(REPRINTED WITH ADOPTED AMENDMENTS) SECOND REPRINT
Assembly Bill No. 521-Committee on Commerce
May 22, 1997
____________
Referred to Committee on Commerce
SUMMARY--Makes various changes relating to availability and portability of health insurance. (BDR 57-1464)
FISCAL NOTE: Effect on Local Government: Yes.
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 insurance; making various changes relating to the availability and portability of health insurance for individuals, small employers and groups in certain circumstances; providing certain minimum benefits for mothers and newborn infants; providing parity for benefits for treatment of mental health in certain circumstances; establishing a program of reinsurance to insure certain eligible employees and persons; creating a board of directors of the program of reinsurance and defining its duties; providing for an assessment to pay for the program of reinsurance; providing certain civil immunity relating to the program of reinsurance; creating a committee on health benefit plans and defining its duties; providing penalties; making an appropriation; 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 689A of NRS is hereby amended by adding thereto the provisions set forth as sections 2 to 57, inclusive, of this act.
Sec. 2 As used in sections 2 to 57, inclusive, of this act, unless the context otherwise requires, the words and terms defined in sections 3 to 31, inclusive, of this act have the meanings ascribed to them in those sections.
Sec. 3 "Affiliated" means any entity or person who directly, or indirectly through one or more intermediaries, controls or is controlled by or is under common control with a specified entity or person.
Sec. 4 "Basic health benefit plan" means the basic health benefit plan developed pursuant to sections 145 to 182, inclusive, of this act.
Sec. 4.5. "Bona fide association" means, with respect to health insurance coverage offered in this state, an association that:
1. Has been actively in existence for at least 5 years;
2. Has been formed and maintained in good faith for purposes other than obtaining insurance;
3. Does not condition membership in the association on any health status-related factor relating to an individual, including an employee of an employer or a dependent of an employee;
4. Makes health insurance coverage offered through the association available to all of its members regardless of any health status-related factors of the members or other individuals who are eligible for such health insurance coverage through a member of the association;
5. Does not make health insurance coverage offered through the association available other than in connection with a member of the association; and
6. Meets such additional requirements as may be imposed by specific statute.
Sec. 5 "Church plan" has the meaning ascribed to it in section 3(33) of the Employee Retirement Income Security Act of 1974, as that section existed on the effective date of this act.
Sec. 6 "Control" has the meaning ascribed to it in NRS 692C.050.
Sec. 7 "Converted policy" means a basic or standard health benefit plan issued in accordance with section 87 of this act and NRS 689B.120 to 689B.240, inclusive.
Sec. 8 "Creditable coverage" means, with respect to a person, health benefits or coverage provided pursuant to:
1. A group health plan;
2. A health benefit plan;
3. Part A or Part B of Title XVIII of the Social Security Act, also known as Medicare;
4. Title XIX of the Social Security Act, also known as Medicaid, other than coverage consisting solely of benefits under section 1928 of that Title;
5. Chapter 55 of Title 10, United States Code (Civilian Health and Medical Program of Uniformed Services (CHAMPUS));
6. A medical care program of the Indian Health Service or of a tribal organization;
7. A state health benefit risk pool;
8. A health plan offered pursuant to chapter 89 of Title 5, United States Code (Federal Employees Health Benefits Program (FEHBP));
9. A public health plan as defined in federal regulations authorized by the Public Health Service Act, section 2701(c)(1)(I), as amended by Public Law 104-191; or
10. A health benefit plan under section 5(e) of the Peace Corps Act (22 U.S.C. § 2504(e)).
Sec. 9 "Dependent" has the meaning ascribed to in NRS 689C.055.
Sec. 10 "Eligible person" means:
1. A person:
(a) Who, as of the date on which he seeks coverage pursuant to this chapter, has an aggregate period of creditable coverage that is 18 months or more;
(b) Whose most recent prior creditable coverage was under a group health plan, governmental plan, church plan or health insurance coverage offered in connection with any such plan;
(c) Who is not eligible for coverage under a group health plan, Part A or Part B of Title XVIII of the Social Security Act, also known as Medicare, a state plan pursuant to Title XIX of the Social Security Act, also known as Medicaid, or any successor program, and who does not have any other health insurance coverage;
(d) Whose most recent health insurance coverage within the period of aggregate creditable coverage was not terminated because of a failure to pay premiums or fraud;
(e) Who has exhausted his continuation of coverage under the Consolidation Omnibus Budget Reconciliation Act of 1985, or under a similar state program, if any; and
(f) Who has not had a break of more than 63 consecutive days in his creditable coverage.
2. Notwithstanding the provisions of paragraph (a) of subsection 1, a newborn child or a child placed for adoption, if the child was enrolled timely and would have otherwise met the requirements of an eligible person as set forth in subsection 1.
Sec. 11 "Established geographic service area" means a geographic area, as approved by the commissioner and based on the certificate of authority of the carrier to transact insurance in this state, within which the carrier is authorized to provide coverage.
Sec. 12 "Geographic area" means an area established by the commissioner for use in adjusting the rates for a health benefit plan.
Sec. 13 "Governmental plan" has the meaning ascribed to it in section 3(32) of the Employee Retirement Income Security Act of 1974, as that section existed on the effective date of this act, and any health plan of the Federal Government.
Sec. 14 1. "Group health plan" means an employee welfare benefit plan, as defined in section 3(1) of the Employee Retirement Income Security Act of 1974, as that section existed on the effective date of this act, to the extent that the plan provides medical care to employees or their dependents as defined under the terms of the plan directly, or through insurance, reimbursement or otherwise.
2. The term does not include:
(a) Coverage that is only for accident or disability income insurance, or any combination thereof;
(b) Coverage issued as a supplement to liability insurance;
(c) Liability insurance, including general liability insurance and automobile liability insurance;
(d) Workers' compensation or similar insurance;
(e) Coverage for medical payments under a policy of automobile insurance;
(f) Credit insurance;
(g) Coverage for on-site medical clinics; and
(h) Other similar insurance coverage specified in federal regulations adopted pursuant to Public Law 104-191 under which benefits for medical care are secondary or incidental to other insurance benefits.
3. The term does not include the following benefits if the benefits are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of a health benefit plan:
(a) Limited-scope dental or vision benefits;
(b) Benefits for long-term care, nursing home care, home health care or community-based care, or any combination thereof; and
(c) Such other similar benefits as are specified in federal regulations adopted pursuant to Public Law 104-191.
4. The term does not include the following benefits if the benefits are provided under a separate policy, certificate or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and such benefits are paid for a claim without regard to whether benefits are provided for such a claim under any group health plan maintained by the same plan sponsor:
(a) Coverage that is only for a specified disease or illness; and
(b) Hospital indemnity or other fixed indemnity insurance.
5. The term does not include any of the following, if offered as a separate policy, certificate or contract of insurance:
(a) Medicare supplemental health insurance as defined in section 1882(g)(1) of the Social Security Act, as that section existed on the effective date of this act;
(b) Coverage supplemental to the coverage provided pursuant to chapter 55 of Title 10, United States Code (Civilian Health and Medical Program of Uniformed Services (CHAMPUS)); and
(c) Similar supplemental coverage provided under a group health plan.
Sec. 15 1. "Health benefit plan" means a policy, contract, certificate or agreement offered by a carrier to provide for, deliver payment for, arrange for the payment of, pay for or reimburse any of the costs of health care services. Except as otherwise provided in this section, the term includes short-term and catastrophic health insurance policies, and a policy that pays on a cost-incurred basis.
2. The term does not include:
(a) Coverage that is only for accident or disability income insurance, or any combination thereof;
(b) Coverage issued as a supplement to liability insurance;
(c) Liability insurance, including general liability insurance and automobile liability insurance;
(d) Workers' compensation or similar insurance;
(e) Coverage for medical payments under a policy of automobile insurance;
(f) Credit insurance;
(g) Coverage for on-site medical clinics; and
(h) Other similar insurance coverage specified in federal regulations issued pursuant to Public Law 104-191 under which benefits for medical care are secondary or incidental to other insurance benefits.
3. The term does not include the following benefits if the benefits are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of a health benefit plan:
(a) Limited-scope dental or vision benefits;
(b) Benefits for long-term care, nursing home care, home health care or community-based care, or any combination thereof; and
(c) Such other similar benefits as are specified in any federal regulations adopted pursuant to Public Law 104-191.
4. The term does not include the following benefits if the benefits are provided under a separate policy, certificate or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and such benefits are paid for a claim without regard to whether benefits are provided for such a claim under any group health plan maintained by the same plan sponsor:
(a) Coverage that is only for a specified disease or illness; and
(b) Hospital indemnity or other fixed indemnity insurance.
5. The term does not include any of the following, if offered as a separate policy, certificate or contract of insurance:
(a) Medicare supplemental health insurance as defined in section 1882(g)(1) of the Social Security Act, as that section existed on the effective date of this act;
(b) Coverage supplemental to the coverage provided pursuant to chapter 55 of Title 10, United States Code (Civilian Health and Medical Program of Uniformed Services (CHAMPUS)); and
(c) Similar supplemental coverage provided under a group health plan.
Sec. 16 "Health status-related factor" means, with regard to a person who is or seeks to be insured:
1. Health status;
2. Any medical conditions, including physical or mental illness, or both;
3. Claims experience;
4. Receipt of health care;
5. Medical history;
6. Genetic information;
7. Evidence of insurability, including conditions arising out of acts of domestic violence; and
8. Disability.
Sec. 17 "Individual carrier" means any entity subject to the provisions of this Title and the regulations adopted pursuant thereto, that contracts or offers to contract to provide for, deliver payment for, arrange for payment of, pay for, or reimburse any cost of health care services, including a sickness and accident health service corporation, and any other entity providing a plan of health insurance, health benefits or health services to individuals and their dependents in this state.
Sec. 18 "Individual health benefit plan" means:
1. A health benefit plan for individuals and their dependents, other than a converted policy or a plan for coverage of a bona fide association; and
2. A certificate issued to an individual that evidences coverage under a policy or contract issued to a trust or an association or to any other similar group of persons, other than a plan for coverage of a bona fide association, regardless of the situs of delivery of the policy or contract, if the individual pays the premium and is not being covered under the policy or contract pursuant to any provision for the continuation of benefits applicable under federal or state law.
Sec. 19 "Individual reinsuring carrier" means an individual carrier that is eligible to reinsure eligible persons in the program of reinsurance established pursuant to sections 145 to 182, inclusive, of this act.
Sec. 20 "Individual risk-assuming carrier" means an individual carrier that has elected to act as a risk-assuming carrier.
Sec. 21 (Deleted by amendment.)
Sec. 22 "Plan for coverage of a bona fide association" means a health benefit plan for the members, and their dependents, of a bona fide association in this state regardless of the situs of delivery of the policy or contract, if the health benefit plan conforms with section 35 of this act.
Sec. 23 "Plan of operation" means the plan of operation of the program of reinsurance established pursuant to sections 145 to 182, inclusive, of this act.
Sec. 24 "Plan sponsor" has the meaning ascribed to it in section 3(16)(B) of the Employee Retirement Security Act of 1974, as that section existed on the effective date of this act.
Sec. 25 "Preexisting condition" means a condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received during the 6 months preceding the effective date of the new coverage. The term does not include genetic information in the absence of a diagnosis of the condition related to such information.
Sec. 26 (Deleted by amendment.)
Sec. 27 "Producer" means an agent or broker licensed pursuant to this Title.
Sec. 28 (Deleted by amendment.)
Sec. 29 "Program of reinsurance" means the program of reinsurance for small employers and eligible persons established pursuant to section 159 of this act.
Sec. 30 "Provision for a restricted network" means any provision of a health benefit plan that conditions the payment of benefits, in whole or in part, on the use of a provider of health care that has entered into a contractual arrangement with an individual carrier to provide health care services to individuals covered by the plan.
Sec. 31 "Standard health benefit plan" means a standard health benefit plan developed pursuant to sections 145 to 182, inclusive, of this act.
Sec. 32 1. Sections 2 to 57, inclusive, of this act, apply to:
(a) Any health benefit plan that must be made available to eligible persons; and
(b) Any certificate issued to a trust or an association or other similar groupings of persons for coverage of eligible persons,
regardless of the location of delivery of the policy or certificate, if the eligible person pays the premium and is not otherwise covered under the policy or contract pursuant to any federal or state law relating to the continuation of benefits.
2. For the purposes of sections 2 to 57, inclusive, of this act, and except as otherwise provided in subsection 3, two or more individual carriers which are affiliated companies or which are eligible to file a consolidated tax return shall be deemed to be one individual carrier, and any restriction or limitation imposed by sections 2 to 57, inclusive, of this act, applies as if all health benefit plans delivered or issued for delivery to eligible persons in this state by the affiliated individual carriers were issued by one individual carrier.
3. An affiliated individual carrier that is a health maintenance organization having a certificate of authority issued pursuant to the provisions of chapter 695C of NRS may be considered a separate individual carrier for the purposes of sections 2 to 57, inclusive, of this act.
4. Unless otherwise authorized by the commissioner, an individual carrier shall not enter into any ceding arrangement with respect to a health benefit plan delivered or issued for delivery to any eligible person in this state if the ceding arrangement would result in the ceding individual carrier retaining less than 50 percent of the insurance obligations or risks for that health benefit plan.
Sec. 33 For the purposes of sections 2 to 57, inclusive, of this act:
1. Any plan, fund or program which would not be, but for section 2721(e) of the Public Health Service Act, as amended by Public Law 104-191, as that section existed on the effective date of this act, an employee welfare benefit plan and which is established or maintained by a partnership to the extent that the plan, fund or program provides medical care to current or former partners in the partnership or to their dependents, as defined under the terms of the plan, fund or program, directly or through insurance, reimbursement or otherwise, must be treated, subject to subsection 2, as an employee welfare benefit plan which is a group health plan.
2. In the case of a group health plan, a partnership shall be deemed to be the employer of each partner.
Sec. 33.5. A person who meets the requirements to be an eligible person as set forth in section 10 of this act, except that the person had a break in creditable coverage of more than 63 days, shall be deemed to be an eligible person and is eligible to obtain health insurance coverage pursuant to this chapter as an eligible person if the person seeks that coverage between January 1, 1998, and January 31, 1998, inclusive.
Sec. 34 For the purposes of providing coverage under a health benefit plan pursuant to the provisions of sections 2 to 57, inclusive, of this act, a producer may only market association memberships to eligible persons, accept applications for such membership, or sign up such members in a bona fide association if the eligible persons being marketed are actively engaged in, or directly related to, the bona fide association.
Sec. 35 For the purposes of sections 2 to 57, inclusive, of this act, a plan for coverage of a bona fide association must:
1. Conform with sections 48 to 52, inclusive, of this act concerning rates.
2. Provide for the renewability of coverage for members of the bona fide association, and their dependents, if such coverage meets the criteria set forth in section 38 of this act.
3. Provide for the availability of coverage for members of the bona fide association, and their dependents, if such coverage conforms with section 40 of this act, except that the bona fide association is not required to offer basic and standard health benefit plan coverage to its members or their dependents.
4. Conform with subsection 1 of section 42 of this act, relating to preexisting conditions.
Sec. 36 Supplemental coverage is not a health benefit plan if:
1. On or before March 1 of each year, the individual carrier files a certification with the commissioner which contains:
(a) A statement from the individual carrier certifying that the policies or certificates described are being offered and marketed as supplemental health insurance and not as a substitute for hospital or medical expense insurance or major medical expense insurance; and
(b) A summary description of each policy or certificate described, including the average annual premium rates, or range of premium rates for cases in which premiums vary by age, sex or other factors, charged for the policies and certificates in this state.
2. In the case of a policy or certificate that is offered for the first time in this state on or after January 1, 1998, the individual carrier files with the commissioner the statement and summary description required by subsection 1 at least 30 days before the date on which the policy or certificate is issued or delivered in this state.
Sec. 37 1. An employee welfare benefit plan for providing benefits for employees of more than one employer under which individual health insurance coverage is provided must comply with the provisions of sections 2 to 57, inclusive, of this act, and with NRS 679B.139 and the regulations adopted by the commissioner pursuant thereto.
2. As used in this section, the term "employee welfare benefit plan for providing benefits for employees of more than one employer" is intended to be equivalent to the term "employee welfare benefit plan which is a multiple employer welfare arrangement" as used in federal statutes and regulations.
Sec. 38 1. Except as otherwise provided in this section, coverage under an individual health benefit plan must be renewed by the individual carrier that issued the plan, at the option of the individual, unless:
(a) The individual has failed to pay premiums or contributions in accordance with the terms of the health benefit plan or the individual carrier has not received timely premium payments.
(b) The individual has performed an act or a practice that constitutes fraud or has made an intentional misrepresentation of material fact under the terms of the coverage.
(c) The individual carrier decides to discontinue offering and renewing all health benefit plans delivered or issued for delivery in this state. If the individual carrier decides to discontinue offering and renewing such plans, the individual carrier shall:
(1) Provide notice of its intention to the commissioner and the chief regulatory officer for insurance in each state in which the individual carrier is licensed to transact insurance at least 60 days before the date on which notice of cancellation or nonrenewal is delivered or mailed to the persons covered by the insurance to be discontinued pursuant to subparagraph (2).
(2) Provide notice of its intention to all persons covered by the discontinued insurance and to the commissioner and the chief regulatory officer for insurance in each state in which such a person is known to reside. The notice must be made at least 180 days before the nonrenewal of any health benefit plan by the individual carrier.
(3) Discontinue all health insurance issued or delivered for issuance for individuals in this state and not renew coverage under any health benefit plan issued to such individuals.
(d) The commissioner finds that the continuation of the coverage in this state by the individual carrier would not be in the best interests of the policyholders or certificate holders of the individual carrier or would impair the ability of the individual carrier to meet its contractual obligations. If the commissioner makes such a finding, the commissioner shall assist the persons covered by the discontinued insurance in this state in finding replacement coverage.
2. An individual carrier may discontinue the issuance and renewal of a form of a product of a health benefit plan if the commissioner finds that the form of the product offered by the individual carrier is obsolete and is being replaced with comparable coverage. A form of a product of a health benefit plan may be discontinued by the individual carrier pursuant to this subsection only if:
(a) The individual carrier notifies the commissioner and the chief regulatory officer for insurance in each state in which it is licensed of its decision pursuant to this subsection to discontinue the issuance and renewal of the form of the product at least 60 days before the individual carrier notifies the persons covered by the discontinued insurance pursuant to paragraph (b).
(b) The individual carrier notifies each person covered by the discontinued insurance, the commissioner and the chief regulatory officer for insurance in each state in which a person covered by the discontinued insurance is known to reside of the decision of the individual carrier to discontinue offering the form of the product. The notice must be made to persons covered by the discontinued insurance at least 180 days before the date on which the individual carrier will discontinue offering the form of the product.
(c) The individual carrier offers to each person covered by the discontinued insurance the option to purchase any other health benefit plan currently offered by the individual carrier to individuals in this state.
(d) In exercising the option to discontinue the form of the product and in offering the option to purchase other coverage pursuant to paragraph (c), the individual carrier acts uniformly without regard to the claim experience of the persons covered by the discontinued insurance or any health status-related factor relating to those persons or beneficiaries covered by the discontinued form of the product or any persons or beneficiaries who may become eligible for such coverage.
