS;

(d) To the best of the insurer’s knowledge, the association to whom the policy is delivered is financially sound.

3. With its certification, the insurer shall submit the documents listed in subsections 1 and 3 to 7, inclusive, of NAC 689B.020, and clearly identify within the filing each section which meets the requirements of title 57 of NRS and NAC 689B.010 to 689B.090, inclusive.

4. An insurer certifying its policy shall include a copy of its certification with its marketing and promotional materials furnished to any agent or broker in this State.

(Added to NAC by Comm’r of Insurance, eff. 10-12-88; A 5-27-92)

NAC 689B.040 Standards for rates. (NRS 679B.130) The rate charged by the insurer to a member or employer’s group within the association must be based upon the experience of the entire association. Except as otherwise provided in NAC 689B.050, the insurer may not use rebates, surcharges, adjustments or similar rating standards for an employer’s group based upon the claims experience of the employer’s group.

(Added to NAC by Comm’r of Insurance, eff. 10-12-88)

NAC 689B.050 Establishment of program for rating experience. (NRS 679B.130)

1. An insurer may establish an experience rating program which compares the loss experience of an employer’s group to the loss experience of the entire association and which may result in different premiums. An insurer which establishes such a program must establish its classes or class distinctions and schedules for different premiums based upon commonly accepted actuarial principles. Such a program may not result in rates that exceed the standards established in NRS 686B.050 and 686B.060 or are unfairly discriminatory as described in NRS 686A.100.

2. Upon receiving a request from a customer or the Division, the insurer shall demonstrate, with appropriate statistical evidence, the appropriateness of its classes and class distinctions and the premiums charged.

3. The premium for an employer’s group may be adjusted, pursuant to an experience rating program, at the time the policy is renewed if:

(a) The insurer has mailed a notice to the employer’s group at least 60 days before the renewal date, which clearly explains the amount of the increase and the rationale for it; and

(b) The employer’s group experienced a loss ratio that was at least 150 percent greater than the loss ratio of the association as a whole.

4. If an employer’s group has its premium increased pursuant to this section, the increase may not be greater than 100 percent of the premium for the entire association. The calculation of this limitation may not include the amount of any increases in premiums which have been applied to the entire association.

(Added to NAC by Comm’r of Insurance, eff. 10-12-88; A 5-27-92)

NAC 689B.060 Standards for acceptance or rejection of employer’s group. (NRS 679B.130) At the time that an employer’s group requests membership in an association, the insurer may accept or reject that group in accordance with the following standards:

1. For employer’s groups with more than 10 persons, if information on insurability is collected by the insurer, the insurer may use this information only to determine whether or not it will accept the employer’s entire group. No member of the employer’s group may be excluded from the association by the insurer through the use of a waiver or other device.

2. For employer’s groups of 10 persons or less:

(a) The insurer may request information concerning evidence of insurability for the individual members of the employer’s group.

(b) After the review of this information, the insurer may reject, because of insurability, any member of the employer’s group.

(Added to NAC by Comm’r of Insurance, eff. 10-12-88)

NAC 689B.070 Coverage of employer’s group; standards for exclusion or limitation.

1. Any insurer wishing to exclude or limit the coverage in a policy issued to an association for any person based upon his or her evidence of insurability, must submit the standards for exclusion or limitation to the Division. These standards must comply with the provisions of this section.

2. For all the employer’s groups within the association:

(a) The coverage provided to members of that employer’s group must be a guaranteed renewable policy for as long as the association continues to renew that employer’s group.

(b) Once the insurer accepts the employer’s group, the insurer may not periodically underwrite the employer’s group or use that underwriting to cancel the employer’s group or any person within it or to transfer a member to another policy.

(1) Shall accept that employee and his or her dependents based upon the underwriting standards used at the time the employer’s group was originally underwritten as required by NAC 689B.060 if the request is made within the time established in the policy or by the employer for the eligibility of new employees; and

(2) May request evidence of insurability from the employee and his or her dependents if the request for coverage is not made within the time established in the policy or by the employer for eligibility for new employees.

(Added to NAC by Comm’r of Insurance, eff. 10-12-88; A 5-27-92)

NAC 689B.080 Limiting benefits to certain employer’s groups for preexisting conditions.

