Assembly Bill No. 375

Assembly Bill No. 375-Assemblymen Giunchigliani, Arberry, Buckley, Amodei, Freeman, Bache, Tiffany, Anderson, Lee, Koivisto, Parks, Lambert, Williams, Berman, de Braga, Collins, Chowning, Nolan, Manendo, Price, Segerblom, Carpenter, Hickey, Perkins, Marvel, Herrera, Goldwater and Close

April 17, 1997
____________

Referred to Concurrent Committees on Health and Human Services
and Commerce

SUMMARY--Makes various changes concerning mental health care. (BDR 39-1267)

FISCAL NOTE: Effect on Local Government: No.

Effect on the State or on Industrial Insurance: Yes.

EXPLANATION - Matter in italics is new; matter in brackets [ ] is material to be omitted.

AN ACT relating to mental health care; making various changes concerning mentally ill persons; specifying additional rights of clients of certain facilities; requiring managed care organizations to provide certain benefits for mental health care; requiring certain entities that provide mental health care services through managed care to follow certain procedures before denying mental health care services to an insured; prohibiting such entities from engaging in certain practices that restrict the actions of a provider of mental health care; specifying the time within which such entities shall grant or deny a request for emergency mental health care services; requiring such entities to file a report containing certain information with the commissioner of insurance; requiring all insurers of health care and managed care organizations to establish a system for resolving complaints of insureds relating to mental health care services; and providing other matters properly relating thereto.

THE PEOPLE OF THE STATE OF NEVADA, REPRESENTED IN SENATE AND ASSEMBLY, DO ENACT AS FOLLOWS:

Section 1 Chapter 433 of NRS is hereby amended by adding thereto the provisions set forth as sections 2 to 9, inclusive, of this act.
Sec. 2 "Rights" includes, without limitation, all rights provided to a client pursuant to NRS 433.456 to 433.534, inclusive, and sections 3 to 9, inclusive, of this act, and any regulations adopted pursuant thereto.
Sec. 3 Each client admitted for evaluation, treatment or training to a facility has the following rights concerning admission to the facility, a list of which must be prominently posted in all facilities providing those services and must be otherwise brought to the attention of the client by such additional means as prescribed by regulation:
1. To be not held financially responsible for any evaluation, treatment or training received at the facility if it can be shown by the client that he was admitted to the facility under duress, false pretenses, a misrepresentation, or any improper, unethical or unlawful conduct by a staff member of the facility.
2. To receive a copy, on request, of the criteria upon which the facility makes its decision to admit or discharge a client from the facility. Such criteria must not be based on the availability of insurance coverage or any other financial considerations.
Sec. 4 Each client admitted for evaluation, treatment or training to a facility has the following rights concerning involuntary commitment to the facility, a list of which must be prominently posted in all facilities providing those services and must be otherwise brought to the attention of the client by such additional means as prescribed by regulation:
1. To request and receive an evaluation by a provider of mental health care who does not have a contractual or business relationship with the facility. The evaluation must:
(a) Include, without limitation, a recommendation of whether the client should be involuntarily committed to the facility; and
(b) Be paid for by the client if the insurance carrier of the client refuses to pay for the evaluation.
2. To receive a copy of the procedure of the facility regarding involuntary commitment and treatment.
3. To receive a list of his rights concerning involuntary commitment or treatment.
Sec. 5 Each client admitted for evaluation, treatment or training to a facility has the following rights concerning the suspension or violation of his rights, a list of which must be prominently posted in all facilities providing those services and must be otherwise brought to the attention of the client by such additional means as prescribed by regulation:
1. To receive a list of his rights.
2. To receive a copy of the policy of the facility that sets forth the clinical or medical circumstances under which his rights may be suspended or violated.
3. To have any suspension or violation of his rights documented in his chart or medical record.
4. To have any suspension or violation of his rights reported to the commission for its review and possible investigation pursuant to NRS 433.316.
5. To receive a list of the options available to the client or his family to remedy an actual or a suspected suspension or violation of his rights.
6. To have all policies of the facility regarding the rights of clients prominently posted in the facility.
Sec. 6 Each facility shall, within a reasonable time after a client is admitted to the facility for evaluation, treatment or training, ask the client to sign a document that reflects that he has received a list of his rights and has had those rights explained to him.
Sec. 7 Each facility shall establish and maintain a toll-free telephone number by which a person may ask questions regarding the care, treatment or training that is being or will be received at the facility by a client. The telephone number must be answered 24 hours a day, 7 days a week by a natural person who is qualified to answer such questions.
Sec. 8 Each facility shall make all of its decisions, policies, procedures and practices based upon clinical efficiency rather than cost containment.
Sec. 9 1. An officer, director or employee of a facility shall not retaliate against any person for having:
(a) Reported any violation of law; or
(b) Provided information regarding a violation of law,
by the facility or a staff member of the facility.
2. If any person is found, after notice and a hearing, to have violated any provision of subsection 1, the commission may impose an administrative fine of not more than $1,000 for each violation.
3. Any money collected as a result of an administrative fine imposed pursuant to this section must be deposited in the state general fund.