3. An individual carrier may discontinue the issuance and renewal of a health benefit plan that is made available to individuals pursuant to this chapter only through a bona fide association if:
(a) The membership of the individual in the association was the basis for the provision of coverage;
(b) The membership of the individual in the association ceases; and
(c) The coverage is terminated pursuant to this subsection uniformly without regard to any health status-related factor relating to the covered individual.
4. An individual carrier that elects not to renew a health benefit plan pursuant to paragraph (c) of subsection 1 shall not write new business for individuals pursuant to this chapter for 5 years after the date on which notice is provided to the commissioner pursuant to subparagraph (2) of paragraph (c) of subsection 1.
5. If an individual carrier does business in only one established geographic service area of this state, the provisions of this section apply only to the operations of the individual carrier in that service area.
Sec. 39 1. An individual carrier that offers coverage through a network plan is not required pursuant to section 38 of this act to offer coverage to or accept an application from an eligible person if the eligible person does not reside in the established geographic service area or in a geographic area for which the individual carrier is authorized to transact insurance, provided that the coverage is refused or terminated uniformly without regard to any health status-related factor of any eligible person.
2. As used in this section, "network plan" means a health benefit plan offered by a health carrier under which the financing and delivery of medical care is provided, in whole or in part, through a defined set of providers under contract with the carrier. The term does not include an arrangement for the financing of premiums.
Sec. 40 1. As a condition of transacting insurance in this state with individuals, an individual carrier must actively market to eligible persons each health benefit plan that is actively marketed in this state by the individual carrier to any individual in this state. The health insurance plans marketed pursuant to this section by an individual carrier must include, without limitation, a basic health benefit plan and a standard health benefit plan. An individual carrier shall be deemed to be actively marketing a health benefit plan when it makes available any of its plans to an eligible person who is not currently receiving coverage under a health benefit plan issued by that individual carrier.
2. An individual carrier shall issue to an eligible person any basic or standard individual health benefit plan that it markets in accordance with subsection 1 if the eligible person applies for the plan and agrees to make the required premium payments and satisfy the other reasonable provisions of the health benefit plan that are not inconsistent with sections 2 to 57, inclusive, of this act.
Sec. 41 1. Each individual carrier shall file with the commissioner within 90 days after the date on which a basic health benefit plan and a standard health benefit plan are approved pursuant to section 163 of this act, or for a new individual carrier within 90 days after the date it enters the individual market in this state, in a format and manner prescribed by the commissioner, the basic health benefit plans and the standard health benefit plans to be offered by the individual carrier. A health benefit plan filed pursuant to this section may not be offered by an individual carrier until the earlier of:
(a) The date of approval by the commissioner; or
(b) Thirty days after the date on which the plans are filed, unless the commissioner disapproves the use of the plans before the 30-day period expires.
2. The commissioner may, at any time, after providing notice and an opportunity for a hearing, disapprove the continued use of a basic or standard health benefit plan by the individual carrier on the ground that the plan does not meet the requirements of sections 2 to 57, inclusive, and 145 to 182, inclusive, of this act.
Sec. 42 An individual carrier shall not:
1. Impose on an eligible person any exclusion because of a preexisting condition.
2. Modify a health benefit plan, with respect to an eligible person, through riders, endorsements or otherwise, to restrict or exclude services otherwise covered by the plan.
Sec. 43 An individual carrier is not required pursuant to section 40 of this act to offer coverage to or accept an application for coverage:
1. From an eligible person if he does not reside in the established geographic service area of the individual carrier.
2. Within an area where the individual carrier reasonably anticipates, and demonstrates to the satisfaction of the commissioner, that the individual carrier does not have the capacity within its established geographic service area to deliver adequate service to additional eligible persons because of its obligations to existing policyholders. If an individual carrier is authorized by the commissioner not to offer coverage pursuant to this subsection, the individual carrier shall not thereafter offer coverage in the applicable area to additional eligible persons until the individual carrier demonstrates to the satisfaction of the commissioner that it has regained the capacity to deliver adequate service to additional eligible persons in that service area.
Sec. 44 1. An individual carrier is not required to provide coverage to eligible persons pursuant to section 40 of this act:
(a) During any period in which the commissioner determines that requiring the individual carrier to provide such coverage would place the individual carrier in a financially impaired condition.
(b) If the individual carrier elects not to offer any new coverage to any eligible persons in this state. An individual carrier that elects not to offer new coverage in accordance with this paragraph may maintain its existing policies issued to eligible persons in this state, subject to the requirements of section 38 of this act.
2. An individual carrier that elects not to offer new coverage pursuant to paragraph (b) of subsection 1 shall notify the commissioner forthwith of that election and shall not thereafter write any new business to individuals in this state for 5 years after the date of the notification.
Sec. 45 Nothing in sections 40 to 44, inclusive, of this act requires a health carrier that offers a health benefit plan only in connection with a group health plan or through a bona fide association, or both, to offer such health benefit insurance coverage to individuals.
Sec. 46 1. Within 30 days after the date on which a plan of operation is approved by the commissioner pursuant to section 163 of this act, or for a new carrier within 30 days after the date on which it enters the individual market in this state, an individual carrier shall elect to operate as either an individual risk-assuming carrier or an individual reinsuring carrier and shall notify the commissioner of its election.
2. The initial election of an individual carrier to act as an individual risk-assuming or reinsuring carrier is effective on the individual carrier for 2 years after the date on which it notifies the commissioner pursuant to subsection 1. After the initial 2-year period, such an election is effective for 5 years. The commissioner may allow an individual carrier to modify its election at any time for good cause shown. The commissioner may waive or modify the period during which the election of a carrier to operate as an individual risk-assuming or reinsuring carrier is effective.
3. An individual carrier may apply to the commissioner, in a manner prescribed by the commissioner by regulation, to change its status as an individual risk-assuming or reinsuring carrier.
4. An individual reinsuring carrier that elects or is subsequently authorized by the commissioner to operate as a risk-assuming carrier:
(a) Shall not continue to reinsure any individual health benefit plan with the program of reinsurance.
(b) Shall pay a prorated assessment based upon business issued as an individual reinsuring carrier for any portion of the year that the business was reinsured.
Sec. 47 1. The commissioner may suspend the election of an individual carrier to act as an individual risk-assuming carrier, if the commissioner finds that:
(a) The financial condition of the individual carrier no longer supports the assumption of risk from issuing coverage to eligible persons in compliance with sections 40 to 44, inclusive, of this act without the protection afforded by the program of reinsurance;
(b) The individual carrier has failed to market its health benefit plans fairly to all eligible persons in this state or in its established geographic service area, as applicable; or
(c) The individual carrier has failed to provide coverage to eligible persons as required pursuant to sections 40 to 44, inclusive, of this act.
2. An individual carrier that elects to become an individual risk-assuming carrier is subject to:
(a) The provisions of sections 40 to 44, inclusive, of this act, relating to the availability of coverage; and
(b) The provisions of sections 48 to 52, inclusive, of this act, relating to premium rates.
Sec. 48 1. An individual carrier shall develop its rates for its individual health benefit plans pursuant to sections 2 to 57, inclusive, of this act based on rating characteristics. After any adjustments for rating characteristics and design of benefits, the rate for any block of business for an individual health benefit plan written on or after the effective date of this act must not exceed the rate for any other block of business for an individual health benefit plan offered by the individual carrier by more than 100 percent. The rate for a block of business is equal to the average rate charged to all the insureds in the block of business. In determining whether the rate of a block of business complies with the provisions of this subsection, any differences in rating factors between blocks of business must be considered.
2. In determining the rating factors to establish premium rates for a health benefit plan, an individual carrier shall not use characteristics other than age, sex, occupation, geographic area, composition of the family of the individual and health status.
3. If an individual carrier uses health status as a rating factor in establishing premium rates, the highest factor associated with any classification for health status may not exceed the lowest factor by more than 75 percent.
4. For the purposes of this section, rating characteristics must not include durational or tier rating, or adverse changes in health status or claim experience after the policy is issued.
5. As used in this section, "characteristics" means demographic or other information concerning individuals that is considered by a carrier in the determination of premium rates for individuals.
Sec. 49 1. The amount of change in the rate of a single block of business of an individual carrier in any 12-month period because of claims experience or health status-related factors of that block of business, after adjustment for allowed rating characteristics and design of benefits, must not exceed the amount of any similar change in the rate of any other block of business of that individual carrier during the same period by more than 15 percent.
2. For the purposes of sections 2 to 57, inclusive, of this act, a health benefit plan that contains a provision for a restricted network must not be considered to be a similar design of benefits when compared to a health benefit plan that does not contain such a provision if the restriction of benefits to the network providers results in substantial differences in the cost of claims.
3. An individual carrier shall not transfer an individual or his dependent covered by an individual health benefit plan issued by the individual carrier involuntarily into or out of a block of business.
4. If an individual carrier adjusts its premiums for a block of business to a level that is higher than permitted by requirements relating to the ratio of losses, as set forth in this Title and the regulations adopted pursuant thereto, to comply with this section and section 48 of this act, the individual carrier shall make such adjustments on its entire individual health benefit plan business as needed to meet those requirements.
Sec. 50 The commissioner may adopt regulations to carry out the provisions of sections 48 to 52, inclusive, of this act and to ensure that the practices used by individual carriers relating to the establishment of rates are consistent with the purposes of sections 2 to 57, inclusive, of this act, including, but not limited to, determining the manner in which geographic areas are designated by all individual carriers.
Sec. 51 1. As part of its solicitation and sales materials for an individual health benefit plan, an individual carrier shall disclose, to the extent reasonable:
(a) The extent to which premium rates for an individual and his dependent are established or adjusted based upon rating characteristics;
(b) The right of the individual carrier to change premium rates and the factors, other than claims experience, that may affect changes in premium rates;
(c) Any provisions in the individual health benefit plan relating to the renewability of the plan; and
(d) Any provisions in the individual health benefit plan relating to an exclusion for a preexisting condition.
2. For the purposes of this section, an individual carrier shall maintain at its principal place of business a complete and detailed description of its rating practices and underwriting practices, including information and documentation that demonstrate that its rating methods and practices are based upon commonly accepted actuarial assumptions and are in accordance with sound actuarial principles.
3. On or before March 1 of each year, an individual carrier shall file with the commissioner an actuarial certification that the individual carrier is in compliance with sections 48 to 52, inclusive, of this act and that the rating methods of the individual carrier are actuarially sound. The certification must be in such a form and must contain such information as specified by the commissioner. A copy of the certification must be retained by the individual carrier at its principal place of business.
4. As used in this section, "actuarial certification" means a written statement signed by a member of the American Academy of Actuaries or any other person acceptable to the commissioner that an individual carrier is in compliance with the provisions of sections 48 to 52, inclusive, of this act, based upon an examination conducted by the person which included a review of the appropriate records and the actuarial assumptions and methods used by the individual carrier in establishing premium rates for applicable health benefit plans.
Sec. 52 An individual carrier shall make the information and documents described in sections 48 to 52, inclusive, of this act available to the commissioner upon request. Except in cases of violations of the provisions of this chapter, the information, other than the premium rates charged by the individual carrier, is proprietary, constitutes a trade secret and is not subject to disclosure by the commissioner to persons outside of the division except as agreed to by the individual carrier or as ordered by a court of competent jurisdiction.
Sec. 53 The commissioner shall adopt regulations as necessary to carry out the provisions of sections 2 to 57, inclusive, of this act.
Sec. 54 1. Except as otherwise provided in this section, an individual carrier or a producer shall not, directly or indirectly:
(a) Encourage or direct an eligible person to refrain from filing an application for coverage with an individual carrier because of the health status, claims experience, industry, occupation or geographic location of the eligible person.
(b) Encourage or direct an eligible person to seek coverage from another carrier because of the health status, claims experience, industry, occupation or geographic location of the eligible person.
2. The provisions of subsection 1 do not apply to information provided to an eligible person by an individual carrier or a producer relating to the established geographic service area or a provision for a restricted network of the individual carrier.
3. Except as otherwise provided in this subsection, an individual carrier shall not, directly or indirectly, enter into any contract, agreement or arrangement with a producer if the contract, agreement or arrangement provides for or results in a variation to the compensation paid to a producer for the sale of a health benefit plan because of the health status, claims experience, industry, occupation or geographic location of the individual at the time that the health benefit plan is issued to or renewed by the individual. The provisions of this subsection do not apply to any arrangement for compensation that provides payment to a producer on the basis of a percentage of premiums, except that the percentage may not vary because of the health status, claims experience, industry, occupation or geographic area of the individual.
4. An individual carrier shall not terminate, fail to renew, or limit its contract or agreement of representation with a producer for any reason related to the health status, claims experience, industry, occupation or geographic location of an individual at the time that the health benefit plan is issued to or renewed by the individual placed by the producer with the individual carrier.
5. A denial by an individual carrier of an application for coverage from an eligible person must be in writing and must state the reason for the denial.
6. The commissioner may adopt regulations that set forth additional standards to provide for the fair marketing and broad availability of health benefit plans to eligible persons in this state.
7. A violation of any provision of this section by an individual carrier may constitute an unfair trade practice for the purposes of chapter 686A of NRS.
8. The provisions of this section apply to a third-party administrator if the third-party administrator enters into a contract, agreement or other arrangement with an individual carrier to provide administrative, marketing or other services related to the offering of a health benefit plan to eligible persons in this state.
9. Nothing in this section interferes with the right and responsibility of a broker to advise and represent the best interests of an eligible person who is seeking health insurance coverage from an individual carrier.
Sec. 55 The commissioner may adopt regulations to require an individual carrier, as a condition of transacting business with individuals in this state after the effective date of this act, to reissue a health benefit plan to any individual whose health benefit plan has been terminated or not renewed by the individual carrier after July 1, 1997. The commissioner may prescribe such terms for the reissue of coverage as he finds are reasonable and necessary to provide continuity of coverage to individuals.
Sec. 56 1. To determine the period of creditable coverage of a person, a health insurance issuer offering individual health insurance coverage shall provide written certification of coverage on a form prescribed by the commissioner to the person that certifies:
(a) The period of creditable coverage of the person under the individual health insurance coverage; and
(b) The date that a substantially completed application was received by the health insurance issuer from the person for individual health insurance coverage.
2. The certification of coverage must be provided to the insured:
(a) At the time that the insured ceases to be covered under the individual health insurance coverage or otherwise becomes covered under any provision of the Consolidated Omnibus Budget Reconciliation Act of 1985, as that act existed on the effective date of this act, relating to the continuation of coverage;
(b) If the insured becomes covered under such a provision, at the time that the insured ceases to be covered by that provision; and
(c) Upon the request of the insured, if the request is made not later than 24 months after the date on which the insured ceased to be covered as described in paragraphs (a) and (b).
Sec. 57 On or before July 1 of each year, a trustee of a medical savings account established and maintained in accordance with 26 U.S.C. § 220 shall report to the commissioner the number of medical savings accounts administered by the trustee during the previous calendar year.
Sec. 58 NRS 689A.020 is hereby amended to read as follows:
689A.020Nothing in this chapter applies to or affects:
1. Any policy of liability or [workmen's] workers' compensation insurance with or without supplementary expense coverage therein.
2. Any group or blanket policy . [, except as to NRS 689A.380 (definitions of terms).]
3. Life insurance, endowment or annuity contracts, or contracts supplemental thereto which contain only such provisions relating to health insurance as to:
(a) Provide additional benefits in case of death or dismemberment or loss of sight by accident or accidental means; or
(b) Operate to safeguard such contracts against lapse, or to give a special surrender value or special benefit or an annuity if the insured or annuitant becomes totally and permanently disabled, as defined by the contract or supplemental contract.
4. Reinsurance [.] , except as otherwise provided in sections 2 to 57, inclusive, and 145 to 182, inclusive, of this act, relating to the program of reinsurance.
Sec. 59 Chapter 689B of NRS is hereby amended by adding thereto the provisions set forth as sections 60 to 88, inclusive, of this act.
Sec. 60 As used in sections 60 to 88, inclusive, of this act, unless the context otherwise requires, the words and terms defined in sections 61 to 74, inclusive, of this act have the meanings ascribed to them in those sections.
Sec. 61 "Affiliation period" means a period not to exceed 60 days for new enrollees and 90 days for late enrollees during which no premiums may be collected from and coverage issued would not become effective for an employee or his dependent, if the affiliation period is applied uniformly and without regard to any health status-related factors.
Sec. 62 "Carrier" means any person who provides health insurance in this state, including a fraternal benefit society, a health maintenance organization, a nonprofit hospital and health service corporation, a health insurance company and any other person providing a plan of health insurance or health benefits subject to this Title.
Sec. 63 "Contribution" means the minimum employer contribution toward the premium for enrollment of participants and beneficiaries in a health benefit plan.
Sec. 64 "Creditable coverage" means health benefits or coverage provided to a person pursuant to:
1. A group health plan;
2. A health benefit plan;
3. Part A or Part B of Title XVIII of the Social Security Act, also known as Medicare;
4. Title XIX of the Social Security Act, also known as Medicaid, other than coverage consisting solely of benefits under section 1928 of that Title;
5. Chapter 55 of Title 10, United States Code (Civilian Health and Medical Program of Uniformed Services (CHAMPUS));
6. A medical care program of the Indian Health Service or of a tribal organization;
7. A state health benefit risk pool;
8. A health plan offered pursuant to chapter 89 of Title 5, United States Code (Federal Employees Health Benefits Program (FEHBP));
9. A public health plan as defined in federal regulations authorized by the Public Health Service Act, section 2701(c)(1)(I), as amended by Public Law 104-191; or
10. A health benefit plan under section 5(e) of the Peace Corps Act (22 U.S.C. § 2504(e)).
Sec. 65 1. "Group health plan" means an employee welfare benefit plan, as defined in section 3(1) of the Employee Retirement Income Security Act of 1974, as that section existed on the effective date of this act, to the extent that the plan provides medical care to employees or their dependents as defined under the terms of the plan directly, or through insurance, reimbursement or otherwise.
2. The term does not include:
(a) Coverage that is only for accident or disability income insurance, or any combination thereof;
(b) Coverage issued as a supplement to liability insurance;
(c) Liability insurance, including general liability insurance and automobile liability insurance;
(d) Workers' compensation or similar insurance;
(e) Coverage for medical payments under a policy of automobile insurance;
(f) Credit insurance;
(g) Coverage for on-site medical clinics; and
(h) Other similar insurance coverage specified in federal regulations adopted pursuant to Public Law 104-191 under which benefits for medical care are secondary or incidental to other insurance benefits.
3. The term does not include the following benefits if the benefits are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of a health benefit plan:
(a) Limited-scope dental or vision benefits;
(b) Benefits for long-term care, nursing home care, home health care or community-based care, or any combination thereof; and
(c) Such other similar benefits as are specified in any federal regulations adopted pursuant to Public Law 104-191.
4. The term does not include the following benefits if the benefits are provided under a separate policy, certificate or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and such benefits are paid for a claim without regard to whether benefits are provided for such a claim under any group health plan maintained by the same plan sponsor:
(a) Coverage that is only for a specified disease or illness; and
(b) Hospital indemnity or other fixed indemnity insurance.
5. The term does not include any of the following, if offered as a separate policy, certificate or contract of insurance:
(a) Medicare supplemental health insurance as defined in section 1882(g)(1) of the Social Security Act, as that section existed on the effective date of this act;
(b) Coverage supplemental to the coverage provided pursuant to chapter 55 of Title 10, United States Code (Civilian Health and Medical Program of Uniformed Services (CHAMPUS)); and
(c) Similar supplemental coverage provided under a group health plan.