1. An insurer offering an association to an employer’s group with less than 25 members may limit its benefits from those benefits offered pursuant to NRS 689B.065, if the insurer has filed a plan with the Commissioner which expressly provides for exclusions from coverage for preexisting conditions and the exclusions:

(a) Do not exceed a period of more than 12 months from the effective date of the policy; and

(b) Limit payment for medical treatment to less than $1,000 for each preexisting condition for the 12-month period.

2. The employer shall sign and date a copy of a notice calling the exclusions and reductions in benefits to his or her attention. A copy of the signed disclosure must be maintained by the agent for 3 years after the policy is issued or renewed pursuant to NRS 683A.351.

3. For the purpose of this section, “preexisting condition” means a medical condition of a person for which he or she has received treatment during the 12 months preceding the effective date of the policy.

4. The provisions of this section do not modify the employer’s duty to notify employees of these exclusions as a reduction in benefits pursuant to subsection 2 of NRS 689B.065.

(Added to NAC by Comm’r of Insurance, eff. 10-12-88)

NAC 689B.090 Notice of cancellation, nonrenewal or renewal with altered terms. (NRS 679B.130) Each notice of cancellation, nonrenewal or renewal with altered terms, issued by an insurer or an association to an employer’s group must comply with the provisions of NRS 687B.310 to 687B.410, inclusive, and must be given to each employer’s group in the association.

(Added to NAC by Comm’r of Insurance, eff. 10-12-88)

GUARANTEED ASSOCIATIONS

NAC 689B.095 Actuarial memorandum: Submission by insurer; contents. (NRS 679B.130, 689B.0265) An insurer that offers coverage under a policy of group health insurance to a guaranteed association must submit an actuarial memorandum to the Commissioner which must include, without limitation:

1. The purpose and scope of the actuarial memorandum;

2. The numbers of the forms to which the rates will apply;

3. A description of the benefits included in the coverage;

4. An explanation of how the base rate was developed;

5. The methodology used to determine the underwriting rate;

6. The actuarial assumptions used in establishing the rates;

7. Exhibits addressing all loads and factors considered in establishing the rates;

8. The basis used for the rate structure;

9. An attestation that the actuary has developed the rates in accordance with generally accepted actuarial practices, including that the rates are reasonable in relation to the benefits provided, are not inadequate and are not excessive or unfairly discriminatory; and

10. An actuarial certification that the actuary is qualified to render the actuarial opinion.

(Added to NAC by Comm’r of Insurance by R111-07, eff. 1-30-2008)

NAC 689B.097 Annual approval of actuarial memorandum and applicable rates; submission of additional information. (NRS 679B.130, 689B.0265)

1. The actuarial memorandum required by NAC 689B.095 and the applicable rates must be submitted to and approved by the Commissioner annually.

2. After the submission of the initial actuarial memorandum, each subsequent actuarial memorandum submitted to the Commissioner by the insurer must, in addition to the items required by NAC 689B.095, include, without limitation:

(a) All changes in rates from the inception of coverage;

(b) Any changes in actuarial assumptions;

(d) If a change in rates is being proposed, projections of the loss ratio both before and after the rate change; and

(e) The number of members in the guaranteed association.

(Added to NAC by Comm’r of Insurance by R111-07, eff. 1-30-2008)

NAC 689B.099 Notice of cancellation of policy when fewer than 200 persons covered. (NRS 679B.130) If the number of members, employees of members or employees of a guaranteed association or their dependents covered under a policy of group health insurance falls below 200 in violation of a contract between the insurer and the guaranteed association, the insurer must comply with the notice requirement of subsection 2 of NRS 687B.320 to cancel the policy.

(Added to NAC by Comm’r of Insurance by R111-07, eff. 1-30-2008)

USE OF PREFERRED PROVIDERS OF HEALTH CARE

NAC 689B.110 Disclosure of points at which insured’s payment for coinsurance is no longer required; sample calculation of claim; limitation on approval of policy. (NRS 679B.130, 689B.027, 689B.061)

1. The point at which an insured’s payment for coinsurance is no longer required to be paid for preferred providers of health care and for providers who are not preferred in a policy of group health insurance pursuant to subsection 6 of NRS 689B.061 must be disclosed to the insured and included in the disclosure filed pursuant to NRS 689B.027.

2. Each form of policy filed with the Commissioner must include a sample calculation of a claim using the method of calculation selected by the insurer.