Sec. 10 NRS 433.044 is hereby amended to read as follows:
433.044"Client" means any person who seeks, on his own or [others'] another's initiative, and can benefit from care, treatment and training [in any division facility.] provided by the division.
Sec. 11 NRS 433.456 is hereby amended to read as follows:
433.456 As used in NRS 433.458 to 433.534, inclusive, and sections 3 to 9, inclusive, of this act, unless the context otherwise requires, the words and terms defined in NRS 433.458, 433.459 and 433.461 and section 2 of this act, have the meanings ascribed to them in those sections.
Sec. 12 NRS 433.482 is hereby amended to read as follows:
433.482 Each client admitted for evaluation, treatment or training to a facility has the following personal rights, a list of which must be prominently posted in all facilities providing those services and must be otherwise brought to the attention of the client by such additional means as prescribed by regulation:
1. To wear his own clothing, to keep and use his own personal possessions, including his toilet articles, unless those articles may be used to endanger his or others' lives, and to keep and be allowed to spend a reasonable sum of his own money for expenses and small purchases.
2. To have access to individual space for storage for his private use.
3. To see visitors each day.
4. To have reasonable access to telephones, both to make and receive confidential calls.
5. To have ready access to materials for writing letters, including stamps, and to mail and receive unopened correspondence, but:
(a) For the purposes of this subsection, packages are not considered as correspondence; and
(b) Correspondence identified as containing a check payable to a client may be subject to control and safekeeping by the administrative officer of that facility or his designee, so long as the client's record of treatment documents the action.
6. To have reasonable access to an interpreter if the client does not speak English or is hearing impaired.
7. To designate a person who must be kept informed by the facility of the client's medical and mental condition, providing that the client signs a release allowing the facility to provide such information to the person.
8. To have access to his medical records restricted to those persons that have a waiver of confidentiality from the client or a properly issued subpoena.
9. Other personal rights as specified by regulation of the commission.
Sec. 13 Chapter 433A of NRS is hereby amended by adding thereto a new section to read as follows:
1. If a mentally ill person is admitted to a public or private mental health facility or a hospital as a voluntary client and the facility or hospital changes his status to an emergency admission, the facility or hospital shall, within 24 hours, file a petition with the district court to change the person's status to that of an involuntarily court-admitted person.
2. If the period specified in subsection 1 expires on a day on which the office of the clerk of the district court is not open, the written petition must be filed on or before the close of the business day next following the expiration of that period.
Sec. 14 NRS 433A.014 is hereby amended to read as follows:
433A.014 "Client" means any person who seeks, on his own or another's initiative, and can benefit from care, treatment or training [in a division facility.] provided by the division.
Sec. 15 NRS 433A.115 is hereby amended to read as follows:
433A.1151. As used in NRS 433A.120 to 433A.330, inclusive, and section 13 of this act, unless the context otherwise requires, "mentally ill person" means any person whose capacity to exercise self-control, judgment and discretion in the conduct of his affairs and social relations or to care for his personal needs is diminished to the extent that he presents a clear and present danger of harm to himself or others, but does not include any person in whom that capacity is diminished by epilepsy, mental retardation, Alzheimer's disease, brief periods of intoxication caused by alcohol or drugs, or dependence upon or addiction to alcohol or drugs, unless a mental illness that can be diagnosed is also present which contributes to the diminished capacity of the person.
2. A person presents a clear and present danger of harm to himself if, within the next preceding 30 days, he has:
(a) Acted in a manner from which it may reasonably be inferred that, without the care, supervision or continued assistance of others, he will be unable to satisfy his need for nourishment, personal or medical care, shelter, self-protection or safety, and if there exists a reasonable probability that his death, serious bodily injury or physical debilitation will occur within the next following 30 days unless he is admitted to a mental health facility pursuant to the provisions of NRS 433A.120 to 433A.330, inclusive, and section 13 of this act, and adequate treatment is provided to him;
(b) Attempted or threatened to commit suicide or committed acts in furtherance of a threat to commit suicide, and if there exists a reasonable probability that he will commit suicide unless he is admitted to a mental health facility pursuant to the provisions of NRS 433A.120 to 433A.330, inclusive, and section 13 of this act, and adequate treatment is provided to him; or
(c) Mutilated himself, attempted or threatened to mutilate himself or committed acts in furtherance of a threat to mutilate himself, and if there exists a reasonable probability that he will mutilate himself unless he is admitted to a mental health facility pursuant to the provisions of NRS 433A.120 to 433A.330, inclusive, and section 13 of this act, and adequate treatment is provided to him.
3. A person presents a clear and present danger of harm to others if, within the next preceding 30 days, he has inflicted or attempted to inflict serious bodily harm on any other person, or made threats to inflict harm and committed acts in furtherance of those threats, and if there exists a reasonable probability that he will do so again unless he is admitted to a mental health facility pursuant to the provisions of NRS 433A.120 to 433A.330, inclusive, and section 13 of this act, and adequate treatment is provided to him.
Sec. 16 NRS 433A.140 is hereby amended to read as follows:
433A.1401. Any person may apply to [any] :
(a) A public or private mental health facility in the State of Nevada for admission to [such] the facility ; or
(b) A division facility to receive care, treatment or training provided by the division,
as a voluntary client for the purposes of observation, diagnosis, care and treatment. In the case of a person who has not attained the age of majority, application for voluntary admission or care, treatment or training may be made on his behalf by his spouse, parent or legal guardian.