Sec. 66 "Group participation" means the minimum number of participants or beneficiaries that must be enrolled in a health benefit plan in relation to a specified percentage or number of eligible persons or employees of the employer.
Sec. 67 1. "Health benefit plan" means a policy, contract, certificate or agreement offered by a carrier to provide for, arrange for payment of, pay for or reimburse any of the costs of health care services. Except as otherwise provided in this section, the term includes short-term and catastrophic health insurance policies, and a policy that pays on a cost-incurred basis.
2. The term does not include:
(a) Coverage that is only for accident or disability income insurance, or any combination thereof;
(b) Coverage issued as a supplement to liability insurance;
(c) Liability insurance, including general liability insurance and automobile liability insurance;
(d) Workers' compensation or similar insurance;
(e) Coverage for medical payments under a policy of automobile insurance;
(f) Credit insurance;
(g) Coverage for on-site medical clinics; and
(h) Other similar insurance coverage specified in federal regulations issued pursuant to Public Law 104-191 under which benefits for medical care are secondary or incidental to other insurance benefits.
3. If the benefits are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of a health benefit plan, the term does not include the following benefits:
(a) Limited-scope dental or vision benefits;
(b) Benefits for long-term care, nursing home care, home health care or community-based care, or any combination thereof; and
(c) Such other similar benefits as are specified in any federal regulations adopted pursuant to Public Law 104-191.
4. For the purposes of sections 60 to 88, inclusive, of this act, if the benefits are provided under a separate policy, certificate or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and such benefits are paid for a claim without regard to whether benefits are provided for such a claim under any group health plan maintained by the same plan sponsor, the term does not include:
(a) Coverage that is only for a specified disease or illness; and
(b) Hospital indemnity or other fixed indemnity insurance.
5. For the purposes of sections 60 to 88, inclusive, of this act, if offered as a separate policy, certificate or contract of insurance, the term does not include:
(a) Medicare supplemental health insurance as defined in section 1882(g)(1) of the Social Security Act, as that section existed on the effective date of this act;
(b) Coverage supplemental to the coverage provided pursuant to chapter 55 of Title 10, United States Code (Civilian Health and Medical Program of Uniformed Services (CHAMPUS)); and
(c) Similar supplemental coverage provided under a group health plan.
Sec. 68 "Health status-related factor" means, with regard to an insured or a person to be insured:
1. Health status;
2. Any medical conditions, including physical or mental illness, or both;
3. Claims experience;
4. Receipt of health care;
5. Medical history;
6. Genetic information;
7. Evidence of insurability, including conditions arising out of acts of domestic violence; and
8. Disability.
Sec. 69 (Deleted by amendment.)
Sec. 70 "Open enrollment" means the period designated for enrollment in a health benefit plan.
Sec. 71 "Plan sponsor" has the meaning ascribed to it in section 3(16)(B) of the Employee Retirement Income Security Act of 1974, as that section existed on the effective date of this act.
Sec. 72 "Preexisting condition" means a condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received during the 6 months immediately preceding the effective date of the new coverage. The term does not include genetic information in the absence of a diagnosis of the condition related to such information.
Sec. 73 (Deleted by amendment.)
Sec. 74 "Waiting period" means the period established by a plan of health insurance that must pass before a person who is an eligible participant or beneficiary in a plan is covered for benefits under the terms of the plan.
Sec. 75 For the purposes of sections 60 to 88, inclusive, of this act:
1. Any plan, fund or program which would not be, but for section 2721(e) of the Public Health Service Act, as amended by Public Law 104-191, as that section existed on the effective date of this act, an employee welfare benefit plan and which is established or maintained by a partnership to the extent that the plan, fund or program provides medical care, including items and services paid for as medical care, to current or former partners in the partnership, or to their dependents, as defined under the terms of the plan, fund or program, directly or through insurance, reimbursement, or otherwise, must be treated, subject to the provisions of subsection 2, as an employee welfare benefit plan that is a group health plan.
2. In the case of a group health plan, a partnership shall be deemed to be the employer of each partner.
Sec. 76 1. In determining the applicable creditable coverage of a person for the purposes of sections 60 to 88, inclusive, of this act, a period of creditable coverage must not be included if, after the expiration of that period but before the enrollment date, there was a 63-day period during all of which the person was not covered under any creditable coverage. To establish a period of creditable coverage, a person must present any certificates of coverage provided to him in accordance with section 77 of this act and such other evidence of coverage as required by regulations adopted by the commissioner. For the purposes of this subsection, any waiting period for coverage or an affiliation period must not be considered in determining the applicable period of creditable coverage.
2. In determining the period of creditable coverage of a person for the purposes of section 78 of this act, a carrier shall include each applicable period of creditable coverage without regard to the specific benefits covered during that period, except that the carrier may elect to include applicable periods of creditable coverage based on coverage of specific benefits as specified in the regulations of the United States Department of Health and Human Services, if such an election is made on a uniform basis for all participants and beneficiaries of the health benefit plan or coverage. Pursuant to such an election, the carrier shall include each applicable period of creditable coverage with respect to any class or category of benefits if any level of benefits is covered within that class or category, as specified by those regulations.
3. Regardless of whether coverage is actually provided, if a carrier elects in accordance with subsection 2 to determine creditable coverage based on specified benefits, a statement that such an election has been made and a description of the effect of the election must be:
(a) Included prominently in any disclosure statement concerning the health benefit plan; and
(b) Provided to each person at the time of enrollment in the health benefit plan.
Sec. 77 1. For the purpose of determining the period of creditable coverage of a person accumulated under a health benefit plan or group health insurance, the insurer shall provide written certification on a form prescribed by the commissioner of coverage to the person which certifies the length of:
(a) The period of creditable coverage that the person accumulated under the plan and any coverage under any provision of the Consolidated Omnibus Budget Reconciliation Act of 1985, as that act existed on the effective date of this act, relating to the continuation of coverage; and
(b) Any waiting and affiliation period imposed on the person pursuant to that coverage.
2. The certification of coverage must be provided to the person who was insured:
(a) At the time that he ceases to be covered under the plan, if he does not otherwise become covered under any provision of the Consolidated Omnibus Budget Reconciliation Act of 1985, as that act existed on the effective date of this act, relating to the continuation of coverage;
(b) If he becomes covered under such a provision, at the time that he ceases to be covered by that provision; and
(c) Upon request, if the request is made not later than 24 months after the date on which he ceased to be covered as described in paragraphs (a) and (b).
Sec. 78 1. Except as otherwise provided in this section, a carrier that issues a group health plan or coverage under group health insurance shall not deny, exclude or limit a benefit for a preexisting condition for:
(a) More than 12 months after the effective date of coverage if the employee enrolls through open enrollment or after the first day of the waiting period for such enrollment, whichever is earlier; or
(b) More than 18 months after the effective date of coverage for a late enrollee.
A carrier may not define a preexisting condition more restrictively than that term is defined in section 72 of this act.
2. The period of any exclusion for a preexisting condition imposed by a group health plan or coverage under group health insurance on a person to be insured in accordance with the provisions of this chapter must be reduced by the aggregate period of creditable coverage of that person, if the creditable coverage was continuous to a date not more than 63 days before the effective date of the coverage. The period of continuous coverage must not include:
(a) Any waiting period for the effective date of the new coverage applied by the employer or the carrier; or
(b) Any affiliation period not to exceed 60 days for a new enrollee and 63 days for a late enrollee required before becoming eligible to enroll in the group health plan.
3. A health maintenance organization authorized to transact insurance pursuant to chapter 695C of NRS that does not restrict coverage for a preexisting condition may require an affiliation period before coverage becomes effective under a plan of insurance if the affiliation period applies uniformly to all employees and without regard to any health status-related factors. During the affiliation period, the carrier shall not collect any premiums for coverage of the employee.
4. An insurer that restricts coverage for preexisting conditions shall not impose an affiliation period.
5. A carrier shall not impose any exclusion for a preexisting condition:
(a) Relating to pregnancy.
(b) In the case of a person who, as of the last day of the 30-day period beginning on the date of his birth, is covered under creditable coverage.
(c) In the case of a child who is adopted or placed for adoption before attaining the age of 18 years and who, as of the last day of the 30-day period beginning on the date of adoption or placement for adoption, whichever is earlier, is covered under creditable coverage. The provisions of this paragraph do not apply to coverage before the date of adoption or placement for adoption.
(d) In the case of a condition for which medical advice, diagnosis, care or treatment was recommended or received for the first time while the covered person held creditable coverage, and the medical advice, diagnosis, care or treatment was a benefit under the plan, if the creditable coverage was continuous to a date not more than 63 days before the effective date of the new coverage.
The provisions of paragraphs (b) and (c) do not apply to a person after the end of the first 63-day period during all of which the person was not covered under any creditable coverage.
6. As used in this section, "late enrollee" means an eligible employee, or his dependent, who requests enrollment in a group health plan following the initial period of enrollment, if that initial period of enrollment is at least 30 days, during which the person is entitled to enroll under the terms of the health benefit plan. The term does not include an eligible employee or his dependent if:
(a) The employee or dependent:
(1) Was covered under creditable coverage at the time of the initial enrollment;
(2) Lost coverage under creditable coverage as a result of cessation of contributions by his employer, termination of employment or eligibility, reduction in the number of hours of employment, involuntary termination of creditable coverage, or death of, or divorce or legal separation from, a covered spouse; and
(3) Requests enrollment not later than 30 days after the date on which his creditable coverage was terminated or on which the change in conditions that gave rise to the termination of the coverage occurred.
(b) The employee enrolls during the open enrollment period, as provided in the contract or as otherwise specifically provided by specific statute.
(c) The employer of the employee offers multiple health benefit plans and the employee elected a different plan during an open enrollment period.
(d) A court has ordered coverage to be provided to the spouse or a minor or dependent child of an employee under a health benefit plan of the employee and a request for enrollment is made within 30 days after the issuance of the court order.
(e) The employee changes status from not being an eligible employee to being an eligible employee and requests enrollment, subject to any waiting period, within 30 days after the change in status.
(f) The person has continued coverage in accordance with the Consolidated Omnibus Budget Reconciliation Act of 1985 and such coverage has been exhausted.
Sec. 79 A carrier may modify the health insurance coverage for a product offered pursuant to a group health plan by the carrier at the time of renewal of such coverage, if the modification is consistent with the provisions of this chapter.
Sec. 80 1. Except as otherwise provided in this subsection, a group health plan or coverage offered under group health insurance issued pursuant to this chapter that includes coverage for maternity care and pediatric care for newborn infants may not restrict benefits for any length of stay in a hospital in connection with childbirth for a mother or newborn infant covered by the plan or coverage to:
(a) Less than 48 hours after a normal vaginal delivery; and
(b) Less than 96 hours after a cesarean section.
The provisions of this subsection do not apply to any group health plan or health insurance coverage in any case in which the decision to discharge the mother or newborn infant before the expiration of the minimum period set forth in this subsection is made by the attending physician of the mother or newborn infant.
2. Nothing in this section requires a mother to:
(a) Deliver her baby in a hospital; or
(b) Stay in a hospital for a fixed period following the birth of her child.
3. A group health plan or coverage under group health insurance that offers coverage for maternity care and pediatric care of newborn infants may not:
(a) Deny a mother or her newborn infant coverage or continued coverage under the terms of the plan or coverage if the sole purpose of the denial of coverage or continued coverage is to avoid the requirements of this section;
(b) Provide monetary payments or rebates to a mother to encourage her to accept less than the minimum protection available pursuant to this section;
(c) Penalize, or otherwise reduce or limit, the reimbursement of an attending provider of health care because he provided care to a mother or newborn infant in accordance with the provisions of this section;
(d) Provide incentives of any kind to an attending physician to induce him to provide care to a mother or newborn infant in a manner that is inconsistent with the provisions of this section; or
(e) Except as otherwise provided in subsection 4, restrict benefits for any portion of a hospital stay required pursuant to the provisions of this section in a manner that is less favorable than the benefits provided for any preceding portion of that stay.
4. Nothing in this section:
(a) Prohibits a group health plan or carrier from imposing a deductible, coinsurance or other mechanism for sharing costs relating to benefits for hospital stays in connection with childbirth for a mother or newborn child covered by the plan, except that such coinsurance or other mechanism for sharing costs for any portion of a hospital stay required by this section may not be greater than the coinsurance or other mechanism for any preceding portion of that stay.
(b) Prohibits an arrangement for payment between a group health plan or carrier and a provider of health care that uses capitation or other financial incentives, if the arrangement is designed to provide services efficiently and consistently in the best interest of the mother and her newborn infant.
(c) Prevents a group health plan or carrier from negotiating with a provider of health care concerning the level and type of reimbursement to be provided in accordance with this section.
Sec. 81 A carrier offering group health insurance shall permit an employee or a dependent of an employee covered by the group health insurance who is eligible, but not enrolled, for coverage in connection with the group health insurance to enroll for coverage under the terms of the group health insurance if:
1. The employee or dependent was covered under a different group health insurance or had other health insurance coverage at the time coverage was previously offered to the employee or dependent;
2. The employee stated in writing at that time that the other coverage was the reason for declining enrollment, but only if the plan sponsor or carrier required such a written statement and informed the employee of that requirement and the consequences of the requirement; and
3. The employee or his dependent:
(a) Was covered under any provision of the Consolidated Omnibus Budget Reconciliation Act of 1985 relating to the continuation of coverage and such continuation of coverage was exhausted; or
(b) Was not covered under such a provision and his insurance coverage was lost as a result of cessation of contributions by his employer, termination of employment or eligibility, reduction in the number of hours of employment, or the death of, or divorce or legal separation from, a covered spouse.
Sec. 82 1. A carrier that offers group health insurance which makes coverage available to the dependent of an employee covered by the group health plan shall permit the employee to enroll a dependent after the close of a period of open enrollment if:
(a) The employee is a participant in the group health plan, or has met any waiting period applicable to becoming a participant and is eligible to be enrolled under the plan, except for a failure to enroll during a previous period of open enrollment; and
(b) The person to be enrolled became a dependent of the employee through marriage, birth, adoption or placement for adoption.
2. The group health plan or carrier shall provide a period of special enrollment for the enrollment of a dependent of an employee pursuant to this section. Such a period must be not less than 30 days and must begin on:
(a) The date specified by the group health plan or carrier for the period of special enrollment; or
(b) The date of the marriage, birth, adoption or placement for adoption, as appropriate.
3. If an employee seeks to enroll a dependent during the first 30 days of the period for special enrollment provided pursuant to subsection 2, the coverage of the dependent becomes effective:
(a) In the case of a marriage, not later than the first day of the first month beginning after the date on which the completed request for enrollment is received;
(b) In the case of a birth, on the date of the birth; and
(c) In the case of an adoption or placement for adoption, on the date of the adoption or the placement for adoption.
4. In the case of a birth, an adoption or a placement for adoption of a child of an employee, the spouse of the employee may be enrolled as a dependent pursuant to this section if the spouse is otherwise eligible for coverage under the group health plan.
Sec. 83 1. A carrier shall not place any restriction on a person or his dependent as a condition of being a participant in or a beneficiary of a policy of group health insurance that is inconsistent with the provisions of this chapter.
2. A carrier that offers coverage under a policy of group health insurance pursuant to this chapter shall not establish rules of eligibility, including, but not limited to, rules which define applicable waiting periods, for the initial or continued enrollment under the group health plan offered by the carrier that are based on the following factors relating to the employee or his dependent:
(a) Health status.
(b) Medical condition, including physical and mental illnesses, or both.
(c) Claims experience.
(d) Receipt of health care.
(e) Medical history.
(f) Genetic information.
(g) Evidence of insurability, including conditions which arise out of acts of domestic violence.
(h) Disability.
3. Except as otherwise provided in section 78 of this act, the provisions of subsection 1 do not:
(a) Require a carrier to provide particular benefits other than those that would otherwise be provided under the terms of the group health insurance or coverage; or
(b) Prevent a carrier from establishing limitations or restrictions on the amount, level, extent or nature of the benefits or coverage for similarly situated persons.
4. As a condition of enrollment or continued enrollment under a policy of group health insurance, a carrier shall not require an employee to pay a premium or contribution that is greater than the premium or contribution for a similarly situated person covered by similar coverage on the basis of any factor described in subsection 2 in relation to the employee or his dependent.
5. Nothing in this section:
(a) Restricts the amount that an employer or employee may be charged for coverage by a carrier;
(b) Prevents a carrier from establishing premium discounts or rebates or from modifying otherwise applicable copayments or deductibles in return for adherence by the insured person to programs of health promotion and disease prevention; or
(c) Precludes a carrier from establishing rules relating to employer contribution or group participation when offering health insurance coverage to small employers in this state.
Sec. 84 1. Except as otherwise provided in this section, coverage under a policy of group health insurance must be renewed by the carrier, at the option of the plan sponsor, unless:
(a) The plan sponsor has failed to pay premiums or contributions in accordance with the terms of the group health insurance or the carrier has not received timely premium payments.
(b) The plan sponsor has performed an act or a practice that constitutes fraud or has made an intentional misrepresentation of material fact under the terms of the coverage.
(c) The plan sponsor has failed to comply with any material provision of the group health insurance relating to employer contributions and group participation.
(d) The carrier decides to discontinue offering coverage under group health insurance. If the carrier decides to discontinue offering and renewing such insurance, the carrier shall:
(1) Provide notice of its intention to the commissioner and the chief regulatory officer for insurance in each state in which the carrier is licensed to transact insurance at least 60 days before the date on which notice of cancellation or nonrenewal is delivered or mailed to the persons covered by the discontinued insurance pursuant to subparagraph (2).
(2) Provide notice of its intention to all persons covered by the discontinued insurance and to the commissioner and the chief regulatory officer for insurance in each state in which such a person is known to reside. The notice must be made at least 180 days before the discontinuance of any group health plan by the carrier.
(3) Discontinue all health insurance issued or delivered for issuance for persons in this state and not renew coverage under any group health insurance issued to such persons.
2. A carrier may discontinue the issuance and renewal of a form of a product of group health insurance if the commissioner finds that the form of the product offered by the carrier is obsolete and is being replaced with comparable coverage. A form of a product may be discontinued by the carrier pursuant to this subsection only if:
(a) The carrier notifies the commissioner and the chief regulatory officer in each state in which it is licensed of its decision pursuant to this subsection to discontinue the issuance and renewal of the form of the product at least 60 days before the individual carrier notifies the persons covered by the discontinued insurance pursuant to paragraph (b).
(b) The carrier notifies each person covered by the discontinued insurance and the commissioner and the chief regulatory officer in each state in which such a person is known to reside of the decision of the carrier to discontinue offering the form of the product. The notice must be made at least 180 days before the date on which the carrier will discontinue offering the form of the product.
(c) The carrier offers to each person covered by the discontinued insurance the option to purchase any other health benefit plan currently offered by the carrier to large groups in this state.
(d) In exercising the option to discontinue the form of the product and in offering the option to purchase other coverage pursuant to paragraph (c), the carrier acts uniformly without regard to the claim experience of the persons covered by the discontinued insurance or any health status-related factor relating to those persons or beneficiaries covered by the discontinued form of the product or any person or beneficiary who may become eligible for such coverage.