3. The Commissioner will not approve a policy if the point at which an insured’s payment for coinsurance is no longer required to be paid for preferred providers of health care and for providers who are not preferred is misleading or deceptively affects the risk purported to be assumed.

(Added to NAC by Comm’r of Insurance, eff. 6-1-88; A 6-20-90; 9-16-92)

NAC 689B.120 Contents of policy: General requirements. A policy of group health insurance issued pursuant to NRS 689B.061:

1. Must include a definition for preferred providers of health care and providers of health care who are not preferred.

2. Must include an explanation of the amount of disincentives to be paid for using the services of providers of health care who are not preferred.

3. Must include in the schedule of benefits the amounts for deductibles and coinsurance payable for preferred providers of health care and providers of health care who are not preferred.

4. Must include a description of the type of plan used for preferred providers of health care and whether it is limited to specific services only, such as services obtained from a physician or hospital or for prescription drugs.

5. Must provide that the services covered, if provided by preferred providers of health care, are the same for providers of health care who are not preferred.

6. Must include a statement that the insured should verify whether a provider of health care is a preferred provider of health care.

7. Must provide that, if the insured is confined in a facility which is a preferred provider of health care at a time when the facility terminates its agreement with the insurer, coverage will be provided for the period of confinement at the rate negotiated for that facility before it terminated its agreement and at no additional cost to the insured.

8. Must provide that, if the insured obtains prior authorization for health care services to be rendered by a preferred provider of health care and the provider subsequently terminates his or her agreement with the insurer, coverage will be provided for those services at the rate negotiated for that provider before terminating the agreement and at no additional cost to the insured.

9. May not require that the payments to a provider of health care who is not preferred be based upon the fee schedule or arrangements for preferred providers of health care.

10. May not provide for more than a 50 percent difference or reduction in any payment of otherwise eligible expenses for not complying with any procedures requiring the prior authorization of care or notification that treatment was received for an emergency.

(Added to NAC by Comm’r of Insurance, 7-19-90, eff. 10-1-90)

NAC 689B.130 Contents of policy: Provisions concerning emergencies and medical necessity. (NRS 679B.130, 689B.061) A policy of group health insurance issued pursuant to NRS 689B.061 must:

1. Include the criteria used to determine what is an emergency or treatment for an emergency.

2. Contain a description of any procedures used to determine whether health care services rendered are medically necessary.

3. If necessary, contain a description of the benefits payable for emergency care.

(Added to NAC by Comm’r of Insurance, 7-19-90, eff. 10-1-90)

NAC 689B.140 Filing of information with Division. (NRS 679B.130, 689B.061) Each insurer offering a policy of group health insurance pursuant to NRS 689B.061 shall file with the Division:

1. A copy of each standard agreement made with each preferred provider of health care and a list of the preferred providers of health care used by the insurer according to their specialties.

2. A copy of any agreement made with a third party to act as an administrator for the payment of claims or the collection of premiums. A copy of the rates or payments to be made to the administrator by the insurer may be omitted.

3. A copy of any contracts requiring a preauthorization review or procedures for obtaining authorization for care which may be separate from the policy.

4. A copy of any contracts entered into with persons who conduct utilization reviews or a brief description of the standards or guidelines used for a utilization review and the assurance of quality which may be separate from the policy.

(Added to NAC by Comm’r of Insurance, 7-19-90, eff. 10-1-90; A 5-27-92)

NAC 689B.150 Dissemination of list of preferred providers and any geographic limitations. (NRS 679B.130, 689B.061) An insurer offering a policy of group health insurance pursuant to NRS 689B.061 shall include with its health disclosure form a list of its preferred providers of health care and a description of any geographic limitation to the availability of services.

(Added to NAC by Comm’r of Insurance, 7-19-90, eff. 10-1-90)

NAC 689B.160 Agreements with preferred providers: Notice of termination. (NRS 679B.130) Each agreement entered into by an insurer and a preferred provider of health care must require a party who wishes to terminate the agreement to give notice to the other party at least 90 days before the date of termination.