2. If the application is for admission to a division facility, or for care, treatment or training provided by the division, the applicant must be admitted or provided such services as a voluntary client if an examination by [admitting] personnel of the facility qualified to make such a determination reveals that the person needs and may benefit from services offered by the mental health facility.
3. Any person admitted to a public or private mental health facility as a voluntary client must be released immediately after the filing of a written request for release with the responsible physician or his designee within the normal working day. When a person is released pursuant to this subsection, the facility and its agents and employees are not liable for any debts or contractual obligations, medical or otherwise, incurred or damages caused by the actions of the person.
4. Any person admitted to a public or private mental health facility as a voluntary client who has not requested release may nonetheless be released by the medical director of the facility when examining personnel at the facility determine that the client has recovered or has improved to such an extent that he is not considered a danger to himself or others and that the services of that facility are no longer beneficial to him or advisable.
5. A person who requests care, treatment or training from the division pursuant to this section must be evaluated by the personnel of the division within 72 hours to determine whether he will benefit from the services offered by the division. If it is determined that the person will benefit from such services, he is entitled to receive them.
Sec. 17 NRS 433A.150 is hereby amended to read as follows:
433A.150 1. Any mentally ill person may be detained in a public or private mental health facility or hospital under an emergency admission for evaluation, observation and treatment subject to subsection 2.
2. Except as otherwise provided in subsection [3,] 4, a person admitted to a mental health facility or hospital under subsection 1 must not be detained in excess of 72 hours, including Saturdays and Sundays, from the time of his admission unless within that period a written petition for an involuntary court-ordered admission has been filed with the clerk of the district court pursuant to section 13 of this act and NRS 433A.200.
3. Except as otherwise provided in subsection 4, if a person is admitted to a mental health facility or hospital under a voluntary or emergency admission and the facility or hospital files a written petition with the district court to change his status to that of an involuntarily court-admitted person, the person must not be held for more than 12 calendar days after the voluntary or emergency admission without a hearing in the district court to determine if he should be held in the facility or hospital on an involuntary basis.
4. If the [72-hour] period specified in subsection 2 or 3 expires on a day on which the office of the clerk of the district court is not open, the written petition must be filed on or before the close of the business day next preceding the expiration of that period, except that, if that business day is the same day as that upon which the person was admitted, the petition must be filed on or before the close of the business day next following the expiration of that period.
Sec. 18 NRS 433A.160 is hereby amended to read as follows:
433A.160 1. Application for an emergency admission of an allegedly mentally ill person for evaluation and observation may only be made by an accredited agent of the department, an officer authorized to make arrests in the State of Nevada or a physician, psychologist, social worker or registered nurse. The agent, officer, physician, psychologist, social worker or registered nurse may take an allegedly mentally ill person into custody without a warrant to apply for emergency admission for evaluation, observation and treatment under NRS 433A.150 and may transport the person or arrange the transportation for him with a local law enforcement agency to a public or private mental health facility for that purpose.
2. The application must reveal the circumstances under which the person was taken into custody and the reasons therefor.
3. For the purposes of subsection 1, "an accredited agent of the department" means any person appointed or designated by the director of the department to take into custody and transport to a mental health facility pursuant to subsections 1 and 2 those persons in need of emergency admission.
4. [Any person who has reason to believe that another person is mentally ill may apply to the district attorney of the county where the allegedly mentally ill person is found, and the district attorney may, if satisfied that as a result of mental illness the person is likely to harm himself or others:
(a) Issue an order to any peace officer for the immediate apprehension of the person and his transportation to a public or private mental health facility; and
(b) Make application for the admission of the person under the emergency admission provisions of NRS 433A.150.
5.] Each person admitted to a public or private mental health facility or hospital under an emergency admission must be evaluated at the time of admission by a psychiatrist or a physician who is not a psychiatrist. Each such emergency admission must be approved by a psychiatrist.
Sec. 19 NRS 433A.390 is hereby amended to read as follows:
433A.390 1. When a client, involuntarily admitted to a mental health facility by court order, is released at the end of the time specified pursuant to NRS 433A.310, written notice must be given to the admitting court at least 10 days before the release of the client. The client may then be released without requiring further orders of the court.
2. An involuntarily [court admitted] court-admitted client may be conditionally released before the period specified in NRS 433A.310 when:
(a) An evaluation team established under NRS 433A.250 or two persons professionally qualified in the field of psychiatric mental health, at least one of them being a physician, determines that the client has recovered from his mental illness or has improved to such an extent that he is no longer considered to present a clear and present danger of harm to himself or others; and
(b) Under advisement from the evaluation team or two persons professionally qualified in the field of psychiatric mental health, at least one of them being a physician, the medical director of the mental health facility authorizes the release and gives written notice to the admitting court . [10 days before the release of the client.]
3. The release of an involuntarily court-admitted client pursuant to subsection 2 becomes unconditional 10 days after the release unless the admitting court, within that period, issues an order providing otherwise.
Sec. 20 Title 57 of NRS is hereby amended by adding thereto a new chapter to consist of the provisions set forth as sections 21 to 50, inclusive, of this act.