3. A carrier may discontinue the issuance and renewal of any type of group health insurance offered by the carrier in this state that is made available pursuant to this chapter only to a member of a bona fide association if:
(a) The membership of the person in the bona fide association was the basis for the provision of coverage under the group health insurance;
(b) The membership of the person in the bona fide association ceases; and
(c) Coverage is terminated pursuant to this subsection for all such former members uniformly without regard to any health status-related factor relating to the former member.
4. A carrier that elects not to renew group health insurance pursuant to paragraph (d) of subsection 1 shall not write new business pursuant to this chapter for 5 years after the date on which notice is provided to the commissioner pursuant to subparagraph (2) of paragraph (d) of subsection 1.
5. If the carrier does business in only one established geographic service area of this state, the provisions of this section apply only to the operations of the carrier in that service area.
6. As used in this section, "bona fide association" has the meaning ascribed to it in section 4.5 of this act.
Sec. 85 1. A carrier that offers coverage through a network plan is not required to offer coverage to or accept an application from an employer that does not employ or no longer employs any enrollees who reside or work in the established geographic service area of the carrier or the geographic area for which the carrier is authorized to transact insurance, provided that such coverage is refused or terminated uniformly without regard to any health status-related factor for any employee of the employer.
2. As used in this section, "network plan" means a health benefit plan offered by a health carrier under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the carrier. The term does not include an arrangement for the financing of premiums.
Sec. 86 1. A plan sponsor of a governmental plan that is a group health plan to which the provisions of sections 60 to 88, inclusive, of this act otherwise apply may elect to exclude the governmental plan from compliance with those sections. Such an election:
(a) Must be made in such a form and in such a manner as the commissioner prescribes by regulation.
(b) Is effective for a single specified year of the plan or, if the plan is provided pursuant to a collective bargaining agreement, for the term of that agreement.
(c) May be extended by subsequent elections.
(d) Excludes the governmental plan from those provisions in this chapter that apply only to group health plans.
2. If a plan sponsor of a governmental plan makes an election pursuant to this section, the plan sponsor shall:
(a) Annually and at the time of enrollment, notify the enrollees in the plan of the election and the consequences of the election; and
(b) Provide certification and disclosure of creditable coverage under the plan with respect to those enrollees pursuant to section 77 of this act.
3. As used in this section, "governmental plan" has the meaning ascribed to in section 3(32) of the Employee Retirement Income Security Act of 1974, as that section existed on the effective date of this act.
Sec. 87 1. Not later than 180 days after the date on which the basic and standard health benefit plans are approved pursuant to section 163 of this act as part of the plan of operation of the program of reinsurance, each carrier required to offer to a person a converted policy pursuant to NRS 689B.120 shall only offer as a converted policy a choice of the basic and standard health benefit plans.
2. A person with a converted policy issued before the effective date of the requirement set forth in subsection 1 may, at each annual renewal of the converted policy elect a basic or standard health benefit plan as a substitute converted policy, except that the carrier may, if the person has not made an election within 3 years after first becoming eligible to do so, require the person to make such an election. Once a person has elected either the basic or standard health benefit plan as a substitute converted policy, he may not elect another converted policy.
3. If the carrier issues basic and standard health benefit plans in this state to small employers, the rates for converted policies must be consistent with those policies, as calculated pursuant to NRS 689C.230. A carrier that does not write insurance to small employers in this state shall set the premiums for its converted policies issued or delivered for issuance pursuant to this section at the average rate, as determined by the commissioner, charged by the five largest carriers that provide coverage to small employers pursuant to this chapter for their basic and standard health benefit plans. The commissioner shall annually determine the average rate charged, as measured by the premium volume of the plans, by those five largest carriers.
4. The rates for new and renewal converted policies for persons with the same converted policies whose case characteristics are similar must be the same.
5. Any losses suffered by a carrier on its converted policies issued pursuant to this section must be spread across the entire book of the health benefit coverage of the carrier issued or delivered for issuance to small employers and large group employers in this state.
6. The commissioner shall adopt such regulations as are necessary to carry out the provisions of this section.
Sec. 88 1. Except as otherwise provided in this section, if group health insurance for groups of 51 persons or more which is issued or delivered for issuance in this state and which offers both medical and surgical benefits and mental health benefits:
(a) Does not include an aggregate lifetime limit on substantially all medical and surgical benefits, the group health insurance may not impose an aggregate lifetime limit on the mental health benefits.
(b) Includes an aggregate lifetime limit on substantially all medical and surgical benefits, the aggregate lifetime limit on the mental health benefits offered by the group health insurance must not be less than the aggregate lifetime limit set for the medical and surgical benefits.
(c) Includes no aggregate lifetime limits, or different aggregate lifetime limits, on different categories of medical and surgical benefits, the applicable aggregate lifetime limit that must be applied in accordance with paragraph (b) to the mental health benefits of the group health insurance must be computed by taking into account the weighted average of the aggregate lifetime limits applicable to such categories of medical and surgical benefits offered by the group health insurance. The computation of the aggregate lifetime limit must be consistent with the rules adopted by the Secretary of the United States Department of Labor pursuant to 29 U.S.C. § 1185a.
2. Except as otherwise provided in this section, if group health insurance for groups of 51 persons or more which is issued or delivered for issuance in this state and which offers both medical and surgical benefits and mental health benefits:
(a) Does not include an annual limit on substantially all medical and surgical benefits, the group health insurance may not impose an annual limit on the mental health benefits.
(b) Includes an annual limit on substantially all medical and surgical benefits, the annual limit on the mental health benefits offered by the group health insurance must not be less than the annual limit set for the medical and surgical benefits.
(c) Includes no annual limit, or different annual limits, on different categories of medical and surgical benefits, the applicable annual limit that must be applied in accordance with paragraph (b) to the mental health benefits of the group health insurance must be computed by taking into account the weighted average of the annual limits applicable to such categories of medical and surgical benefits offered by the group health insurance. The computation of the annual limit must be consistent with the rules adopted by the Secretary of the United States Department of Labor pursuant to 29 U.S.C. § 1185a.
3. Nothing in this section:
(a) Requires group health insurance to provide mental health benefits.
(b) Except as specifically provided in subsection 1, affects the terms or conditions of group health insurance that provides mental health benefits, relating to the amount, duration or scope of those benefits, including, but not limited to, cost sharing, limits on numbers of visits or days of coverage and requirements relating to medical necessity.
4. Group health insurance is not required to comply with the provisions of this section if the application of this section would result in an increase in the cost under the group health insurance of 1 percent or more.
5. If the group health insurance offers a participant or beneficiary more than one benefit package option, the provisions of this section must be applied separately to each such option offered.
6. As used in this section:
(a) "Aggregate lifetime limit" means a limitation on the total amount of benefits that may be paid with respect to those benefits under group health insurance with respect to a policyholder or other coverage unit.
(b) "Annual limit" means a limitation on the total amount of benefits that may be paid with respect to those benefits in a 12-month period under group health insurance with respect to an individual or other coverage unit.
(c) "Medical and surgical benefits" means benefits, as defined under the group health insurance, provided by such insurance for medical or surgical services. The term does not include benefits for services relating to mental health.
(d) "Mental health benefits" means benefits, as defined under the group health insurance, provided by such insurance for services relating to mental health. The term does not include benefits provided for the treatment of substance abuse or chemical dependency.
Sec. 89 NRS 689B.027 is hereby amended to read as follows:
689B.0271. The commissioner shall adopt regulations which require an insurer to file with the commissioner, for his approval, a disclosure summarizing the coverage provided by each policy of group health insurance offered by the insurer. The disclosure must include:
(a) Any significant exception, reduction or limitation that applies to the policy;
(b) Any restrictions on payments for emergency care, including related definitions of an emergency and medical necessity; [and]
(c) Any provisions concerning the insurer's right to change premium rates and the characteristics, other than claim experience, that affect changes in premium rates;
(d) Any provisions relating to renewability;
(e) Any provisions relating to preexisting conditions; and
(f) Any other information,
that the commissioner finds necessary to provide for full and fair disclosure of the provisions of the policy.
2. The disclosure must be written in language which is easily understood and must include a statement that the disclosure is a summary of the policy only, and that the policy itself should be read to determine the governing contractual provisions.
3. The commissioner shall not approve any proposed disclosure submitted to him pursuant to this section which does not comply with the requirements of this section and the applicable regulations.
4. The insurer shall make available to an employer upon request a copy of the disclosure approved by the commissioner pursuant to this section for each policy of health insurance coverage for which that employer may be eligible.
Sec. 90 NRS 689B.033 is hereby amended to read as follows:
689B.0331. All group health insurance policies providing coverage on an expense-incurred basis and all employee welfare plans providing medical, surgical or hospital care or benefits established or maintained for employees or their families or dependents, or for both, must as to the family members' coverage provide that the health benefits applicable for children are payable with respect to:
(a) A newly born child of the insured from the moment of birth;
(b) An adopted child from the date the adoption becomes effective, if the child was not placed in the home before adoption; and
(c) A child placed with the insured for the purpose of adoption from the moment of placement as certified by the public or private agency making the placement. The coverage of such a child ceases if the adoption proceedings are terminated as certified by the public or private agency making the placement.
The policies must provide the coverage specified in subsection 3 and must not exclude premature births.
2. The policy or contract may require that notification of:
(a) The birth of a newly born child;
(b) The effective date of adoption of a child; or
(c) The date of placement of a child for adoption,
and payments of the required premium or fees, if any, must be furnished to the insurer or welfare plan within 31 days after the date of birth, adoption or placement for adoption in order to have the coverage continue beyond the 31-day period.
3. The coverage for newly born and adopted children and children placed for adoption consists of coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities and, within the limits of the policy, necessary transportation costs from place of birth to the nearest specialized treatment center under major medical policies, and with respect to basic policies to the extent such costs are charged by the treatment center.
4. An insurer shall not restrict the coverage of a dependent child adopted or placed for adoption solely because of a preexisting condition the child has at the time he would otherwise become eligible for coverage pursuant to the group health policy. Any provision relating to an exclusion for a preexisting condition must comply with section 78 of this act.
Sec. 91 NRS 689B.170 is hereby amended to read as follows:
689B.1701. A converted policy must not exclude a preexisting condition not excluded by the group policy, but a converted policy may provide that any hospital, surgical or medical benefits payable under it may be reduced by the amount of any benefits payable under the group policy after its termination. A converted policy may provide that during the first policy year the benefits payable under it, together with the benefits payable under the group policy, must not exceed those that would have been payable if the policyholder's insurance under the group policy had remained in effect.
2. Any exclusion for a preexisting condition provided by a converted policy must comply with section 78 of this act.
Sec. 92 NRS 689B.245 is hereby amended to read as follows:
689B.2451. If an employer who employs less than 20 employees maintains a policy of group health insurance which covers those employees, the policy must contain a provision which permits:
(a) An employee to elect to continue identical coverage under the policy, excluding coverage provided for eye or dental care, if:
(1) His employment is terminated for any reason other than gross misconduct; or
(2) The number of his working hours is reduced so that he ceases to be eligible for coverage.
(b) The spouse or dependent child of an employee to elect to continue coverage, excluding coverage provided for eye or dental care, if:
(1) The employee's employment is terminated for any reason other than gross misconduct or the number of his working hours is reduced so that he ceases to be eligible for coverage;
(2) The employee dies;
(3) The employee and his spouse are divorced or legally separated;
(4) The dependent child ceases to be eligible for coverage under the terms of the policy; or
(5) The spouse ceases to be eligible for coverage after becoming eligible for Medicare.
2. The period of continued coverage is limited to:
(a) Eighteen months for an employee.
(b) Thirty-six months for an employee's spouse or dependent child.
3. An employee who voluntarily leaves his employment, or the spouse or dependent child of that employee, is not eligible to continue coverage pursuant to this section.
4. An employee, spouse or dependent child who has not been covered under any group policy of the employer for at least 12 consecutive months before the termination of his coverage is not eligible to continue coverage pursuant to this section.
5. A provision for continued coverage must include coverage for any child born to, legally adopted by or placed for adoption with the employee during the period of continued coverage. Such a child is eligible for continued coverage only to the end of the period of continued coverage as established pursuant to subsection 2.
Sec. 93 Chapter 689C of NRS is hereby amended by adding thereto the provisions set forth as sections 94 to 182, inclusive, of this act.
Sec. 94 "Affiliated" means any entity or person who directly, or indirectly through one or more intermediaries, controls or is controlled by or is under common control with a specified entity or person.
Sec. 95 "Affiliation period" means a period, not to exceed 60 days for new enrollees and 90 days for late enrollees, during which no premiums may be collected from and coverage issued would not become effective for a small employer or an eligible employee or his dependent, if the affiliation period is applied uniformly and without regard to any health status-related factors.
Sec. 96 "Basic health benefit plan" means the basic health benefit plan developed pursuant to sections 145 to 182, inclusive, of this act.
Sec. 96.5. "Bona fide association" has the meaning ascribed to it in section 4.5 of this act.
Sec. 97 "Control" has the meaning ascribed to it in NRS 692C.050.
Sec. 98 "Converted policy" means a basic or standard health benefit plan issued in accordance with sections 145 to 182, inclusive, of this act.
Sec. 99 "Creditable coverage" means health benefits or coverage provided to a person pursuant to:
1. A group health plan;
2. A health benefit plan;
3. Part A or Part B of Title XVIII of the Social Security Act, also known as Medicare;
4. Title XIX of the Social Security Act, also known as Medicaid, other than coverage consisting solely of benefits under section 1928 of that Title;
5. Chapter 55 of Title 10, United States Code (Civilian Health and Medical Program of Uniformed Services (CHAMPUS));
6. A medical care program of the Indian Health Service or of a tribal organization;
7. A state health benefit risk pool;
8. A health plan offered pursuant to chapter 89 of Title 5, United States Code (Federal Employees Health Benefits Program (FEHBP));
9. A public health plan as defined in federal regulations authorized by the Public Health Service Act, section 2701(c)(1)(I), as amended by Public Law 104-191; or
10. A health benefit plan under section 5(e) of the Peace Corps Act (22 U.S.C. § 2504(e)).
Sec. 100 "Established geographic service area" means a geographic area, as approved by the commissioner and based on the certificate of authority of the carrier to transact insurance in this state, within which the carrier is authorized to provide coverage.
Sec. 101 "Geographic area" means an area established by the commissioner for use in adjusting the rates for a health benefit plan.
Sec. 102 1. "Group health plan" means an employee welfare benefit plan, as defined in section 3(1) of the Employee Retirement Income Security Act of 1974, as that section existed on the effective date of this act, to the extent that the plan provides medical care to employees or their dependents as defined under the terms of the plan directly, or through insurance, reimbursement or otherwise.
2. The term does not include:
(a) Coverage that is only for accident or disability income insurance, or any combination thereof;
(b) Coverage issued as a supplement to liability insurance;
(c) Liability insurance, including general liability insurance and automobile liability insurance;
(d) Workers' compensation or similar insurance;
(e) Coverage for medical payments under a policy of automobile insurance;
(f) Credit insurance;
(g) Coverage for on-site medical clinics; and
(h) Other similar insurance coverage specified in federal regulations adopted pursuant to Public Law 104-191 under which benefits for medical care are secondary or incidental to other insurance benefits.
3. The term does not include the following benefits if the benefits are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of a health benefit plan:
(a) Limited-scope dental or vision benefits;
(b) Benefits for long-term care, nursing home care, home health care or community-based care, or any combination thereof; and
(c) Such other similar benefits as are specified in federal regulations adopted pursuant to Public Law 104-191.
4. The term does not include the following benefits if the benefits are provided under a separate policy, certificate or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and such benefits are paid for a claim without regard to whether benefits are provided for such a claim under any group health plan maintained by the same plan sponsor:
(a) Coverage that is only for a specified disease or illness; and
(b) Hospital indemnity or other fixed indemnity insurance.
5. The term does not include any of the following, if offered as a separate policy, certificate or contract of insurance:
(a) Medicare supplemental health insurance as defined in section 1882(g)(1) of the Social Security Act, as that section existed on the effective date of this act;
(b) Coverage supplemental to the coverage provided pursuant to chapter 55 of Title 10, United States Code (Civilian Health and Medical Program of Uniformed Services (CHAMPUS)); and
(c) Similar supplemental coverage provided under a group health plan.
Sec. 103 "Health status-related factor" means, with regard to a person who is or seeks to be insured:
1. Health status;
2. Any medical conditions, including physical or mental illness, or both;
3. Claims experience;
4. Receipt of health care;
5. Medical history;
6. Genetic information;
7. Evidence of insurability, including conditions arising out of acts of domestic violence; and
8. Disability.
Sec. 104 (Deleted by amendment.)
Sec. 105 "Network plan" means a health benefit plan offered by a health carrier under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the carrier. The term does not include an arrangement for the financing of premiums.
Sec. 106 "Open enrollment" means the period designated for enrollment in a health benefit plan.
Sec. 107 "Plan for coverage of a bona fide association" has the meaning ascribed to it in section 22 of this act.
Sec. 108 "Plan sponsor" has the meaning ascribed to it in section 3(16)(B) of the Employee Retirement Income Security Act of 1974, as that section existed on the effective date of this act.
Sec. 109 "Preexisting condition" means a condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received during the 6 months immediately preceding the effective date of the new coverage. The term does not include genetic information in the absence of a diagnosis of the condition related to such information.
Sec. 110 (Deleted by amendment.)
Sec. 111 "Producer" means an agent or broker licensed pursuant to this Title.
Sec. 112 (Deleted by amendment.)
Sec. 113 "Program of reinsurance" means the program of reinsurance for small employers and eligible persons established pursuant to section 159 of this act.
Sec. 114 "Risk-assuming carrier" means a small employer carrier that has elected to act as a risk-assuming carrier.
Sec. 115 "Standard health benefit plan" means a standard health benefit plan developed pursuant to sections 145 to 182, inclusive, of this act.
Sec. 116 "Waiting period" means the period established by a plan of health insurance that must pass before a person who is an eligible participant or beneficiary in a plan is covered for benefits under the terms of the plan.
Sec. 117 1. For the purposes of this chapter, and except as otherwise provided in subsection 2, two or more carriers which are affiliated companies or which are eligible to file a consolidated tax return shall be deemed to be one carrier, and any restrictions or limitations imposed by the provisions of this chapter apply as if the health benefit plans delivered or issued for delivery to small employers in this state by such carriers were issued by one carrier.
2. An affiliated carrier that is a health maintenance organization having a certificate of authority issued pursuant to the provisions of chapter 695C of NRS may be considered a separate carrier for the purposes of this chapter.
3. Unless otherwise authorized by the commissioner, a carrier shall not enter into any ceding arrangement with respect to a health benefit plan delivered or issued for delivery to a small employer in this state if, as a result of the ceding arrangement, the ceding carrier retains less than 30 percent of the insurance obligation or risk for that health benefit plan.
Sec. 118 For the purposes of this chapter:
1. Any plan, fund or program which would not be, but for section 2721(e) of the Public Health Service Act, as amended by Public Law 104-191, as that section existed on the effective date of this act, an employee welfare benefit plan and which is established or maintained by a partnership to the extent that the plan, fund or program provides medical care to current or former partners in a partnership, or to their dependents, as defined under the terms of the plan, fund or program, directly, or through insurance, reimbursement or otherwise, must be treated, subject to the provisions of subsection 2, as an employee welfare benefit plan that is a group health plan.