(Added to NAC by Comm’r of Insurance, 7-19-90, eff. 10-1-90)

PAYMENT OF BENEFITS

NAC 689B.180 Subrogation: Right of insurer and insured to recover from third party; lien against recovery; subrogation not basis for denial of payment of benefits. (NRS 679B.130)

1. Except as otherwise provided by specific federal or state statute or regulation, an insurer may include in a policy of group health insurance issued pursuant to chapter 689B of NRS a provision for subrogation regarding the right of an insured to recover, and the imposition of a lien upon any recovery by an insured, from a third person for the cost of medical benefits reimbursed by the insurer to the insured because of injuries incurred by the insured as a result of the actions of the third person. The amount of the lien must not be more than the amount of the reimbursements paid by the insurer.

2. An insurer shall not deny the payment of any benefits based upon such a provision for subrogation.

(Added to NAC by Comm’r of Insurance, eff. 12-15-94)

NAC 689B.190 Group benefits payable by more than one insurer to provider; restrictions. (NRS 679B.130) When the benefits of a policy of group health insurance issued pursuant to chapter 689B of NRS are payable by more than one insurer to a provider, the policy must not require the insured, or any secondary insurer who is a:

1. Group health insurer;

2. Health maintenance organization; or

3. Nonprofit corporation for hospital, medical or dental service,

Ê to pay more than the remaining deductible and coinsurance, if any, based upon the rates established by the primary insurer for its payment of that provider.

(Added to NAC by Comm’r of Insurance, eff. 12-15-94)

NAC 689B.195 Determination of benefits; consideration of benefits payable under another policy not allowed. (NRS 679B.130) A policy of group health insurance issued pursuant to chapter 689B of NRS:

1. Must not, for the determination of benefits payable for the coordination of benefits, provide for the consideration of any benefits payable pursuant to any health insurance under a franchise plan, no-fault automobile insurance or automobile medical insurance.

2. Must provide for the payment of benefits without regard to any benefits payable pursuant to any health insurance under a franchise plan, no-fault automobile insurance or automobile medical insurance.

(Added to NAC by Comm’r of Insurance, eff. 12-15-94; A by R089-17, 5-16-2018)

SUMMARY OF COVERAGE

NAC 689B.205 Disclosures in advertising and sales materials; inclusion of certain information in health benefit plan. (NRS 679B.130, 689B.027)

1. As part of the disclosure required by NRS 689B.027, an insurer shall disclose in the advertising and sales materials that the insurer provides to employers:

(a) The term of the contract applicable to the premium rates;

(b) A general description of the underwriting factors that the insurer used to calculate premiums; and

2. An insurer shall include a copy of the information described in paragraph (c) of subsection 1 in the health benefit plan that the insurer provides to an insured.

(Added to NAC by Comm’r of Insurance by R009-02, eff. 5-23-2002; A by R009-02, 7-11-2002)

REVISER’S NOTE.

The regulation of the Commissioner of Insurance filed with the Secretary of State on July 11, 2002 (LCB File No. R009-02), the source of this section (section 6 of this regulation), contains the following provision not included in NAC:

“Sec. 20. Sections 6, 13, 16 and 19 of this regulation [NAC 689B.205, 689C.172, 695B.035 and 695C.295] apply to any disclosures given for health insurance, group contracts for hospital or medical service and group health care plans offered by insurers, nonprofit corporations for hospital, medical or dental services and health maintenance organizations that are offered or issued on or after July 10, 2002.”

NAC 689B.210 “Group policyholder” interpreted; filing, contents and delivery of disclosure.

1. For the purposes of NRS 689B.028, “group policyholder” includes an employer’s group in a marketing program of an association.

2. Each insurer shall file with the Commissioner, for the Commissioner’s approval, a disclosure summarizing the coverage provided by a policy of group health insurance offered by the insurer.

3. The disclosure must:

(a) Be in at least 10-point type;

(b) Include the name, address and telephone number of the insurance company;

(d) Include a statement describing the principal benefits and the type of coverage being provided;

(e) Include a description of any provision of the policy which significantly excludes, eliminates, reduces or in any other manner operates to limit the payment of the benefits;

(f) Include a statement concerning the renewal provisions of the policy; and

(g) Define the term “usual and customary” or any similar term used in the policy.

4. The agent for the insurer, the insurer after a response to a direct-response solicitation or the broker representing the proposed insured shall deliver the approved disclosure summary to the proposed policyholder as provided in NRS 689B.028.