Sec. 21 As used in this chapter, unless the context otherwise requires, the words and terms defined in sections 22 to 29, inclusive, of this act, have the meanings ascribed to them in those sections.
Sec. 22 "Fee-for-service" means a method of providing or arranging for the provision of mental health care services wherein an insurer:
1. Reimburses a provider of mental health care for each service provided to an insured;
2. Allows an insured to choose any provider of mental health care and does not encourage the use of any specific provider of mental health care; and
3. Does not require any preauthorization or referral for a specific service to be covered.
Sec. 23 "Insured" means a person covered by a policy of health insurance which provides mental health care services through managed care, or any other person who is a beneficiary of mental health care services rendered by a managed care organization or pursuant to a contract with a managed care organization.
Sec. 24 "Managed care" means all methods of providing or arranging for the provision of health care services, other than a method based on fee-for-service. The term includes, without limitation, a health maintenance organization, preferred provider organization, point-of-service plan and exclusive provider organization.
Sec. 25 "Managed care organization" means an organization that provides managed care.
Sec. 26 "Mental health care services" means any care, treatment or training related to the mental health of the insured.
Sec. 27 "Policy of insurance" means any agreement between an insured and an insurer or between an insured and a managed care organization for the provision of health care services.
Sec. 28 "Primary care physician" means a physician whose responsibilities include, without limitation, providing initial and primary health care services to an insured, maintaining the continuity of care for the insured and referring the insured to a specialized provider of health care when necessary.
Sec. 29 "Provider of mental health care" means any physician, hospital or other person who is licensed or otherwise authorized in this state to furnish mental health care services.
Sec. 30 1. The provisions of this chapter apply to each organization and insurer that provides or arranges for the provision of mental health care services through managed care and each managed care organization that conducts business in this state, including, without limitation, an insurer that issues a policy of health insurance, an insurer that issues a policy of 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 and each insurer that issues a policy of health insurance which provides mental health care services through managed care shall comply with any other applicable provision of this Title.
Sec. 31 Each managed care organization that provides benefits for the physical health care of an insured in this state shall provide benefits for the mental health care of the insured in the same amount that is available for the physical health care of the insured.
Sec. 32 Each managed care organization and each insurer that issues a policy of health insurance which provides mental health care services through managed care shall establish and maintain a toll-free telephone number by which a person may ask questions regarding the care, treatment or training that is being or will be received by an insured. The telephone number must be answered 24 hours a day, 7 days a week, by a natural person who is qualified to answer such questions.
Sec. 33 Each managed care organization and each insurer that issues a policy of health insurance which provides mental health care services through managed care shall make all of its decisions, policies, procedures and practices regarding mental health care services based upon clinical efficiency rather than cost containment.
Sec. 34 Each managed care organization and each insurer that issues a policy of health insurance which provides mental health care services through managed care shall maintain a policy of liability insurance against a reckless or negligent decision to deny coverage of a mental health care service for an insured or to provide a mental health care service to an insured.
Sec. 35 Each managed care organization and each insurer that issues a policy of health insurance which provides mental health care services through managed care shall authorize coverage of a mental health care service that has been recommended for the insured by a provider of mental health care acting within the scope of his practice if that service is covered by the managed care organization or under the policy, unless:
1. A provider of mental health care who possesses the relevant education, training and expertise to evaluate the mental condition of the insured denies coverage;
2. The provider of mental health care has personally examined the insured in a timely manner; and
3. The decision to deny coverage for the mental health care service and the reason for the decision have been transmitted in writing in a timely manner to the insured and to the provider of mental health care who recommended the service, the primary care physician of the insured or any other person responsible for providing mental health care services to the insured, if any.
Sec. 36 1. Each managed care organization and each insurer that issues a policy of health insurance which provides mental health care services through managed care shall establish written criteria:
(a) Setting forth the manner in which it determines whether to authorize or deny coverage of a mental health care service; and
(b) Setting forth its method for assuring the quality of the mental health care services provided to an insured.
2. Such written criteria must be:
(a) Established for each mental health care service covered by the managed care organization or the policy of health insurance;
(b) Established by a provider of mental health care who provides those services;
(c) Based on generally accepted practices of the psychiatric community at the time the criteria is established;
(d) Updated at least one time each year; and
(e) Made available for public inspection.
Sec. 37 No managed care organization or insurer that issues a policy of health insurance which provides mental health care services through managed care may restrict or interfere with any communication between a provider of mental health care and his patient regarding any information that the provider of mental health care determines is relevant to the mental health or mental care of the patient.
Sec. 38 1. No managed care organization or insurer that issues a policy of health insurance which provides mental health care services through managed care may terminate a contract with, demote, refuse to contract with, refuse to compensate or otherwise penalize a provider of mental health care solely because the provider:
(a) Advocates in private or in public on behalf of a patient;
(b) Assists a patient in seeking reconsideration of a decision by the managed care organization or insurer to deny a mental health care service; or
(c) Reports a violation of law to an appropriate authority.