2. In the case of a group health plan, a partnership shall be deemed to be the employer of each partner.
Sec. 119 For the purposes of providing coverage under a health benefit plan pursuant to the provisions of this chapter, a producer may only market association memberships to small employers and eligible employees, accept applications for such membership or sign up such members in a bona fide association if the small employers and eligible employees being marketed are actively engaged in, or directly related to, the bona fide association.
Sec. 120 1. If an employer was not in existence throughout the entire preceding calendar year, the determination of whether the employer is a small or large employer must be based on the average number of employees reasonably expected to be employed on business days in the current calendar year.
2. Except as otherwise provided by specific statute, the provisions of this chapter that apply to a small employer at the time that a carrier issues a health benefit plan to the small employer pursuant to the provisions of this chapter continue to apply at least until the plan anniversary following the date on which the small employer no longer meets the requirements of being a small employer.
Sec. 121 1. As a condition of transacting business in this state with small employers, a carrier shall actively market to a small employer each health benefit plan which is actively marketed in this state by the carrier to any small employer in this state. The health insurance plans marketed pursuant to this section by the carrier must include, without limitation, a basic health benefit plan and a standard health benefit plan. A carrier shall be deemed to be actively marketing a health benefit plan when it makes available any of its plans to a small employer that is not currently receiving coverage under a health benefit plan issued by that carrier.
2. A carrier shall issue to a small employer any health benefit plan marketed in accordance with this section if the eligible small employer applies for the plan and agrees to make the required premium payments and satisfy the other reasonable provisions of the health benefit plan that are not inconsistent with NRS 689C.015 to 689C.350, inclusive, and sections 94 to 143, inclusive, and 145 to 182, inclusive, of this act, except that a carrier is not required to issue a health benefit plan to a self-employed person who is covered by, or is eligible for coverage under, a health benefit plan offered by another employer.
Sec. 122 1. Each carrier shall file with the commissioner, in a format and manner prescribed by the commissioner, the basic health benefit plans and the standard health benefit plans to be offered by the carrier. A health benefit plan filed pursuant to this section may not be offered by a carrier until the earlier of:
(a) The date of approval by the commissioner; or
(b) Thirty days after the date on which the plans are filed, unless the commissioner disapproves the use of the plans before the 30-day period expires.
2. The commissioner may, at any time, after providing notice and an opportunity for a hearing, disapprove the continued use of a basic or standard health benefit plan by a carrier on the ground that the plan does not meet the requirements of NRS 689C.015 to 689C.350, inclusive, and sections 94 to 143, inclusive, and 145 to 182, inclusive, of this act.
Sec. 123 1. A carrier is not required to provide coverage to small employers pursuant to section 121 of this act:
(a) During any period in which the commissioner determines that requiring the carrier to provide such coverage would place the carrier in a financially impaired condition.
(b) If the carrier elects not to offer any new coverage to any small employers in this state. A carrier that elects not to offer new coverage in accordance with this paragraph may maintain its existing policies issued to small employers in this state, subject to the requirements of NRS 689C.310 and 689C.320.
2. A carrier that elects not to offer new coverage pursuant to paragraph (b) of subsection 1 shall notify the commissioner forthwith of that election and shall not thereafter write any new business to small employers in this state for 5 years after the date of the notification.
Sec. 124 Except as otherwise provided in NRS 689C.170 and 689C.180, a carrier shall not modify a health benefit plan with respect to a small employer or any eligible employee or dependent of an eligible employee, through riders or endorsements, or otherwise, to restrict or exclude coverage or benefits for specific diseases, medical conditions or services otherwise covered by the plan.
Sec. 125 A carrier that offers coverage through a network plan is not required to offer coverage to or accept any applications for coverage from the eligible employees of a small employer pursuant to NRS 689C.310 and 689C.320 if:
1. The eligible employees do not reside or work in the established geographic service area of the network plan.
2. For a small employer whose eligible employees reside or work in the established geographic service area of the network plan, the carrier demonstrates to the satisfaction of the commissioner that the carrier does not have the capacity to deliver adequate service to additional small employers and eligible employees because of the existing obligations of the carrier. If a carrier is authorized by the commissioner not to offer coverage pursuant to this subsection, the carrier shall not thereafter offer coverage to additional small employers and eligible employees within that established geographic service area until the carrier demonstrates to the satisfaction of the commissioner that it has regained the capacity to deliver adequate service to additional small employers and eligible employees within that service area.
Sec. 126 The provisions of sections 121 and 122 of this act and NRS 689C.190 do not apply to health benefit plans offered by a carrier if the carrier makes the health benefit plan available in the small employer market only through a bona fide association.
Sec. 127 A health benefit plan and a carrier offering such a plan shall permit an employee or a dependent of an employee covered by the health benefit plan who is eligible, but not enrolled, for coverage in connection with the health benefit plan to enroll for coverage under the terms of the health benefit plan if:
1. The employee or dependent was covered under a different health benefit plan or had other health insurance coverage at the time coverage was previously offered to the employee or dependent;
2. The employee stated in writing at that time that the other coverage was the reason for declining enrollment, but only if the plan sponsor or carrier required such a written statement and informed the employee of that requirement and the consequences of the requirement; and
3. The employee or his dependent:
(a) Was covered under any provision of the Consolidated Omnibus Budget Reconciliation Act of 1985 relating to the continuation of coverage and such continuation of coverage was exhausted; or
(b) Was not covered under such a provision and his insurance coverage was lost as a result of cessation of contributions by his employer, termination of employment or eligibility, reduction in the number of hours of employment, or the death of, or divorce or legal separation from, a covered spouse.
Sec. 128 1. A health benefit plan and a carrier of such a plan that makes coverage available to the dependent of a covered employee shall permit the employee to enroll a dependent after the close of a period of open enrollment if:
(a) The employee is a participant in the health benefit plan, or has met any waiting period applicable to becoming a participant and is eligible to be enrolled under the plan, except for a failure to enroll during a previous period of open enrollment; and
(b) The person to be enrolled became a dependent of the employee through marriage, birth, adoption or placement for adoption.
2. The health benefit plan or carrier shall provide a period of special enrollment for the enrollment of a dependent of an employee pursuant to this section. Such a period must be not less than 30 days and must begin on:
(a) The date specified by the health benefit plan or carrier for the period of special enrollment; or
(b) The date of the marriage, birth, adoption or placement for adoption, as appropriate.
3. If an employee seeks to enroll a dependent during the first 30 days of the period for special enrollment provided pursuant to subsection 2, the coverage of the dependent becomes effective:
(a) In the case of a marriage, not later than the first day of the first month beginning after the date on which the completed request for enrollment is received;
(b) In the case of a birth, on the date of the birth; and
(c) In the case of an adoption or placement for adoption, on the date of the adoption or the placement for adoption.
4. In the case of a birth, an adoption or a placement for adoption of a child of an employee, the spouse of the employee may be enrolled as a dependent pursuant to this section if the spouse is otherwise eligible for coverage under the health benefit plan.
Sec. 129 1. Within 30 days after the date on which a plan of operation is approved by the commissioner pursuant to section 163 of this act, or for a new carrier within 30 days after the date on which it enters the small employer market, each carrier shall elect to operate as either a risk-assuming carrier or a reinsuring carrier and shall notify the commissioner of its election
2. The initial election of a carrier to act as a risk-assuming or reinsuring carrier is effective on the carrier for 2 years after the date on which it notifies the commissioner pursuant to subsection 1. After the initial 2-year period, such an election is effective for 5 years. The commissioner may allow a carrier to modify its election at any time for good cause shown. The commissioner may waive or modify the period during which the election of a carrier to operate as a risk-assuming or reinsuring carrier is effective.
3. A carrier may apply to the commissioner, in a manner prescribed by the commissioner by regulation, to change its status as a risk-assuming or reinsuring carrier.
4. A reinsuring carrier that elects or is subsequently authorized by the commissioner to operate as a risk-assuming carrier:
(a) Shall not continue to reinsure any small employer health benefit plan with the program of reinsurance.
(b) Shall pay a prorated assessment based upon business issued as a reinsuring carrier for any portion of the year that the business was reinsured.
5. As used in this section:
(a) "Plan of operation" means the plan of operation of the program of reinsurance established pursuant to sections 145 to 182, inclusive, of this act.
(b) "Reinsuring carrier" means a carrier participating in the program of reinsurance established pursuant to sections 145 to 182, inclusive, of this act.
Sec. 130 1. The commissioner may suspend the election of a carrier to act as a risk-assuming carrier if the commissioner finds that:
(a) The financial condition of the carrier will no longer support the assumption of risk from issuing coverage to small employers in compliance with section 121 of this act and NRS 689C.190 without the protection afforded by the program of reinsurance;
(b) The carrier has failed to market its health benefit plans fairly to all small employers in this state or in its established geographic service area, as applicable; or
(c) The carrier has failed to provide coverage to eligible small employers as required pursuant to section 121 of this act and NRS 689C.190.
2. A carrier that elects to be a risk-assuming carrier is subject to:
(a) The provisions of sections 121 of this act, relating to the availability of coverage; and
(b) The provisions of NRS 689C.260, relating to classes of businesses.
Sec. 131 1. Except as otherwise provided in this section, a carrier or a producer shall not, directly or indirectly:
(a) Encourage or direct a small employer to refrain from filing an application for coverage with the carrier because of the health status, claims experience, industry, occupation or geographic location of the small employer.
(b) Encourage or direct a small employer to seek coverage from another carrier because of the health status, claims experience, industry, occupation or geographic location of the small employer.
2. The provisions of subsection 1 do not apply to information provided to a small employer by a carrier or a producer relating to the established geographic service area or a provision for a restricted network of the carrier.
3. Except as otherwise provided in this subsection, a carrier shall not, directly or indirectly, enter into any contract, agreement or arrangement with a producer if the contract, agreement or arrangement provides for or results in a variation to the compensation that is paid to a producer for the sale of a health benefit plan because of the health status, claims experience, industry, occupation or geographic location of the small employer at the time that the health benefit plan is issued to or renewed by the small employer. The provisions of this subsection do not apply to any arrangement for compensation that provides payment to a producer on the basis of percentage of premium, except that the percentage may not vary because of the health status, claims experience, industry, occupation or geographic area of the small employer.
4. A carrier shall not terminate, fail to renew, or limit its contract or agreement of representation with a producer for any reason related to the health status, claims experience, occupation or geographic location of a small employer at the time that the health benefit plan is issued to or renewed by the small employer placed by the producer with the carrier.
5. A carrier or producer shall not induce or otherwise encourage a small employer to separate or otherwise exclude an employee or a dependent of the employee from health coverage or benefits provided in connection with the employment of the employee.
6. A violation of any provision of this section by a carrier may constitute an unfair trade practice for the purposes of chapter 686A of NRS.
7. The provisions of this section apply to a third-party administrator if the third-party administrator enters into a contract, agreement or other arrangement with a carrier to provide administrative, marketing or other services related to the offering of a health benefit plan to small employers in this state.
8. Nothing in this section interferes with the right and responsibility of a broker to advise and represent the best interests of a small employer who is seeking health insurance coverage from a small employer carrier.
Sec. 132 1. A denial by a carrier of an application for coverage from a small employer must be in writing and must state the reason for the denial.
2. The commissioner may adopt regulations that set forth standards to provide for the fair marketing and broad availability of health benefit plans to small employers in this state.
Sec. 133 The commissioner may adopt regulations to require a carrier, as a condition of transacting insurance with small employers in this state after the effective date of this act, to reissue a health benefit plan to any small employer whose health benefit plan has been terminated or not renewed by the carrier after July 1, 1997. The commissioner may prescribe such terms for the reissue of coverage as he finds are reasonable and necessary to provide continuity of coverage to small employers.
Sec. 134 1. Except as otherwise provided in this subsection, a health benefit plan issued pursuant to this chapter that includes coverage for maternity care and pediatric care for newborn infants may not restrict benefits for any length of stay in a hospital in connection with childbirth for a mother or newborn infant covered by the plan to:
(a) Less than 48 hours after a normal vaginal delivery; and
(b) Less than 96 hours after a cesarean section.
2. Nothing in this section requires a mother to:
(a) Deliver her baby in a hospital; or
(b) Stay in a hospital for a fixed period following the birth of her child.
The provisions of this subsection do not apply to any health benefit plan in any case in which the decision to discharge the mother or newborn infant before the expiration of the minimum period set forth in this subsection is made by the attending physician of the mother or newborn infant.
3. A health benefit plan that offers coverage for maternity care and pediatric care of newborn infants may not:
(a) Deny a mother or her newborn infant coverage or continued coverage under the terms of the plan if the sole purpose of the denial of coverage or continued coverage is to avoid the requirements of this section;
(b) Provide monetary payments or rebates to a mother to encourage her to accept less than the minimum protection available pursuant to this section;
(c) Penalize, or otherwise reduce or limit, the reimbursement of an attending provider of health care because he provided care to a mother or newborn infant in accordance with the provisions of this section;
(d) Provide incentives of any kind to an attending physician to induce him to provide care to a mother or newborn infant in a manner that is inconsistent with the provisions of this section; or
(e) Except as otherwise provided in subsection 4, restrict benefits for any portion of a hospital stay required pursuant to the provisions of this section in a manner that is less favorable than the benefits provided for any preceding portion of that stay.
4. Nothing in this section:
(a) Prohibits a health benefit plan or carrier from imposing a deductible, coinsurance or other mechanism for sharing costs relating to benefits for hospital stays in connection with childbirth for a mother or newborn child covered by the plan, except that such coinsurance or other mechanism for sharing costs for any portion of a hospital stay required by this section may not be greater than the coinsurance or other mechanism for any preceding portion of that stay.
(b) Prohibits an arrangement for payment between a health benefit plan or carrier and a provider of health care that uses capitation or other financial incentives, if the arrangement is designed to provide services efficiently and consistently in the best interest of the mother and her newborn infant.
(c) Prevents a health benefit plan or carrier from negotiating with a provider of health care concerning the level and type of reimbursement to be provided in accordance with this section.
Sec. 135 1. A carrier shall not place any restriction on a small employer or an eligible employee or his dependent as a condition of being a participant in or a beneficiary of a health benefit plan that is inconsistent with NRS 689C.015 to 689C.350, inclusive, and sections 94 to 143, inclusive, of this act.
2. A carrier that offers health insurance coverage to small employers pursuant to this chapter shall not establish rules of eligibility, including, but not limited to, rules which define applicable waiting periods, for the initial or continued enrollment under a health benefit plan offered by the carrier that are based on the following factors relating to the eligible employee or his dependent:
(a) Health status.
(b) Medical condition, including physical and mental illnesses, or both.
(c) Claims experience.
(d) Receipt of health care.
(e) Medical history.
(f) Genetic information.
(g) Evidence of insurability, including conditions which arise out of acts of domestic violence.
(h) Disability.
3. Except as otherwise provided in NRS 689C.190, the provisions of subsection 1 do not:
(a) Require a carrier to provide particular benefits other than those that would otherwise be provided under the terms of the health benefit plan or coverage; or
(b) Prevent a carrier from establishing limitations or restrictions on the amount, level, extent or nature of the benefits or coverage for similarly situated persons.
4. As a condition of enrollment or continued enrollment under a health benefit plan, a carrier shall not require any person to pay a premium or contribution that is greater than the premium or contribution for a similarly situated person covered by similar coverage on the basis of any factor described in subsection 2 in relation to the person or his dependent.
5. Nothing in this section:
(a) Restricts the amount that a small employer may be charged for coverage by a carrier;
(b) Prevents a carrier from establishing premium discounts or rebates or from modifying otherwise applicable copayments or deductibles in return for adherence by the insured person to programs of health promotion and disease prevention; or
(c) Precludes a carrier from establishing rules relating to employer contribution or group participation when offering health insurance coverage to small employers in this state.
6. As used in this section:
(a) "Contribution" means the minimum employer contribution toward the premium for enrollment of participants and beneficiaries in a health benefit plan.
(b) "Group participation" means the minimum number of participants or beneficiaries that must be enrolled in a health benefit plan in relation to a specified percentage or number of eligible persons or employees of the employer.
Sec. 136 1. In determining the applicable creditable coverage of a person for the purposes of NRS 689C.190, a period of creditable coverage must not be included if, after the expiration of that period but before the enrollment date, there was a 63-day period during all of which the person was not covered under any creditable coverage. To establish a period of creditable coverage, an eligible employee must present any certificates of coverage provided to him in accordance with section 137 of this act and such other evidence of coverage as required by regulations adopted by the commissioner. For the purposes of this subsection, any waiting period for coverage or an affiliation period must not be considered in determining the applicable period of creditable coverage.
2. In determining the period of creditable coverage of a person for the purposes of NRS 689C.190, a carrier shall include each applicable period of creditable coverage without regard to the specific benefits covered during that period, except that the carrier may elect to include applicable periods of creditable coverage based on coverage of specific benefits as specified by the United States Department of Health and Human Services by regulation, if such an election is made on a uniform basis for all participants and beneficiaries of the health benefit plan or coverage. Pursuant to such an election, the carrier shall include each applicable period of creditable coverage with respect to any class or category of benefits if any level of benefits is covered within that class or category, as specified by those regulations.
3. Regardless of whether coverage is actually provided, if a carrier elects in accordance with subsection 2 to determine creditable coverage based on specified benefits, a statement that such an election has been made and a description of the effect of the election must be:
(a) Included prominently in any disclosure statement concerning the health benefit plan; and
(b) Provided to each eligible employee at the time of enrollment in the health benefit plan.
Sec. 137 1. For the purposes of determining the period of creditable coverage of a person accumulated under a health benefit plan or group health insurance, the insurer shall provide written certification of coverage on a form prescribed by the commissioner to the person which certifies the length of:
(a) The period of creditable coverage that the person accumulated under the plan and any coverage under any provision of the Consolidated Omnibus Budget Reconciliation Act of 1985, as that act existed on the effective date of this act, relating to the continuation of coverage; and
(b) Any waiting and affiliation period imposed on the person pursuant to that coverage.
2. The certification of coverage must be provided to the person who was insured:
(a) At the time that he ceases to be covered under the plan, if he does not otherwise become covered under any provision of the Consolidated Omnibus Budget Reconciliation Act of 1985, as that act existed on the effective date of this act, relating to the continuation of coverage;
(b) If he becomes covered under such a provision, at the time that he ceases to be covered by that provision; and
(c) Upon request, if the request is made not later than 24 months after the date on which he ceased to be covered as described in paragraphs (a) and (b).
Sec. 138 A carrier may modify the health insurance coverage for a product offered to small employers pursuant to a group health plan if, for coverage that is available in that market other than through one or more bona fide associations, the modification is consistent with the provisions of this Title and is effective on a uniform basis among such group health plans.
Sec. 139 1. An employee welfare benefit plan for providing benefits for employees of more than one employer under which health insurance coverage is provided to small employers must comply with the provisions of this chapter and with NRS 679B.139 and the regulations adopted by the commissioner pursuant thereto.
2. As used in this section, the term "employee welfare benefit plan for providing benefits for employees of more than one employer" is intended to be equivalent to the term "employee welfare benefit plan which is a multiple employer welfare arrangement" as used in federal statutes and regulations.
Sec. 140 1. An employee, spouse or dependent child shall notify the employer that he is eligible to continue his coverage pursuant to NRS 689C.340 not later than 60 days after he becomes eligible to do so.
2. The employer shall, within 14 days after receipt of notification pursuant to subsection 1, provide adequate information to the employee, spouse or dependent child regarding the election to continue coverage and the premium required to be paid.