5. The provisions of this section do not apply to policies supplementing Medicare which are governed by the provisions of NAC 687B.200 to 687B.330, inclusive.

(Added to NAC by Comm’r of Insurance, eff. 2-21-90; A 7-16-92, eff. 7-30-92)

PREMIUM RATES

NAC 689B.230 Limitation on frequency of increases; exceptions. (NRS 679B.130)

1. Except as otherwise provided in this section, an insurer that issues group health insurance in this State shall not increase the premium rates for the insurance more frequently than every 6 months unless the increase in the premium rates is being made because:

(a) An employer has requested a change in its health benefit plan;

(b) There has been a change in the number of employees covered by an employer that would affect the insurance premium rate of the employer; or

(c) There has been a change in federal or state law which affects the cost of providing services under the health benefit plan.

2. If an insurer issues group health insurance to a class of employers that consists solely of bona fide associations and uses a common date of renewal for that class, an increase in the premium rates for that class does not violate the provisions of subsection 1 solely because at least one but not all the members of that class will have an increase in premium rates more frequently than every 6 months.

(Added to NAC by Comm’r of Insurance by R009-02, eff. 5-23-2002; A by R009-02, 7-11-2002)

SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS

NAC 689B.250 Requirements for approval. (NRS 679B.130, 689B.0285, 689B.029, 689B.0295) To obtain approval of a system for resolving complaints of insureds concerning health care services covered by an insurer from the Commissioner as required pursuant to NRS 689B.0285, an insurer must:

1. Demonstrate that the system will resolve oral and written complaints concerning:

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

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

2. Submit to the Division:

(a) The name and title of the employee responsible for the system;

(b) A description of the procedure used to notify an insured of the decision regarding the complaint; and

(Added to NAC by Comm’r of Insurance by R132-98, eff. 3-30-99)

NAC 689B.260 Annual report. (NRS 679B.130, 689B.029)

1. An insurer shall submit its annual report regarding its system for resolving complaints as required pursuant to NRS 689B.029 on or before June 1 of each year. The insurer shall retain a copy of the annual report for at least 3 years or until the next examination conducted by the Division, whichever is longer.

2. The insurer is not required to include in the annual report information concerning an oral inquiry by an insured relating to a misunderstanding or miscommunication if the misunderstanding or miscommunication was resolved within 1 working day after the inquiry was made. If the misunderstanding or miscommunication was not resolved within 1 working day, the insurer shall report it as a complaint in the annual report.

(Added to NAC by Comm’r of Insurance by R132-98, eff. 3-30-99; A by R008-02, 5-23-2002)

BLANKET POLICIES

NAC 689B.280 Compliance with NAC 689B.205 and 689B.230. (NRS 679B.130, 689B.090) An insurer that offers blanket accident and health insurance in this State shall comply with the provisions of NAC 689B.205 and 689B.230.

(Added to NAC by Comm’r of Insurance by R009-02, eff. 5-23-2002; A by R009-02, 7-11-2002)

PORTABILITY AND ACCOUNTABILITY

NAC 689B.295 Definitions. (NRS 679B.130) As used in NAC 689B.295 to 689B.310, inclusive, unless the context otherwise requires, the words and terms defined in NRS 689B.350 to 689B.460, inclusive, have the meanings ascribed to them in those sections.

(Added to NAC by Comm’r of Insurance by R009-02, eff. 5-23-2002; A by R009-02, 7-11-2002)

NAC 689B.300 Evidence of creditable coverage. (NRS 679B.130, 689B.480) If a person is unable to obtain a certificate of creditable coverage pursuant to NRS 689B.490, a carrier shall accept from the person other evidence of creditable coverage if it determines that the evidence reasonably establishes prior continuous creditable coverage. Such evidence may include, without limitation, a copy of:

1. A policy of health insurance or evidence of coverage;

2. A billing statement for the payment of premiums;

3. A cancelled check evidencing payment for health insurance coverage;

4. A proof of insurance card issued by an insurer;

5. An explanation of benefits relating to a specific claim for medical services that were provided to the person by an insurer;

6. A letter notifying the person that he or she is eligible for coverage pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1985, Public Law 99-272;

7. A letter written by the liquidator of an insurer that verifies the dates that the person was covered by the insurer under a policy of health insurance;

8. A statement written by the person that includes the name and telephone number of any insurer under which the person previously received health insurance coverage;