2. This section does not prohibit termination of a contract with or disciplinary action against a provider of mental health care for just cause. For the purposes of this subsection, "just cause" includes, without limitation, taking such action:
(a) Because the provider of mental health care has committed malpractice;
(b) To prevent the provider of mental health care from endangering a patient or to discipline the provider of mental health care for endangering a patient;
(c) When the provider of mental health care has abused alcohol or a controlled substance in a manner which affected his ability to perform his job;
(d) To prevent the provider of mental health care from sexually abusing a patient or to discipline the provider of mental health care for sexually abusing a patient; or
(e) Because of economic necessity.
Sec. 39 No managed care organization or insurer that issues a policy of health insurance which provides mental health care services through managed care may offer or pay a bonus, or provide an incentive or other financial compensation, directly or indirectly, to a provider of mental health care as an inducement to deny, withhold, limit or delay appropriate mental health care services to an insured.
Sec. 40 1. If a managed care organization or an insurer that issues a policy of health insurance which provides for mental health care services through managed care requires preauthorization before it will provide coverage to an insured for an emergency mental health care service, the managed care organization or insurer shall grant or deny authorization for the service within 30 minutes after receiving a request from or on behalf of the insured.
2. If the authorization for the emergency service is not granted or denied within the time specified in subsection 1, the managed care organization or insurer shall provide coverage for the emergency service requested, whether or not:
(a) The condition actually required immediate psychiatric attention;
(b) The managed care organization or insurer otherwise would have denied coverage; or
(c) The service was provided at a facility or by a provider of mental health care which is not otherwise covered by the managed care organization or under the policy.
3. A policy of insurance subject to the provisions of this section that is delivered, issued for delivery or renewed on or after October 1, 1997, has the legal effect of including the coverage required by this section, and any provision of the policy or the renewal which is in conflict with this section is void.
Sec. 41 A provider of mental health care who is responsible for determining the mental health care services that will be provided to an insured or for establishing a procedure for ensuring the quality of care of an insured who:
1. Is employed by a managed care organization or by an insurer that issues a policy of health insurance which provides mental health care services through managed care; or
2. Has entered into a contract with a managed care organization or with an insurer that issues a policy of health insurance which provides mental health care services through managed care,
is subject to the same standards and disciplinary procedures as other providers of health care who provide direct care to the insureds of any other policy of health insurance issued in the State of Nevada.
Sec. 42 1. In addition to any other report which is required to be filed with the commissioner, each managed care organization and each insurer that issues a policy of health insurance which provides mental health care services through managed care shall file with the commissioner, on or before March 1 of each year, a report regarding its methods for ensuring the quality of mental health care services provided to its insureds.
2. Each managed care organization and insurer shall include in its report the criteria, data or studies used to:
(a) Assess the nature, scope and quality of mental health care services provided by the managed care organization or insurer; or
(b) Determine any reduction or modification of the provision of mental health care services.
3. If the managed care organization or insurer is not owned and operated by a public entity and it covers or benefits more than 100 insureds, the report filed pursuant to subsection 1 must include:
(a) A copy of all of its financial reports and income tax returns required to be filed by federal and state tax and security laws;
(b) A statement of any financial interest it has in any other business which is related to health care that is greater than 5 percent of that business or $5,000, whichever is less; and
(c) A description of each complaint filed with or against it that resulted in arbitration, a lawsuit or other legal proceeding, unless disclosure is prohibited by law or a court order.
4. 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, except that a copy of a federal income tax return included with such a report is confidential.
Sec. 43 Any person who:
1. Makes any decision regarding the mental health care of an insured; and
2. Receives, collects, disburses or invests money for a managed care organization or for an insurer that issues a policy of health insurance which provides mental health care services through managed care,
shall act in a fiduciary relationship to the insureds for whom he makes such decisions with respect to such money.
Sec. 44 1. Each managed care organization and each insurer that issues a policy of health insurance which provides mental health care services through managed care shall establish a system for resolving any complaints of an insured concerning mental health care services covered by the managed care organization or under the policy. The system must be approved by the commissioner in consultation with the commission on mental health and mental retardation.
2. A system for resolving complaints pursuant to subsection 1 must include an initial investigation and review of the complaint by a review board and a procedure for appealing a determination regarding the complaint. The majority of the members on a review board must be mental health care providers that are not members of the managed care organization.
3. Except as otherwise provided in this subsection, a determination must be made regarding the complaint or appeal and the insured must be notified by the review board of its determination not later than 30 days after the complaint or appeal is filed. If the complaint involves an imminent and serious threat to the mental health of the insured, the managed care organization or insurer shall inform the insured immediately of his right to an expedited review of his complaint, and the review board shall notify the insured in writing of its determination within 72 hours after the complaint is filed.
4. The commissioner or the commission on mental health and mental retardation may examine the system for resolving complaints established pursuant to this section at such times as it deems necessary or appropriate.
5. The medical records of a natural person and the records of a physician are not subject to an examination pursuant to subsection 4, but are subject to a properly issued subpoena upon a showing of good cause.
Sec. 45 1. Each managed care organization and each insurer that issues a policy of health insurance which provides mental health care services through managed care shall submit to the commissioner and the commission on mental health and mental retardation an annual report regarding its system for resolving complaints established pursuant to section 44 of this act on a form prescribed by the commissioner in consultation with the commission on mental health and mental retardation which includes, without limitation:
(a) A description of the procedures used for resolving any complaints of an insured;
(b) The total number of complaints and appeals handled through the system for resolving complaints since the last report and a compilation of the causes underlying the complaints filed;
(c) The current status of each complaint and appeal filed; and
(d) The average amount of time that was needed to resolve a complaint and an appeal, if any.