3. If the employee, spouse or dependent child elects to continue coverage, he shall notify the insurer of his election and pay to the insurer the premium required by section 141 of this act within 60 days after receipt of the information provided pursuant to subsection 2.
Sec. 141 1. Any person who elects to continue coverage pursuant to NRS 689C.340 shall pay a premium for that coverage in an amount not to exceed 125 percent of the premium charged to the employer by the insurer for coverage of that person on the date on which that person became eligible for continued coverage.
2. If there is a change in the rate charged or benefits provided under the policy during the time of continued coverage, the premium may not exceed 125 percent of the new rate charged to the employer.
3. The premiums must be paid to the insurer on a quarterly basis.
4. If the payment of a premium is not received by the insurer within 30 days after the date on which it is due, continued coverage must be terminated.
Sec. 142 If an employer changes his insurer during the period of a person's continued coverage, the new insurer shall provide continued coverage for that person for the remainder of the continuation period in accordance with the provisions of section 141 of this act.
Sec. 143 Continued coverage pursuant to NRS 689C.340 ceases before the end of the period provided in that section if:
1. The employer discontinues group health insurance for his employees;
2. The employee, spouse or dependent child fails to pay the required premiums;
3. The employee, spouse or dependent child becomes covered under any other policy of group health insurance;
4. The employee or spouse qualifies for Medicare; or
5. The spouse remarries and becomes eligible for coverage under a policy of group health insurance of the new spouse.
Sec. 144 A voluntary purchasing group and any contract issued to such a group pursuant to NRS 689C.360 to 689C.600, inclusive, and this section are subject to the provisions of NRS 689C.015 to 689C.350, inclusive, and sections 94 to 143, inclusive, of this act, to the extent applicable and not in conflict with the express provisions of NRS 689C.360 to 689C.600, inclusive, and this section.
Sec. 145 As used in sections 145 to 182, inclusive, of this act, unless the context otherwise requires, the words and terms defined in sections 146 to 158, inclusive, of this act have the meanings ascribed to them in those sections.
Sec. 146 "Board" means the board of directors of the program of reinsurance established pursuant to section 160 of this act.
Sec. 147 "Church plan" has the meaning ascribed to it in section 3(33) of the Employee Retirement Income Security Act of 1974, as that section existed on the effective date of this act.
Sec. 148 "Committee" means the committee on health benefit plans that is created pursuant to section 179 of this act.
Sec. 149 "Eligible person" has the meaning ascribed to it in section 10 of this act.
Sec. 150 "Individual carrier" means any entity subject to the provisions of this Title and the regulations adopted pursuant thereto, that contracts or offers to contract to provide for, deliver payment for, arrange for payment of, pay for, or reimburse any cost of health care services, including a sickness and accident health service corporation, and any other entity providing a plan of health insurance, health benefits or health services to individuals and their dependents in this state.
Sec. 151 "Individual health benefit plan" means:
1. A health benefit plan, other than a converted policy or a plan for coverage of a bona fide association, for individuals and their dependents; and
2. A certificate issued to an individual that evidences coverage under a policy or contract issued to a trust, an association or other similar group of persons, other than a plan for coverage of a bona fide association, regardless of the situs of delivery of the policy or contract, if the eligible person pays the premium and is not being covered under the policy or contract pursuant to any provision for the continuation of benefits applicable under federal or state law.
Sec. 152 "Individual reinsuring carrier" means an individual carrier that has elected to reinsure eligible persons in the program of reinsurance.
Sec. 153 "Individual risk-assuming carrier" means an individual carrier that has elected to act as a risk-assuming carrier.
Sec. 154 "Plan of operation" means the plan of operation of the program of reinsurance.
Sec. 155 (Deleted by amendment.)
Sec. 156 "Program of reinsurance" means the program of reinsurance for small employers and eligible persons created pursuant to section 159 of this act.
Sec. 157 "Reinsuring carrier" means a small employer carrier participating in the program of reinsurance.
Sec. 158 "Risk-assuming carrier" means a small employer carrier that has elected to act as a risk-assuming carrier.
Sec. 159 There is hereby created a nonprofit entity to be known as the program of reinsurance for small employers and eligible persons.
Sec. 160 1. The board of directors of the program of reinsurance is hereby created. The board consists of:
(a) Eight members to be appointed by the commissioner as follows:
(1) Six persons who represent carriers that provide health insurance coverage to small employers pursuant to the provisions of this chapter or to individuals pursuant to chapter 689A of NRS, or to both small employers and individuals; and
(2) Two persons who represent small employers and eligible persons; and
(b) The commissioner, or his designated representative, who is an ex officio, nonvoting member of the board.
2. Members of the board serve without compensation except that while engaged in the business of the board, each member is entitled to receive the per diem allowance or travel expenses provided for state officers and employees generally, to be paid from the proceeds of the assessments received by the program of reinsurance as an administrative expense of the program of reinsurance.
3. After the initial term, the term of each appointed member is 3 years. Members may be reappointed. A member may be removed from the board by the commissioner for good cause shown.
4. At the expiration of the term of a member of the board, or if the member resigns or is otherwise unable to complete his term, the commissioner shall appoint a replacement not later than 30 days after the vacancy occurs. All vacancies on the board must be filled in the same manner of appointment as the member who created the vacancy.
Sec. 161 (Deleted by amendment.)
Sec. 162 1. The board shall meet:
(a) Until a plan of operation, other than a temporary plan of operation, has been approved by the commissioner, twice a year;
(b) Once a plan of operation has been so approved, once a year; and
(c) At such other times as the commissioner deems necessary.
2. The board shall elect from its membership a chairman who shall serve for a term of 2 years. Any vacancy occurring in this position must be filled by election of the members of the board for the remainder of the unexpired term.
Sec. 163 1. Not later than 120 days after the initial appointment of the board, the board shall submit to the commissioner a plan of operation that ensures the fair, reasonable and equitable administration of the program of reinsurance. Once a plan of operation has been approved by the commissioner, the board may amend the plan of operation as needed, subject to the approval of the commissioner.
2. The commissioner shall, after notice and a hearing, approve a plan of operation and any amendment to the plan of operation submitted for his approval if he determines that the plan or amendment is suitable to:
(a) Ensure the fair, reasonable and equitable administration of the program of reinsurance; and
(b) Provide for the sharing of the gains and losses of the program of reinsurance on an equitable basis in accordance with the provisions of sections 145 to 182, inclusive, of this act.
3. If the board fails to submit a suitable plan of operation within 120 days after its appointment or if the commissioner determines in accordance with subsection 2 that the plan of operation as submitted is not suitable, the commissioner may, after notice and a hearing, adopt and carry out a temporary plan of operation which is effective only until the approval of a plan of operation submitted by the board.
4. Before approving a plan of operation submitted by the board, the commissioner may amend the plan if he determines that such an amendment is necessary to ensure that the plan is suitable pursuant to subsection 2.
5. A plan of operation becomes effective upon the written approval of the commissioner.
Sec. 164 A plan of operation and a temporary plan of operation must:
1. Establish procedures for the handling and accounting of the assets of the program of reinsurance and for an annual fiscal reporting to the commissioner.
2. Establish procedures for selecting an administering carrier and set forth the powers and duties of the administering carrier.
3. Establish procedures for reinsuring risks pursuant to the program of reinsurance.
4. Establish procedures for collecting assessments to pay claims and administrative expenses incurred or estimated to be incurred by the program of reinsurance.
5. Establish a methodology for applying the minimum amount of claims and the maximum liability of the reinsuring or individual reinsuring carrier as set forth in section 166 of this act.
6. Provide for any additional matters necessary to carry out and administer the program of reinsurance.
Sec. 165 Notwithstanding any provision of this Title to the contrary, the program of reinsurance shall be deemed to have the general powers and authority granted under the laws of this state to insurance companies and health maintenance organizations licensed to transact business in this state, except that the program of reinsurance shall not issue any health benefit plans directly to small employers or individuals, or both. The program of reinsurance may:
1. With the approval of the commissioner, enter into such contracts as are necessary to carry out the provisions of this chapter and sections 2 to 57, inclusive, of this act, including entering into contracts with similar programs of reinsurance of other states for the joint performance of common functions, or with persons or other organizations for the performance of administrative functions, relating to programs of reinsurance.
2. Take any legal action necessary or proper to recover assessments and penalties for or on behalf of the program of reinsurance, or to avoid the payment of improper claims against the program of reinsurance.
3. Sue or be sued by a reinsuring carrier or an individual reinsuring carrier relating to the carrier's participation in the program of reinsurance.
4. Define the health benefit plans for which reinsurance will be provided and issue reinsurance policies, in accordance with the requirements of this chapter and sections 2 to 57, inclusive, of this act.
5. Establish rules, conditions and procedures for reinsuring risks under the program of reinsurance.
6. Establish actuarial functions as appropriate for the operation of the program of reinsurance.
7. Make assessments in accordance with the provisions of sections 170, 171 and 173 of this act and make advance interim assessments as may be reasonable and necessary to pay for any organizational and interim operating expenses. Any interim assessment must be credited as an offset against any assessments due after the close of the fiscal year.
8. Appoint appropriate legal, actuarial and other committees as necessary to provide technical assistance in the operation of the program of reinsurance, design of policies and other similar contract of insurance, and any other function within the authority of the program of reinsurance.
9. Borrow money to effect the purposes of the program of reinsurance. Any note or other evidence of indebtedness of the program of reinsurance not in default shall be deemed to be legal investments for carriers and may be carried as admitted assets.
Sec. 166 1. The program of reinsurance must reinsure:
(a) For a basic or standard health benefit plan, the level of coverage provided; and
(b) For any other plan, up to the level of coverage provided in a basic or standard health benefit plan.
2. A reinsuring carrier may reinsure a small employer within 60 days after the beginning of coverage of the small employer under a health benefit plan, or for an eligible employee or his dependent, within 60 days after the beginning of coverage of the employee or dependent under a health benefit plan. An individual reinsuring carrier may reinsure an eligible person or his dependent within 60 days after the effective date of coverage of the person or dependent under a health benefit plan.
3. The program of reinsurance may not reimburse a reinsuring carrier or an individual reinsuring carrier for a claim of a reinsured eligible employee or eligible person, or a dependent of such an employee or person, as appropriate, until the reinsuring or individual reinsuring carrier has incurred in a calendar year the minimum amount of claims of the eligible employee, eligible person or dependent of benefits covered by the program of reinsurance. After the amount of claims of the eligible employee, eligible person or dependent is equal to or greater than the required minimum amount, the reinsuring or individual reinsuring carrier is liable for 10 percent of the next $50,000 of payments of benefits that are paid during that calendar year and the program of reinsurance must reinsure the remainder of the benefit payments. The total liability of a carrier in a calendar year pursuant to this subsection may not exceed the maximum liability established by the board.
4. For the purposes of subsection 3, the board shall establish:
(a) The minimum amount of claims, which must be in an amount that is equal to or greater than $5,000, that must be incurred before the program of reinsurance will reimburse the reinsuring or individual reinsuring carrier.
(b) The maximum liability of a reinsuring or individual reinsuring carrier, which must be in an amount that is equal to or greater than $10,000.
The board shall annually adjust the minimum amount of claims and the maximum liability of a reinsuring or individual reinsuring carrier to reflect increases in the costs and utilization within the standard market for health benefit plans within this state. Unless the board proposes and the commissioner approves a factor that would provide for a lower adjustment, the adjustments must not be less than the annual change in the component for medical care of the Consumer Price Index for All Urban Consumers of the United States Department of Labor, Bureau of Labor Statistics.
5. A reinsuring carrier that provides health insurance coverage to small employers may terminate reinsurance with the program of reinsurance for a reinsured employee or dependent, and an individual reinsuring carrier may terminate reinsurance with the program of reinsurance for an eligible person or dependent, on the anniversary date of the health benefit plan.
6. The premium rates charged for reinsurance by the program of reinsurance to a health maintenance organization that is federally qualified pursuant to 42 U.S.C. §§ 300 et seq. and is subject to requirements limiting the amount of risk that may be ceded to a program of reinsurance that are more restrictive than the amounts set forth in subsection 5 must be reduced to reflect that portion of the risk above the amount determined pursuant to this section, if any, that may not be ceded to the program of reinsurance.
7. A reinsuring carrier or an individual reinsuring carrier purchasing reinsurance pursuant to this chapter or sections 2 to 57, inclusive, of this act shall apply its techniques for handling managed care and claims, including utilization review, individual case management, preferred provider provisions and other provisions or methods of operating relating to managed care, to the health benefit plans that are being reinsured pursuant to the program of reinsurance in a manner that is consistent with the business of the carrier that is not reinsured.
Sec. 167 1. The plan of operation must include a methodology for determining premium rates to be charged by the program of reinsurance for reinsuring small employers and eligible persons pursuant to sections 145 to 182, inclusive, of this act. The methodology must:
(a) Include a system for the classification of small employers which reflects the types of case characteristics commonly used by carriers that provide health insurance coverage to small employers pursuant to the provisions of this chapter; and
(b) Provide for the development of initial base premium rates for reinsurance to be used pursuant to subsection 2 to determine the premium rates for the program of reinsurance. The board shall establish such base rates, subject to the approval of the commissioner, at levels that reasonably approximate the gross premiums charged to small employers by small employer carriers, to eligible employees and their dependents by small employer carriers, or to eligible persons by individual carriers, as appropriate, for health benefit plans with benefits similar to the standard health benefit plan, as adjusted to reflect the minimum amount of claims and the maximum liability established pursuant to section 166 of this act.
2. Premiums for the program of reinsurance:
(a) For an entire small employer group, must be at a rate that is at least 1 1/2 times the base premium rate established pursuant to subsection 1.
(b) For an eligible employee and his dependent, must be at a rate that is at least five times the base premium rate established pursuant to subsection 1.
(c) For an eligible person, must be at a rate that is at least 1 1/2 times the base premium rate established pursuant to subsection 1.
3. The board shall periodically review the methodology established pursuant to this section, including the system of classification and any rating factors, to ensure that the methodology reasonably reflects the claims experience of the program of reinsurance. The board may, subject to the approval of the commissioner, change the methodology as needed.
4. The board may adjust the factor by which the base premium rate must be multiplied pursuant to this section to determine the premium rates to be charged for the program of reinsurance to reflect the use of effective measures of cost containment and any arrangements for managed care.
Sec. 168 1. If a health benefit plan for a small employer, an eligible employee or an eligible person is entirely or partially reinsured with the program of reinsurance, the premiums charged to the small employer, eligible employee or eligible person for any rating period during which such coverage is entirely or partially reinsured must meet the requirements for premium rates set forth in sections 48 to 52, inclusive, of this act, or as established in accordance with NRS 689C.230, as appropriate.
2. As used in this section, "rating period" means the calendar period for which premium rates established by a carrier subject to this section and section 167 of this act are assumed to be in effect.
Sec. 169 On or before March 1 of each year, the board shall determine, separately account for and report to the commissioner the net loss of the program of reinsurance for the previous calendar year, including administrative expenses and incurred losses for that year. Such a determination and accounting must take into account any investment income and other appropriate gains and losses for reinsured small employers and eligible employees and their dependents and for reinsured eligible persons.
Sec. 170 1. Any net loss from reinsuring small employers and eligible employees and their dependents must be recouped by assessments against reinsuring carriers.
2. As part of the plan of operation, the board shall establish a formula pursuant to which assessments may be made against reinsuring carriers to recover the net loss. The formula must be based on:
(a) The share of each reinsuring carrier of the total premiums earned by all reinsuring carriers during the preceding calendar year from existing health benefit plans delivered or issued for delivery to small employers in this state; and
(b) The share of each reinsuring carrier of the premiums earned by all reinsuring carriers in the preceding calendar year from newly issued health benefit plans delivered or issued for delivery during that year to small employers in this state.
3. An assessment made against a reinsuring carrier pursuant to this section must not be less than 50 percent nor more than 150 percent of an amount equal to the proportion of the total premium earned by the reinsuring carrier during the preceding calendar year from health benefit plans delivered or issued for delivery to small employers in this state to the total premiums earned by all such carriers in the preceding calendar year for such health benefit plans.
4. The board may, with the approval of the commissioner, change the formula for determining assessments against reinsuring carriers established pursuant to this section as necessary. The board may provide that, during any transitional period, the shares of the assessment base attributable to the total premiums and to the premiums of the previous year may vary.
5. Subject to the approval of the commissioner, the board shall adjust the formula for assessing reinsuring carriers that are approved health maintenance organizations which are federally qualified under 42 U.S.C. §§ 300 et seq., to the extent that any restrictions are placed on such reinsuring carriers that are not imposed on other small employer carriers.
6. In determining the amount of net loss pursuant to this section, the board shall include any expenses incurred by the program of reinsurance in providing such reinsurance.
Sec. 171 1. Any net loss from reinsuring individual eligible persons and their dependents must be recouped by assessments against individual reinsuring carriers.
2. As part of the plan of operation, the board shall establish a formula pursuant to which assessments may be made against individual reinsuring carriers to recover the net loss. The formula must be based on:
(a) The share of each individual reinsuring carrier of the total premiums earned by all individual reinsuring carriers during the preceding calendar year from existing health benefit plans delivered or issued for delivery to individuals in this state; and
(b) The share of each individual reinsuring carrier of the premiums earned by all individual reinsuring carriers in the preceding calendar year from newly issued health benefit plans delivered or issued for delivery during that year to individuals in this state.
3. An assessment made against an individual reinsuring carrier pursuant to this section must not be less than 50 percent nor more than 150 percent of an amount equal to the proportion of the total premium earned by the individual reinsuring carrier during the preceding calendar year from health benefit plans delivered or issued for delivery to individuals in this state to the total premiums earned by all such carriers in the preceding calendar year for such health benefit plans.
4. The board may, with the approval of the commissioner, change the formula for determining assessments against individual reinsuring carriers established pursuant to this section as necessary. The board may provide that, during any transitional period, the shares of the assessment base attributable to the total premiums and to the premiums of the previous year may vary.
5. Subject to the approval of the commissioner, the board shall adjust the formula for assessing individual reinsuring carriers that are approved health maintenance organizations which are federally qualified under 42 U.S.C. §§ 300 et seq., to the extent that any restrictions are placed on such individual reinsuring carriers that are not imposed on other individual carriers.
6. In determining the amount of net loss pursuant to this section, the board shall include any expenses incurred by the program of reinsurance in providing such reinsurance.
Sec. 172 1. On or before March 1 of each year, the board shall determine, separately account for and file with the commissioner an estimate of the assessments needed to fund the losses incurred by the program of reinsurance in the previous calendar year for:
(a) Reinsured small employer groups, eligible employees and the dependents of such employees; and
(b) Reinsured eligible persons.
2. If the board determines that the amount of the assessments against reinsuring carriers needed to fund the losses incurred by the program of reinsurance in the previous calendar year will exceed 5 percent of the total premiums earned in the previous calendar year from health benefit plans delivered or issued for delivery in this state by reinsuring carriers and individual reinsuring carriers, the board shall evaluate the operation of the program of reinsurance and report its findings, including any recommendations for changes to the plan of operation, to the commissioner not later than 90 days after the end of the calendar year in which the losses were incurred. The evaluation must include an estimate of future assessments and administrative costs of the program of reinsurance, the appropriateness of the premium charged, the level of retention of insurers under the program of reinsurance and the costs of coverage for small employers. If the board fails to file the report timely with the commissioner, the commissioner may evaluate the operations of the program of reinsurance and make such amendments to the plan of operation as he determines to be necessary to reduce future losses and assessments.