9. Evidence of a payroll deduction from the person’s salary for health insurance coverage;

10. Any record from a provider of medical care that indicates that the person had health insurance coverage; or

11. Any combination thereof.

(Added to NAC by Comm’r of Insurance by R224-97, eff. 11-16-98)

NAC 689B.305 Restrictions on rules of eligibility and on premium and contribution rates. (NRS 679B.130)

1. A group health plan and a carrier that issues group health insurance pursuant to chapter 689B of NRS shall not include or establish any rule of eligibility, including continued eligibility, for any individual to enroll for benefits under the terms of the group health plan or group health insurance that discriminates based upon any health status-related factor that relates to the individual or a dependent of the individual.

2. A group health plan and a carrier that issues group health insurance pursuant to chapter 689B of NRS shall not include or establish any rule of eligibility, or set a premium or contribution rate, for any individual based on whether the individual is:

(a) Confined to a hospital or other health care institution; or

(b) Actively at work, including whether an individual is continuously employed, unless the group health plan or group health insurance treats absence from work because of a health factor as being actively at work.

3. As used in this section, “rule of eligibility” includes, without limitation, any rule of eligibility relating to:

(a) The effective date of coverage;

(b) Waiting or affiliation periods;

(d) Eligibility for benefit packages, including rules pursuant to which individuals may change their selection among benefit packages.

(Added to NAC by Comm’r of Insurance by R009-02, eff. 5-23-2002; A by R009-02, 7-11-2002)

NAC 689B.310 Converted policies. (NRS 679B.130, 689B.590)

1. If a person is issued a converted policy before the date on which basic and standard health benefit plans were required to be offered pursuant to subsection 1 of NRS 689B.590, the carrier shall notify the person in writing, not less than 60 days before the annual renewal date of the converted policy, of the right to elect a basic or standard health benefit plan as a substitute to the current converted policy. The notice must include, without limitation, the premium rates charged by the carrier for the basic and standard health benefit plans.

2. A carrier that issues health benefit plans to small employers and large employers in this State shall allocate premium and loss experience on its converted policies issued pursuant to NRS 689B.590 based on:

(a) The number of persons with converted policies whose most recent coverage was under a health benefit plan issued to a small employer or a large employer relative to the total number of persons with converted policies; or

(b) The proportion of total premiums earned in the book of health benefit plan business containing small employers or large employers relative to the total premiums earned from all health benefit plans for small employers and large employers during the period of experience.

3. As used in this section:

(a) “Large employer” has the meaning ascribed to it in 42 U.S.C. § 300gg-91(e)(2).

(b) “Small employer” has the meaning ascribed to it in NRS 689C.095.

(Added to NAC by Comm’r of Insurance by R224-97, eff. 11-16-98)

POLICIES FOR STOP-LOSS INSURANCE

NAC 689B.350 General provisions. (NRS 679B.130)

1. An insurer shall not issue a policy for stop-loss insurance for a group health plan subject to the provisions of this chapter and chapter 689B of NRS if the policy for stop-loss insurance:

(a) Has an annual attachment point for claims incurred per individual that is lower than $10,000;

(b) Has an annual aggregate attachment point for groups of not more than 50 persons that is lower than the greater of:

(1) The number of group members times $4,000;

(2) One hundred and twenty percent of expected claims; or

(3) Ten thousand dollars;

(c) Has an annual aggregate attachment point for groups of more than 50 persons that is lower than 110 percent of expected claims; or

(d) Provides direct coverage of health care expenses of an individual.

2. For the purposes of this section, an insurer shall determine the number of persons in a group on a consistent basis at least annually.

3. If a policy for stop-loss insurance for a group health plan does not meet the criteria set forth in this section, the policy will be deemed to be a health benefit plan for the purposes of this chapter and chapter 689B of NRS.

4. As used in this section:

(a) “Attachment point” means the amount of claims incurred by an insured group beyond which an insurer incurs a liability for payment.

(b) “Expected claims” means the amount of claims that, in the absence of a stop-loss policy or other insurance, are projected to be incurred by an insured group through its health plan.

(c) “Stop-loss insurance” means insurance purchased by an employer to limit exposure to claim expenses under a health benefit plan provided by the employer.

(Added to NAC by Comm’r of Insurance by R113-00, eff. 3-30-2001)