2. Each managed care organization and each insurer shall maintain records of complaints filed with it which concern something other than mental 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.
Sec. 46 1. Each managed care organization and each insurer that issues a policy of health insurance which provides mental health care services through managed care shall provide written notice to an insured, in clear and comprehensible language that is understandable to an ordinary layperson, explaining the right of the insured to file a complaint and to obtain an expedited review pursuant to section 44 of this act. The notice must be provided to an insured:
(a) Before he pays for any coverage to be provided by the managed care organization or insurer;
(b) Any time that the managed care organization or insurer denies coverage of a mental health care service or limits coverage of a mental health care service to an insured; and
(c) Any other time deemed necessary by the commissioner.
2. Any time that a managed care organization or insurer denies coverage of a mental health care service to an insured, it shall notify the insured in writing of:
(a) The reason for denying coverage of the service;
(b) The name of the person responsible for the decision to deny the service;
(c) The criteria by which the managed care organization or insurer determines whether to authorize or deny coverage of a mental health care service; and
(d) His right to file a complaint.
Sec. 47 Each managed care organization and each insurer that issues a policy of health insurance which provides mental health care services through managed care shall allow any person or facility that wishes to join the managed care organization for the purpose of providing mental health care services to join the managed care organization if the person or facility:
1. Is qualified under the laws of this state to provide such care; and
2. Agrees to accept the terms and conditions established by the managed care organization for other providers of mental health care services to provide such care.
Sec. 48 Each managed care organization and each insurer that issues a policy of health insurance which provides mental health care services through managed care shall protect the confidentiality of the records of an insured related to mental health care services. Such records are subject to a properly issued subpoena upon a showing of good cause.
Sec. 49 Any document required to be filed with the commissioner pursuant to this chapter must be treated as a public record, except that a copy of a federal income tax return is confidential.
Sec. 50 1. An officer, director or employee of a managed care organization or an insurer that issues a policy of health insurance which provides mental health care services through managed care shall not retaliate against any person for having:
(a) Reported any violation of law; or
(b) Provided information regarding a violation of law,
by the managed care organization or the insurer.
2. If any person is found, after notice and a hearing, to have violated any provision of subsection 1, the commissioner may impose an administrative fine of not more than $1,000 for each violation.
3. Any money collected as a result of an administrative fine imposed pursuant to this section must be deposited in the state general fund.
Sec. 51 Chapter 689A of NRS is hereby amended by adding thereto the provisions set forth as sections 52 to 55, inclusive, of this act.
Sec. 52 As used in sections 52 to 55, inclusive, of this act, "mental health care service" means any care, treatment or training related to the mental health of an insured.
Sec. 53 1. Each insurer that issues a policy of health insurance in this state shall establish a system for resolving any complaints of an insured concerning mental health care services covered under the policy. The system must be approved by the commissioner in consultation with the commission on mental health and mental retardation.
2. A system for resolving complaints pursuant to subsection 1 must include an initial investigation and review of the complaint by a review board and a procedure for appealing a determination regarding the complaint. The majority of the members on the review board must be providers of mental health care that do not have a contractual or other business relationship with the insurer.
3. The commissioner or the commission on mental health and mental retardation may examine the system for resolving complaints established pursuant to this section at such times as the commissioner or commission deems necessary or appropriate.
4. The medical records of a natural person and the records of a physician are not subject to an examination pursuant to subsection 3, but are subject to a properly issued subpoena upon a showing of good cause.
Sec. 54 1. Each insurer that issues a policy of health insurance in this state shall submit to the commissioner and the commission on mental health and mental retardation an annual report regarding its system for resolving complaints established pursuant to section 53 of this act on a form prescribed by the commissioner in consultation with the commission on mental health and mental retardation which includes, without limitation:
(a) A description of the procedures used for resolving any complaints of an insured;
(b) The total number of complaints and appeals handled through the system for resolving complaints since the last report and a compilation of the causes underlying the complaints filed;
(c) The current status of each complaint and appeal filed; and
(d) The average amount of time that was needed to resolve a complaint and an appeal, if any.
2. Each insurer shall maintain records of complaints filed with it which concern something other than mental 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.
Sec. 55 1. Each insurer that issues a policy of health insurance in this state shall provide written notice to an insured, in clear and comprehensible language that is understandable to an ordinary layperson, explaining the right of the insured to file a complaint. The notice must be provided to an insured:
(a) Before he pays for any coverage to be provided by the insurer;
(b) Any time that the insurer denies coverage of a mental health care service or limits coverage of a mental health care service to an insured; and
(c) Any other time deemed necessary by the commissioner.
2. Any time that an insurer denies coverage of a mental health care service to an insured, it shall notify the insured in writing of:
(a) The reason for denying coverage of the service;
(b) The criteria by which the insurer determines whether to authorize or deny coverage of a mental health care service; and
(c) His right to file a complaint.
Sec. 56 Chapter 689B of NRS is hereby amended by adding thereto the provisions set forth as sections 57 to 60, inclusive, of this act.