Sec. 173 1. If, in each of 2 consecutive years, the board determines that the amount of the assessment needed exceeds 5 percent of the total premiums earned in the previous calendar year from health benefit plans delivered or issued for delivery to small employers by reinsuring carriers, the program of reinsurance is eligible for additional funding pursuant to this section.
2. If, in each of 2 consecutive years, the board determines that the amount of the assessment needed exceeds 5 percent of the total premiums earned in the previous calendar year from health benefit plans delivered or issued for delivery to individuals by individual reinsuring carriers, the program of reinsurance is eligible for additional funding pursuant to this section.
3. To raise such additional funding, the board shall establish a formula pursuant to which additional assessments may be made on all carriers that offer a health benefit plan or provide stop-loss coverage for a health benefit plan which is an employee-sponsored plan or a plan established pursuant to the Labor-Management Relations Act, 1947, as amended. The total additional assessments on all such carriers combined may not exceed one-half of 1 percent of the total premiums earned from all health benefit plans and stop-loss coverage issued in this state in the previous calendar year.
Sec. 174 1. If the amount of the assessments exceeds the net losses of the program of reinsurance from reinsuring small employers and eligible employees, the excess amount must be retained by the board and used to offset future losses or to reduce the premiums of the reinsuring carriers.
2. If the amount of the assessments exceeds the net losses of the program of reinsurance from reinsuring eligible persons, the excess amount must be retained by the board and used to offset future losses or to reduce the premiums of the individual reinsuring carriers.
3. As used in this section, "future losses" includes reserves for claims that have been incurred, but have not yet been reported.
Sec. 175 1. Each assessment against a reinsuring carrier and individual reinsuring carrier must be determined annually by the board based on annual statements and such other reports deemed relevant by the board and filed by the reinsuring carriers with the board.
2. The plan of operation must provide for the imposition of an interest penalty for late payment of assessments.
3. A reinsuring or individual reinsuring carrier may seek from the commissioner a deferment of any part of an assessment imposed by the board pursuant to section 170 of this act. The commissioner may defer any part of the assessment if he determines that the payment of the assessment would place the carrier in a financially impaired condition. If any amount of an assessment against a carrier is deferred pursuant to this subsection, the amount so deferred must be assessed against the other participating carriers in a manner consistent with section 170 of this act. A carrier receiving a deferment pursuant to this subsection remains liable to the program of reinsurance for the amount deferred and shall not reinsure any small employers, eligible employees or eligible persons with the program of reinsurance until the deferred assessment is paid.
Sec. 175.3. 1. The board shall issue to each insurer paying an assessment under this chapter a certificate of contribution, in a form prescribed by the commissioner, for the amount so paid. All outstanding certificates are of equal dignity and priority without reference to the amounts or dates of issue. A member insurer may show a certificate of contribution as an asset in its financial statement in such form, for such amount, if any, and for such period as the commissioner may approve.
2. A carrier may offset against its liability for premium tax to this state, accrued with respect to business transacted in a calendar year, an amount equal to 20 percent of the amount certified pursuant to subsection 1 in each of the 5 calendar years following the year in which the assessment was paid. If an insurer ceases to transact business, it may offset all uncredited assessments against its liability for premium tax for the year in which it ceases to transact business.
Sec. 175.7. Subject to the approval of the commissioner, the board shall adjust the formula for assessing carriers that are approved health maintenance organizations which are federally qualified under 42 U.S.C. §§ 300 et seq., to the extent that any restrictions are placed on such carriers that are not imposed on other carriers.
Sec. 176 Except as otherwise provided in section 165 of this act, neither participation in the program of reinsurance as a reinsuring carrier or individual reinsuring carrier, the establishment of rates, forms or procedures, nor any other joint or collective action required by sections 145 to 182, inclusive, of this act may be the basis of any legal action, civil liability or penalty against the program of reinsurance or any of the participating reinsuring carriers and individual reinsuring carriers, either jointly or separately.
Sec. 177 As part of the plan of operation, the board shall develop standards that set forth the manner and levels of compensation that may be paid to producers for the sale of basic and standard health benefit plans issued in accordance with the program of reinsurance. In establishing such standards, the board shall consider:
1. The need to ensure the broad availability of coverages;
2. The objectives of the program of reinsurance;
3. The time and effort expended in placing the coverage;
4. The need to provide on-going service to small employers, eligible employees and eligible persons;
5. The level of compensation currently used in the industry; and
6. The overall cost of coverage to small employers, eligible employees and eligible persons selecting such coverage.
Sec. 178 The commissioner may, by regulation, prescribe standards for determining whether a policy issued as a stop-loss policy is a health benefit plan for the purposes of this chapter.
Sec. 179 1. The committee on health benefit plans is hereby created consisting of eight members. The commissioner shall appoint to the committee representatives of carriers, small employers and eligible employees, eligible persons, health care providers, producers and third-party administrators.
2. Members of the committee serve without compensation, but while engaged in the business of the committee, each member is entitled to receive the per diem allowance or travel expenses provided for state officers and employees generally, to be paid from the proceeds of the assessments received by the program of reinsurance as an administrative expense of the program of reinsurance.
3. After the initial term, the term of each appointed member is 3 years. Members may be reappointed. A member may be removed from the committee by the commissioner for good cause shown.
4. At the expiration of the term of a member, or if the member resigns or is otherwise unable to complete his term, the commissioner shall appoint a replacement not later than 30 days after the vacancy occurs.
Sec. 180 1. The committee shall meet:
(a) Until a plan of operation, other than a temporary plan of operation, has been approved by the commissioner, twice a year;
(b) Once a plan of operation has been so approved, once a year; and
(c) At such other times as the commissioner deems necessary.
2. The committee shall elect from its membership a chairman who shall serve for a term of 2 years. Any vacancy occurring in this position must be filled by election of the members of the committee for the remainder of the unexpired term.
3. The committee shall:
(a) Recommend to the board the form and level of coverages to be made available by small employers pursuant to NRS 689C.190 and sections 121, 122 and 123 of this act, and by individual carriers pursuant to sections 48 to 52, inclusive, of this act.
(b) Recommend to the board levels for benefits and cost sharing, exclusions and limitations for a basic health benefit plan and a standard health benefit plan.
(c) Design a basic health benefit plan and a standard health benefit plan that are consistent with the basic method of operation and the benefit plans of health maintenance organizations authorized to transact insurance in this state, including any restrictions imposed by federal law.
4. The basic and standard health benefit plans recommended by the committee may include features for the containment of costs, including:
(a) Utilization review of health care services, including a review of the medical necessity of hospital and physician services;
(b) Case management;
(c) Selective contracting with hospitals, physicians and other providers of health care;
(d) Reasonable benefit differentials applicable to providers that participate and providers that do not participate in arrangements using a provision for a restricted network; and
(e) Other provisions relating to managed care.
5. The committee shall submit its recommendations for a basic and a standard health benefit plan to the commissioner not later than 120 days after the date on which the committee is appointed.
6. As used in this section, "provision for a restricted network" means any provision of a health benefit plan that conditions the payment of benefits, in whole or in part, on the use of health care providers that have entered into a contractual arrangement with the carrier to provide health care services to persons covered by the plan.
Sec. 181 1. At least once every 3 years, the board, in consultation with the committee, shall study and submit a report to the commissioner concerning the effectiveness of sections 145 to 182, inclusive, of this act.
2. The report:
(a) Must analyze the effectiveness of sections 145 to 182, inclusive, of this act in promoting the stability of rates, the availability of products and the affordability of coverage;
(b) May contain recommendations for actions to improve the overall effectiveness, efficiency and fairness of the marketplace for health insurance for small employers and individuals;
(c) Must address the issue of whether carriers and producers are fairly and actively marketing or issuing health benefit plans to small employers in accordance with the provisions of this chapter and to individuals in accordance with sections 2 to 57, inclusive, of this act; and
(d) May contain recommendations for the regulation of the marketplace for health insurance for small employers and individuals and other regulatory standards or actions.
Sec. 182 Notwithstanding any specific statute to the contrary, a statute that requires the coverage of a specific health care service or benefit, or the reimbursement, utilization or inclusion of a specific category of licensed health care practitioner, is not applicable to a basic health benefit plan delivered or issued for delivery to small employers or eligible persons in this state pursuant to this chapter or chapter 689A of NRS.
Sec. 183 NRS 689C.015 is hereby amended to read as follows:
689C.015[As] Except as otherwise provided in this chapter, as used in [NRS 689C.015 to 689C.350, inclusive,] this chapter, unless the context otherwise requires, the words and terms defined in NRS 689C.025 to 689C.095, inclusive, and sections 94 to 116, inclusive, of this act have the meanings ascribed to them in those sections.
Sec. 184 (Deleted by amendment.)
Sec. 185 NRS 689C.075 is hereby amended to read as follows:
689C.0751. "Health benefit plan" means a policy or certificate for hospital or medical expenses, a contract for dental, hospital or medical services, or a health care plan of a health maintenance organization available for use, offered or sold to a small employer. [The term does not include coverage issued as a supplement to liability insurance, workers' compensation or similar insurance, automobile medical payment insurance, accident insurance only policies, credit insurance, plans for dental care, optometric plans, coverage provided as a supplement to Medicare, coverage for long-term care, disability income or specified disease, hospital confinement indemnity, or limited-benefit health insurance if the requirements of NRS 689C.105 are satisfied.] Except as otherwise provided in this section, the term includes short-term and catastrophic health insurance policies, and a policy that pays on a cost-incurred basis.
2. The term does not include:
(a) Coverage that is only for accident or disability income insurance, or any combination thereof;
(b) Coverage issued as a supplement to liability insurance;
(c) Liability insurance, including general liability insurance and automobile liability insurance;
(d) Workers' compensation or similar insurance;
(e) Coverage for medical payments under a policy of automobile insurance;
(f) Credit insurance;
(g) Coverage for on-site medical clinics; and
(h) Other similar insurance coverage specified in federal regulations issued pursuant to Public Law 104-191 under which benefits for medical care are secondary or incidental to other insurance benefits.
3. If the benefits are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of a health benefit plan, the term does not include the following benefits:
(a) Limited-scope dental or vision benefits;
(b) Benefits for long-term care, nursing home care, home health care or community-based care, or any combination thereof; and
(c) Such other similar benefits as are specified in any federal regulations adopted pursuant to Public Law 104-191.
4. If the benefits are provided under a separate policy, certificate or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and such benefits are paid for a claim without regard to whether benefits are provided for such a claim under any group health plan maintained by the same plan sponsor, the term does not include:
(a) Coverage that is only for a specified disease or illness; and
(b) Hospital indemnity or other fixed indemnity insurance.
5. If offered as a separate policy, certificate or contract of insurance, the term does not include:
(a) Medicare supplemental health insurance as defined in section 1882(g)(1) of the Social Security Act, as that section existed on the effective date of this act;
(b) Coverage supplemental to the coverage provided pursuant to chapter 55 of Title 10, United States Code (Civilian Health and Medical Program of Uniformed Services (CHAMPUS)); and
(c) Similar supplemental coverage provided under a group health plan.
Sec. 186 NRS 689C.095 is hereby amended to read as follows:
689C.0951. "Small employer" means any person or governmental entity actively engaged in a business [which, on at least one-half of its working days during the preceding year, employed no fewer than 2 and no more than 25 employees, which] :
(a) Which, with respect to a calendar year and a plan year, employed on business days during the preceding calendar year an average of at least 2, but not more than 50 employees, a majority of whom are residents of this state, who have a normal work week of 30 hours or more, and which employs at least 2 employees on the first day of the plan year;
(b) Which was not formed primarily for the purpose of purchasing insurance [, and in] ; and
(c) In which a relationship between the employer and the employees exists in good faith.
For the purposes of determining the number of eligible employees, organizations which are affiliated or which are eligible to file a combined tax return for the purposes of taxation constitute one employer.
2. For the purposes of this section, organizations are "affiliated" if one directly, or indirectly, through one or more intermediaries, controls or is controlled by, or is under common control with, the other, as determined pursuant to the provisions of NRS 692C.050.
Sec. 187 NRS 689C.155 is hereby amended to read as follows:
689C.155The commissioner may adopt regulations to carry out the provisions of NRS 689C.115 to 689C.145, inclusive, and sections 94 to 143, inclusive, and 145 to 182, inclusive, of this act, and to ensure that rating practices used by carriers serving small employers are consistent with those sections, including regulations that:
1. Ensure that differences in rates charged for health benefit plans by such carriers are reasonable and reflect only differences in the designs of the plans, the terms of the coverage, the amount contributed by the employers to the cost of coverage and differences based on the rating factors established by the carrier.
2. Prescribe the manner in which characteristics may be used by such carriers.
Sec. 188 NRS 689C.170 is hereby amended to read as follows:
689C.1701. A carrier serving small employers may vary the application of requirements for minimum participation of eligible employees and minimum employer's contributions only by the size of the small employer's group.
2. In applying requirements for minimum participation with respect to a small employer, a carrier shall not consider employees or dependents who have [qualifying existing] creditable coverage when determining whether the applicable percentage of participation is met, but may consider employees or dependents who have coverage under another health benefit plan that is sponsored by the employer.
3. A carrier shall not deny an application for coverage solely because the applicant works in a certain industry.
4. After a small employer has been accepted for coverage, a carrier shall not increase any requirement for minimum employee participation or modify any requirement for minimum employer contribution applicable to the small employer.
Sec. 189 NRS 689C.180 is hereby amended to read as follows:
689C.1801. If a carrier serving small employers offers coverage to a small employer, the carrier shall offer the same coverage to all of the eligible employees of the small employer and their dependents. A carrier shall not offer coverage to only certain members of a small employer's group or to only part of the group, but may exclude an otherwise eligible employee, or his dependent, who requests enrollment in a health benefit plan after the end of the initial period during which the employee or dependent is entitled to enroll under the terms of the plan, if the initial period is at least 30 days.
2. A carrier shall not exclude an eligible employee or dependent if:
(a) The employee or dependent:
(1) Was covered under other [qualifying] creditable coverage at the time of the initial period for enrollment;
(2) Lost coverage under the other [qualifying] creditable coverage as a result of termination of employment or eligibility, the involuntary termination of the [qualifying] creditable coverage, the death of a spouse or divorce; and
(3) Requests enrollment within 30 days after termination of the other [qualifying] creditable coverage;
(b) The employee is employed by an employer that offers multiple health benefit plans and elects a different plan during an open period for enrollment; or
(c) A court has ordered that coverage be provided for a dependent under a covered employee's health benefit plan and the request for enrollment is made within 30 days after issuance of the court order.
[3. As used in this section, "qualifying coverage" means benefits or coverage provided under:
(a) Medicare or Medicaid; or
(b) A plan of health insurance or health benefits which provides basic medical and hospital care, including, without limitation, emergency care, inpatient and outpatient hospital services, physicians' services, outpatient medical services, and laboratory and X-ray services.]
Sec. 190 NRS 689C.190 is hereby amended to read as follows:
689C.1901. Except as otherwise provided in [subsection 2,] this section, a carrier serving small employers that issues a health benefit plan shall not deny, exclude or limit a [covered] benefit for a preexisting condition:
(a) For more than [6] 12 months after the effective date of coverage if the employee enrolls through open enrollment [.
(b) For more than 6 months after the effective date of coverage if the employee is a qualified late enrollee.
(c) For more than 12 months after the effective date of coverage if the employee is not a qualified late enrollee and enrolls after the close of open enrollment.
2. A carrier that issues a health benefit plan shall not deny, exclude or limit coverage for a preexisting condition during the 6 months immediately following the effective date of coverage if the employee had existing coverage continuously for up to not more than 90 days before the effective date of coverage under the health benefit plan, excluding any] or after the first day of the waiting period for such enrollment, whichever is earlier; or
(b) For more than 18 months after the effective date of coverage for a late enrollee. A carrier may not define a preexisting condition in its health benefit plan more restrictively than that term is defined in section 109 of this act.
2. The period of any exclusion for a preexisting condition imposed by a health benefit plan on a person to be insured in accordance with the provisions of this chapter must be reduced by the aggregate period of creditable coverage of that person, if the creditable coverage was continuous to a date not more than 63 days before the effective date of the new coverage. The period of continuous coverage must not include:
(a) Any waiting period for the effective date of the new coverage applied by the employer or the carrier; or
(b) Any affiliation period , not to exceed 60 days for a new enrollee and 90 days for a late enrollee, required before becoming eligible to enroll in the health benefit plan.
3. A [carrier] health maintenance organization authorized to transact insurance pursuant to chapter 695C of NRS that does not restrict coverage for a preexisting condition may require an affiliation period before coverage becomes effective under a plan of insurance if the affiliation period applies uniformly to all employees [. An insurer that imposes an affiliation period may require an employee to be employed for not more than:
(a) Sixty days after the employee enrolls in the plan of insurance through open enrollment;
(b) Sixty days after the employee enrolls in the plan of insurance if he is a qualified late enrollee; or
(c) One hundred eighty days after the employee enrolls in the plan if he is not a qualified late enrollee and enrolls after the close of open enrollment,
before coverage of the employee becomes effective.] and without regard to any health status-related factors. During the affiliation period , the carrier shall not collect any premiums for coverage of the employee.
4. [An insurer] A carrier that restricts coverage for preexisting conditions shall not impose an affiliation period.
5. A carrier shall not impose any exclusion for a preexisting condition:
(a) Relating to pregnancy.
(b) In the case of a person who, as of the last day of the 30-day period beginning on the date of his birth, is covered under creditable coverage.
(c) In the case of a child who is adopted or placed for adoption before attaining the age of 18 years and who, as of the last day of the 30-day period beginning on the date of adoption or placement for adoption, whichever is earlier, is covered under creditable coverage. The provisions of this paragraph do not apply to coverage before the date of adoption or placement for adoption.
(d) In the case of a condition for which medical advice, diagnosis, care or treatment was recommended or received for the first time while the covered person held creditable coverage, and the medical advice, diagnosis, care or treatment was a covered benefit under the plan, if the creditable coverage was continuous to a date not more than 90 days before the effective date of the new coverage.
The provisions of paragraphs (b) and (c) do not apply to a person after the end of the first 63-day period during all of which the person was not covered under any creditable coverage.
6. As used in this section [:
(a) "Affiliation period" means a period of time during which an employee must be employed by his current employer.
(b) "Open enrollment" means the period of time designated for enrollment in a health benefit plan.
(c) "Preexisting condition" means a condition for which medical advice, diagnosis, care or treatment was recommended or received during the 6 months immediately preceding the effective date of coverage.
(d) "Qualified late enrollee" means:
(1) An eligible employee or his dependent:
(I) Who enrolls in a plan of insurance after the close of open enrollment;
(II) Who was insured under existing coverage at the time of open enrollment;
(III) Whose existing coverage was canceled because of an unforeseen event; and
(IV) Who requests enrollment in the plan of insurance not more than 30 days after his existing coverage is canceled.
(2) An eligible employee or his dependent who enrolls in a health benefit plan during the period for open enrollment offered by his employer and then seeks to change to a different health benefit plan offered by the employer after the close of open enrollment.