Sec. 57 As used in sections 57 to 60, inclusive, of this act, "mental health care service" means any care, treatment or training related to the mental health of an insured.
Sec. 58 1. Each insurer that issues a policy of group health insurance in this state shall establish a system for resolving any complaints of an insured concerning mental health care services covered under the policy. The system must be approved by the commissioner in consultation with the commission on mental health and mental retardation.
2. A system for resolving complaints pursuant to subsection 1 must include an initial investigation and review of the complaint by a review board and a procedure for appealing a determination regarding the complaint. The majority of the members on the review board must be providers of mental health care that do not have a contractual or other business relationship with the insurer.
3. The commissioner or the state board of health may examine the system for resolving complaints established pursuant to this section at such times as the commissioner or the state board of health deems necessary or appropriate.
4. The medical records of a natural person and the records of a physician are not subject to an examination pursuant to subsection 3, but are subject to a properly issued subpoena upon a showing of good cause.
Sec. 59 1. Each insurer that issues a policy of group health insurance in this state shall submit to the commissioner and the commission on mental health and mental retardation an annual report regarding its system for resolving complaints established pursuant to section 58 of this act on a form prescribed by the commissioner in consultation with the commission on mental health and mental retardation which includes, without limitation:
(a) A description of the procedures used for resolving any complaints of an insured;
(b) The total number of complaints and appeals handled through the system for resolving complaints since the last report and a compilation of the causes underlying the complaints filed;
(c) The current status of each complaint and appeal filed; and
(d) The average amount of time that was needed to resolve a complaint and an appeal, if any.
2. Each insurer shall maintain records of complaints filed with it which concern something other than mental 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.
Sec. 60 1. Each insurer that issues a policy of group health insurance in this state shall provide written notice to an insured, in clear and comprehensible language that is understandable to an ordinary layperson, explaining the right of the insured to file a complaint. The notice must be provided to an insured:
(a) Before he pays for any coverage to be provided by the insurer;
(b) Any time that the insurer denies coverage of a mental health care service or limits coverage of a mental health care service to an insured; and
(c) Any other time deemed necessary by the commissioner.
2. Any time that an insurer denies coverage of a mental health care service to an insured, it shall notify the insured in writing of:
(a) The reason for denying coverage of the service;
(b) The criteria by which the insurer determines whether to authorize or deny coverage of a mental health care service; and
(c) His right to file a complaint.
Sec. 61 Chapter 695B of NRS is hereby amended by adding thereto the provisions set forth as sections 62 to 65, inclusive, of this act.
Sec. 62 As used in sections 62 to 65, inclusive, of this act, "mental health care service" means any care, treatment or training related to the mental health of an insured.
Sec. 63 1. Each insurer that issues a contract for hospital or medical services in this state shall establish a system for resolving any complaints of an insured concerning mental health care services covered under the policy. The system must be approved by the commissioner in consultation with the commission on mental health and mental retardation.
2. A system for resolving complaints pursuant to subsection 1 must include an initial investigation and review of the complaint by a review board and a procedure for appealing a determination regarding the complaint. The majority of the members on the review board must be providers of mental health care that do not have a contractual or other business relationship with the insurer.
3. The commissioner or the commission on mental health and mental retardation may examine the system for resolving complaints established pursuant to this section at such times as the commissioner or commission deems necessary or appropriate.
4. The medical records of a natural person and the records of a physician are not subject to an examination pursuant to subsection 3, but are subject to a properly issued subpoena upon a showing of good cause.
Sec. 64 1. Each insurer that issues a contract for hospital or medical services in this state shall submit to the commissioner and the commission on mental health and mental retardation an annual report regarding its system for resolving complaints established pursuant to section 63 of this act on a form prescribed by the commissioner in consultation with the commission on mental health and mental retardation which includes, without limitation:
(a) A description of the procedures used for resolving any complaints of an insured;
(b) The total number of complaints and appeals handled through the system for resolving complaints since the last report and a compilation of the causes underlying the complaints filed;
(c) The current status of each complaint and appeal filed; and
(d) The average amount of time that was needed to resolve a complaint and an appeal, if any.
2. Each insurer shall maintain records of complaints filed with it which concern something other than mental 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.
Sec. 65 1. Each insurer that issues a contract for hospital or medical services in this state shall provide written notice to an insured, in clear and comprehensible language that is understandable to an ordinary layperson, explaining the right of the insured to file a complaint. The notice must be provided to an insured:
(a) Before he pays for any coverage to be provided by the insurer;
(b) Any time that the insurer denies coverage of a mental health care service or limits coverage of a mental health care service to an insured; and
(c) Any other time deemed necessary by the commissioner.
2. Any time that an insured denies coverage of a mental health care service to a beneficiary or subscriber, it shall notify the beneficiary or subscriber in writing of:
(a) The reason for denying coverage of the service;
(b) The criteria by which the insurer determines whether to authorize or deny coverage of a mental health care service; and
(c) His right to file a complaint.
Sec. 66 NRS 695C.055 is hereby amended to read as follows:
695C.0551. The provisions of NRS 449.465, 679B.158 and 680B.025 to 680B.060, inclusive, subsections 2, 4, 18, 19 and 32 of NRS 680B.010 and NRS 689C.015 to 689C.350, inclusive, and sections 21 to 50, inclusive, of this act apply to a health maintenance organization.
2. For the purposes of subsection 1, unless the context requires that a provision apply only to insurers, any reference in those sections to "insurer" must be replaced by "health maintenance organization."
Sec. 67 NRS 695C.070 is hereby amended to read as follows:
695C.070Each application for a certificate of authority [shall] must be verified by an officer or authorized representative of the applicant, [shall] must be in a form prescribed by the commissioner, and [shall] must set forth or be accompanied by the following:
1. A copy of the basic organizational document, if any, of the applicant, and all amendments thereto;
2. A copy of the bylaws, rules or regulations, or similar document, if any, regulating the conduct of the internal affairs of the applicant;
3. A list of the names, addresses [,] and official positions of the persons who are to be responsible for the conduct of the affairs of the applicant, including , without limitation, all members of the board of directors, board of trustees, executive committee, or other governing board or committee, the officers in the case of a corporation, and the partners or members in the case of a partnership or association;
4. A copy of any contract made or to be made between any providers or persons listed in subsection 3 and the applicant;
5. A statement generally describing the health maintenance organization, its health care plan or plans, location of facilities at which health care services will be regularly available to enrollees, the type of health care personnel who will provide the health care services;
6. A copy of the form of evidence of coverage to be issued to the enrollees;
7. A copy of the form of the group contract, if any, which is to be issued to employers, unions, trustees or other organizations;
8. Certified financial statements showing the applicant's assets, liabilities and sources of financial support;
9. The proposed method of marketing the plan, a financial plan which includes a [three-year] 3-year projection of the initial operating results anticipated and the sources of working capital as well as any other sources of funding;
10. A power of attorney duly executed by the applicant, appointing the commissioner and his duly authorized deputies, as the true and lawful attorney of [such] the applicant in and for this state upon whom all lawful process in any legal action or proceeding against the health maintenance organization on a cause of action arising in this state may be served;
11. A statement reasonably describing the geographic area to be served;
12. A description of the complaint procedures to be [utilized] used as required [under] pursuant to NRS 695C.260 [;] and section 44 of this act;
13. A description of the procedures and programs to be implemented to meet the quality of health care requirements in NRS 695C.080;
14. A description of the benefits available for the physical and mental health of the insureds, including, without limitation, the amount of coverage available for physical and mental health.
15. A description of the mechanism by which enrollees will be afforded an opportunity to participate in matters of program content [under] pursuant to subsection 2 of NRS 695C.110; and
[15.] 16. Such other information as the commissioner may require to make the determinations required in NRS 695C.080.
Sec. 68 NRS 695C.330 is hereby amended to read as follows:
695C.3301. The commissioner may suspend or revoke any certificate of authority issued to a health maintenance organization under this chapter if he finds that any of the following conditions exist:
(a) The health maintenance organization is operating significantly in contravention of its basic organizational document, its health care plan or in a manner contrary to that described in and reasonably inferred from any other information submitted [under] pursuant to NRS 695C.060, 695C.070 and 695C.140, unless amendments to those submissions have been filed with and approved by the commissioner;
(b) The health maintenance organization issues evidence of coverage or uses a schedule of charges for health care services which do not comply with the requirements of NRS 695C.170 to 695C.200, inclusive;
(c) The health care plan does not furnish comprehensive health care services as provided for in subsection 2 of NRS 695C.030;
(d) The state board of health certifies to the commissioner that:
(1) The health maintenance organization does not meet the requirements of subsection 2 of NRS 695C.080; or
(2) The health maintenance organization is unable to fulfill its obligations to furnish health care services as required under its health care plan;
(e) The health maintenance organization is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees;
(f) The health maintenance organization has failed to put into effect a mechanism affording the enrollees an opportunity to participate in matters relating to the content of programs [under] pursuant to NRS 695C.110;
(g) The health maintenance organization has failed to put into effect the system for complaints as required by NRS 695C.260 and section 44 of this act in a manner reasonably to dispose of valid complaints;
(h) The health maintenance organization or any person on its behalf has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive or unfair manner;
(i) The health maintenance organization has failed to provide benefits for mental health care as required pursuant to section 31 of this act;
(j) The continued operation of the health maintenance organization would be hazardous to its enrollees; or
[(j)] (k) The health maintenance organization has otherwise failed [to] substantially to comply with this chapter.
2. A certificate of authority must be suspended or revoked only after compliance with the requirements of NRS 695C.340.
3. When the certificate of authority of a health maintenance organization is suspended, the health maintenance organization shall not, during the period of that suspension, enroll any additional groups or new individual contracts, unless those groups or persons were contracted for before the date of suspension.
4. When the certificate of authority of a health maintenance organization is revoked, the organization shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of the organization. It shall engage in no further advertising or solicitation whatsoever. The commissioner may by written order permit such further operation of the organization as he may find to be in the best interest of enrollees to the end that enrollees will be afforded the greatest practical opportunity to obtain continuing coverage for health care.
Sec. 69 The provisions of this act apply to all contracts for health insurance, managed care or for the provision of health care services entered into or renewed on or after October 1, 1997.