(3) An eligible employee or his dependent for whom a court has ordered the carrier to provide coverage and who requests to be enrolled in a health benefit plan not later than 30 days after the court order is issued.] , "late enrollee" means an eligible employee, or his dependent, who requests enrollment in a health benefit plan of a small employer following the initial period of enrollment, if the initial period of enrollment is at least 30 days, during which the person is entitled to enroll under the terms of the health benefit plan. The term does not include an eligible employee or his dependent if:
(a) The employee or dependent:
(1) Was covered under creditable coverage at the time of the initial enrollment;
(2) Lost coverage under creditable coverage as a result of cessation of employer contribution, termination of employment or eligibility, reduction in the number of hours of employment, involuntary termination of creditable coverage, or the death of, or divorce or legal separation from, a covered spouse; and
(3) Requests enrollment not later than 30 days after the date on which his creditable coverage was terminated or on which the change in conditions that gave rise to the termination of the coverage occurred.
(b) The person enrolls during the open enrollment period, as provided in the contract or as otherwise provided by specific statute.
(c) The person is employed by an employer which offers multiple health benefit plans and the person elected a different plan during an open enrollment period.
(d) A court has ordered coverage to be provided to the spouse or a minor or dependent child of an employee under a health benefit plan of the employee and a request for enrollment is made within 30 days after the issuance of the court order.
(e) The person changes status from not being an eligible employee to being an eligible employee and requests enrollment, subject to any waiting period, within 30 days after the change in status.
(f) The person has continued coverage in accordance with the Consolidated Omnibus Budget Reconciliation Act of 1985 and such coverage has been exhausted.
Sec. 191 NRS 689C.200 is hereby amended to read as follows:
689C.200[1.] A carrier serving small employers is not required [:
(a) To] to accept applications from or offer coverage to:
[(1)] 1. A small employer if the employer is not physically located in the carrier's established geographic area; or
[(2)] 2. An employee if the employee does not work or reside within the carrier's established geographic area . [; or
(b) To offer coverage within an area where the carrier reasonably anticipates, and demonstrates to the satisfaction of the commissioner, that it does not have the capacity to provide service adequately to an applicant because of its obligations to existing policyholders and enrollees. A carrier that cannot offer coverage pursuant to this paragraph may not offer coverage in the applicable area to any new employer group having more than 25 employees or to any small employer until the later of 180 days after each such refusal or the date on which the carrier notifies the commissioner that it has regained capacity to offer health benefit plans to small employers in the area.
2. As used in this section, "established geographic area" means a geographic area approved by the commissioner and based on the carrier's certificate of authority to transact insurance in this state within which the carrier is authorized to provide coverage.]
Sec. 191.3. NRS 689C.210 is hereby amended to read as follows:
689C.2101. Except as otherwise provided in subsection 3, a carrier shall not increase the premium rate charged to a small employer for a new rating period by a percentage greater than the sum of:
(a) The percentage of change in the premium rate for new business for the policy under which the small employer is covered, measured from the first day of the previous rating period to the first day of the new rating period;
(b) An adjustment, not to exceed 15 percent annually, adjusted pro rata for rating periods of less than 1 year, on account of the claim experience, health status, or duration of coverage of the employees or dependents of the small employer as determined from the carrier's rate manual for the class of business; and
(c) Any adjustment on account of change in coverage or change in the characteristics of the small employer as determined from the carrier's rate manual for the class of business.
2. If the carrier no longer issues new policies for that class of business, the carrier shall use the percentage of change in the premium rate for new business for the class of business which is most similar to the closed class of business and for which the carrier is issuing new policies.
3. In the case of health benefit plans delivered or issued for delivery before January 1, 1996, for groups with no fewer than 2 and no more than 25 employees, or before July 1, 1997, for groups with no fewer than 26 and no more than 50 employees, a premium rate for a rating period may exceed the ranges set forth in paragraphs (a) and (b) of subsection 1 for a period of 3 years following that date. In that case, the percentage of increase in the premium rate charged to a small employer for a new rating period may not exceed the sum of:
(a) The percentage of change in the premium rate for new business measured from the first day of the previous rating period to the first day of the new rating period. In the case of a health benefit plan into which the carrier is no longer enrolling new small employers, the carrier shall use the percentage of change in the base premium rate if that change does not exceed, on a percentage basis, the change in the premium rate for new business for the most similar health benefit plan into which the carrier is actively enrolling new small employers.
(b) Any adjustment on account of change in coverage or change in the characteristics of the small employer as determined from the carrier's rate manual for the class of business.
[4. As used in this section, "premium rate for new business" means, for each class of business as to a rating period, the lowest premium rate charged or offered or which could have been charged or offered by the carrier to small employers with similar characteristics for newly issued health benefit plans with the same or similar coverage.]
Sec. 191.5. NRS 689C.230 is hereby amended to read as follows:
689C.2301. The index rate for a rating period for any class of business may not exceed the index rate for any other class of business by more than 20 percent.
2. For a class of business, the premium rates charged during a rating period to small employers with similar characteristics for the same or similar coverage, or the rates that could be charged to such employers under the rating system for that class of business, may not vary , because of health status-related factors, from the index rate by more than [25] 30 percent.
3. As used in this section:
(a) "Base premium rate" means, for each class of business as to a rating period, the lowest premium rate charged or that could have been charged under a rating system for that class of business by the carrier to small employers with similar characteristics for health benefit plans subject to regulation by the commissioner.
(b) "Index rate" means, for each class of business as to a rating period for small employers with similar characteristics, the arithmetic average of the applicable base premium rate and the corresponding highest premium rate.
Sec. 192 NRS 689C.270 is hereby amended to read as follows:
689C.2701. The commissioner shall adopt regulations which require a carrier to file with the commissioner, for his approval, a disclosure offered by the carrier to a small employer. The disclosure must include:
(a) Any significant exception, reduction or limitation that applies to the policy;
(b) Any restrictions on payments for emergency care, including, without limitation, related definitions of an emergency and medical necessity;
(c) The provision of the health benefit plan concerning the carrier's right to change premium rates and the characteristics, other than claim experience, that affect changes in premium rates;
(d) The provisions relating to renewability of policies and contracts;
(e) The provisions relating to any preexisting condition; and
(f) Any other information that the commissioner finds necessary to provide for full and fair disclosure of the provisions of a policy or contract of insurance issued pursuant to this chapter.
2. The disclosure must be written in language which is easily understood and must include a statement that the disclosure is a summary of the policy only, and that the policy itself should be read to determine the governing contractual provisions.
3. The commissioner shall not approve any proposed disclosure submitted to him pursuant to this section which does not comply with the requirements of this section and the applicable regulations.
4. The carrier shall make available to a small employer upon request a copy of the disclosure approved by the commissioner pursuant to this section for policies of health insurance for which that employer may be eligible.
Sec. 193 NRS 689C.310 is hereby amended to read as follows:
689C.3101. Except as otherwise provided in subsections 2 and 3, a carrier shall renew a health benefit plan at the option of the small employer who purchased the plan.
2. A carrier may refuse to issue or to renew a health benefit plan if:
(a) The carrier discontinues transacting insurance in this state or in the geographic area of this state where the employer is located;
(b) The employer fails to pay the premiums or contributions required by the terms of the plan;
(c) The employer misrepresents any information regarding the employees covered under the plan or other information regarding eligibility for coverage under the plan; [or]
(d) The plan sponsor has engaged in an act or practice that constitutes fraud to obtain or maintain coverage under the plan;
(e) The employer is not in compliance with the minimum requirements for participation or employer contribution as set forth in the plan; or
(f) The employer fails to comply with any of the provisions of this chapter.
3. A carrier may require a small employer to exclude a particular employee or his dependent from coverage under a health benefit plan as a condition to renewal of the plan if the employee or his dependent commits fraud upon the carrier or misrepresents a material fact which affects his coverage under the plan.
4. [If a carrier cancels a health benefit plan, it may deny coverage to the small employer for such period and under such conditions as are specified by the commissioner.] A carrier shall discontinue the issuance and renewal of coverage to a small employer if the commissioner finds that the continuation of the coverage would not be in the best interests of the policyholders or certificate holders of the carrier in this state or would impair the ability of the carrier to meet its contractual obligations. If the commissioner makes such a finding, the commissioner shall assist the affected small employers in finding replacement coverage.
5. A carrier may discontinue the issuance and renewal of a form of a product of a health benefit plan offered to small employers pursuant to this chapter if the commissioner finds that the form of the product offered by the carrier is obsolete and is being replaced with comparable coverage. A form of a product of a health benefit plan may be discontinued by a carrier pursuant to this subsection only if:
(a) The carrier notifies the commissioner and the chief regulatory officer for insurance in each state in which it is licensed of its decision pursuant to this subsection to discontinue the issuance and renewal of the form of the product at least 60 days before the carrier notifies the affected small employers pursuant to paragraph (b).
(b) The carrier notifies each affected small employer and the commissioner and the chief regulatory officer for insurance in each state in which any affected small employer is located or eligible employee resides of the decision of the carrier to discontinue offering the form of the product. The notice must be made at least 180 days before the date on which the carrier will discontinue offering the form of the product.
(c) The carrier offers to each affected small employer the option to purchase any other health benefit plan currently offered by the carrier to small employers in this state.
(d) In exercising the option to discontinue the particular form of the product and in offering the option to purchase other coverage pursuant to paragraph (c), the carrier acts uniformly without regard to the claims experience of the affected small employers or any health status-related factor relating to any participant or beneficiary covered by the discontinued product or any new participant or beneficiary who may become eligible for such coverage.
6. A carrier may discontinue the issuance and renewal of a health benefit plan offered to a small employer or an eligible employee pursuant to this chapter only through a bona fide association if:
(a) The membership of the small employer or eligible employee in the association was the basis for the provision of coverage;
(b) The membership of the small employer or eligible employee in the association ceases; and
(c) The coverage is terminated pursuant to this subsection uniformly without regard to any health status-related factor relating to the small employer or eligible employee or his dependent.
7. If a carrier does business in only one established geographic service area of this state, the provisions of this section apply only to the operations of the carrier in that service area.
Sec. 194 NRS 689C.320 is hereby amended to read as follows:
689C.3201. A carrier that discontinues transacting insurance in this state or in a particular geographic area of this state shall:
(a) Notify the commissioner and the chief regulatory officer for insurance in each state in which the carrier is licensed to transact insurance at least 60 days before a notice of cancellation or nonrenewal is delivered or mailed to the affected small employers pursuant to paragraph (b).
(b) Notify the commissioner and each small employer affected not less than 180 days before the expiration of any policy or contract of insurance under any health benefit plan issued to a small employer pursuant to this chapter.
[(b) Notify each small employer affected not less than 180 days before coverage under the health benefit plan of the employer expires.]
2. A carrier that cancels any health benefit plan because it has discontinued transacting insurance in this state or in a particular geographic area of this state [may] :
(a) Shall discontinue the issuance and delivery for issuance of all health benefit plans pursuant to this chapter in this state and not renew coverage under any health benefit plan issued to a small employer; and
(b) May not issue any health benefit plans pursuant to this chapter in this state or in the particular geographic area for [30 months] 5 years after it gives notice to the commissioner pursuant to paragraph (b) of subsection 1.
Sec. 195 NRS 689C.340 is hereby amended to read as follows:
689C.3401. Except as otherwise provided in this section, if an employer who employs less than 20 employees maintains a health benefit plan which covers those employees, the plan must contain a provision which permits:
(a) An employee to elect to continue identical coverage under the plan, excluding coverage provided for eye or dental care, if:
(1) His employment is terminated for any reason other than gross misconduct; or
(2) The number of his working hours is reduced so that he ceases to be eligible for coverage.
(b) The spouse or dependent child of an employee to elect to continue coverage, excluding any coverage provided for eye or dental care, if:
(1) The employee's employment is terminated for any reason other than gross misconduct or the number of his working hours is reduced so that he ceases to be eligible for coverage;
(2) The employee dies;
(3) The employee and his spouse are divorced or legally separated;
(4) The dependent child ceases to be eligible for coverage under the terms of the policy; or
(5) The spouse ceases to be eligible for coverage after becoming eligible for Medicare.
2. The period of continued coverage is limited to:
(a) Eighteen months for an employee.
(b) Thirty-six months for the dependent of an employee.
3. An employee who voluntarily leaves his employment, or the dependent of that employee, is not eligible to continue coverage pursuant to this section.
4. An employee or his dependent who has not been covered under a health benefit plan of the employer for at least 12 consecutive months before the termination of his coverage is not eligible to continue coverage pursuant to this section.
5. A provision for continued coverage must include coverage for any child born to, legally adopted by or placed for adoption with the employee during the period of continued coverage. Such a child is eligible for continued coverage only to the end of the period of continued coverage as established pursuant to subsection 2.
Sec. 196 NRS 689C.360 is hereby amended to read as follows:
689C.360As used in NRS 689C.360 to 689C.600, inclusive, and section 144 of this act, unless the context otherwise requires, the words and terms defined in NRS [689C.360] 689C.380 to 689C.420, inclusive, have the meanings ascribed to them in those sections.
Sec. 197 NRS 689C.460 is hereby amended to read as follows:
689C.4601. If a carrier offers a contract to a voluntary purchasing group, the carrier shall offer the same coverage to all of the eligible employees of the small employers that are members of the voluntary purchasing group and their dependents. A carrier shall not offer coverage to only certain members of that group or to only part of that group, but may exclude an otherwise eligible employee, or his dependent, who requests enrollment in the contract after the end of the initial period during which the employee or dependent is entitled to enroll under the terms of the contract, if the initial period is at least 30 days.
2. A carrier shall not exclude an eligible employee or dependent if:
(a) The employee or dependent:
(1) Was covered under other [qualifying] creditable coverage at the time of the initial period for enrollment;
(2) Lost coverage under the other [qualifying] creditable coverage as a result of termination of employment or eligibility, the involuntary termination of the [qualifying] creditable coverage, the death of a spouse or divorce; and
(3) Requests enrollment within 30 days after termination of the other [qualifying] creditable coverage;
(b) The employee is employed by an employer that offers multiple contracts and elects a different contract during an open period for enrollment; or
(c) A court has ordered that coverage be provided for a dependent under a covered employee's contract and the request for enrollment is made within 30 days after issuance of the court order.
[3. As used in this section, "qualifying coverage" means benefits or coverage provided under:
(a) Medicare or Medicaid; or
(b) A plan of health insurance or health benefits which provides basic medical and hospital care, including, without limitation, emergency care, inpatient and outpatient hospital services, physicians' services, outpatient medical services, and laboratory and X-ray services.]
Sec. 198 NRS 689C.470 is hereby amended to read as follows:
689C.4701. Except as otherwise provided in NRS 689C.360 to 689C.600, inclusive, and section 144 of this act, a carrier shall renew a contract as to all insured small employers that are members of a voluntary purchasing group and their employees and dependents at the request of the purchaser unless:
[1.] (a) Required premiums are not paid;
[2.] (b) The insured employer or other purchaser is guilty of fraud or misrepresentation;
[3.] (c) Provisions of the contract are breached;
[4.] (d) The number or percentage of employees covered under the contract is less than the number or percentage of eligible employees required by the contract;
[5.] (e) The employer or purchaser is no longer engaged in the business in which it was engaged on the effective date of the contract; or
[6.] (f) The commissioner finds that the continuation of the coverage is not in the best interests of the persons insured under the contract or would impair the carrier's ability to meet its contractual obligations. If nonrenewal occurs as a result of findings pursuant to this subsection, the commissioner shall assist affected persons in replacing coverage.
2. A carrier may discontinue issuance and renewal of a form of a product of a health benefit plan offered to a small employer or purchasers pursuant to NRS 689C.360 to 689C.600, inclusive, and section 144 of this act if the commissioner finds that the form of the product offered by the carrier is obsolete and is being replaced with comparable coverage. A form of a product of a health benefit plan may be discontinued by a carrier pursuant to this subsection only if:
(a) The carrier notifies the commissioner and the chief regulatory officer for insurance in each state in which it is licensed of its decision pursuant to this subsection to discontinue offering and renewing the form of the product at least 60 days before the carrier notifies the affected small employers and purchasers pursuant to paragraph (b).
(b) The carrier notifies each affected small employer and purchaser, and the commissioner and the chief regulatory officer for insurance in each state in which any affected small employer is located or employee resides, of the decision of the carrier to discontinue offering the form of the product. The notice must be made at least 180 days before the date on which the carrier will discontinue offering the form of the product.
(c) The carrier offers to each affected small employer and purchaser the option to purchase any other health benefit plan currently offered by the carrier to small employers in this state.
(d) In exercising the option to discontinue the particular form of the product and in offering the option to purchase other coverage pursuant to paragraph (c), the carrier acts uniformly without regard to the claim experience of the affected small employers and any health status-related factor relating to any participant or beneficiary covered by the discontinued product or any new participant or beneficiary who may become eligible for such coverage.
3. A carrier may discontinue the issuance and renewal of a health benefit plan offered to a voluntary purchasing group pursuant to this chapter only through a bona fide association if:
(a) The membership of the small employer who employs the members of the voluntary purchasing group or the purchaser in the association was the basis for the provision of coverage;
(b) The membership of that small employer or the purchaser in the association ceases; and
(c) The coverage is terminated pursuant to this subsection uniformly without regard to any health status-related factor relating to the small employer or the purchaser or his dependent.
Sec. 199 NRS 689C.480 is hereby amended to read as follows:
689C.4801. A carrier may cease to renew all contracts covering voluntary purchasing groups [.] and discontinue issuing and delivering for issuance any such contracts. The carrier shall provide notice [at] :
(a) At least 60 days before the notice of termination is provided pursuant to paragraph (b), to the commissioner and the chief regulatory officer for insurance of each state in which the carrier is licensed to transact insurance; and
(b) At least 180 days before termination of coverage to holders of all affected contracts and to the commissioner and the chief regulatory officer for insurance in each state in which an affected insured person is known to reside.
2. A carrier that exercises its right to cease to renew all contracts covering voluntary purchasing groups shall not [:
(a) Enter into a new contract with a voluntary purchasing group for a period of 30 months after the nonrenewal without prior approval of the commissioner; or
(b) Transfer] transfer or otherwise provide coverage to any of the insureds from a nonrenewed voluntary purchasing group unless the carrier offers to transfer or provide coverage to all affected employers and eligible employees and dependents without regard to characteristics of the insured, experience as to claims, health or duration of coverage.
3. A carrier that decides to terminate its contracts and to discontinue issuing and delivering for issuance any contracts pursuant to this section:
(a) Shall discontinue issuance and delivery for issuance all health benefit plans pursuant to this chapter in this state and, except as otherwise provided in this section, not renew any such contracts; and
(b) Shall not enter into any new contract with a voluntary purchasing group for 5 years after the date on which the carrier terminated its contracts with voluntary purchasing groups.
Sec. 200 NRS 689C.490 is hereby amended to read as follows:
689C.4901. A small employer may, in accordance with the provisions of NRS 689C.490 to 689C.600, inclusive, choose to affiliate voluntarily with other small employers as a voluntary purchasing group to purchase health benefits for eligible employees and their dependents.
2. An employer who affiliates with a voluntary purchasing group shall notify the carrier for that group when the employer has less than 2 or more than [25] 50 employees. The carrier shall:
(a) Upon receiving such a notification, inform the employer of the provisions of paragraph (b).
(b) If the employer ceases to be a small employer, refuse to renew the coverage of that employer and his employees and their dependents under any contract provided through the voluntary purchasing group.
Sec. 201 Chapter 695A of NRS is hereby amended by adding thereto a new section to read as follows:
1. To the extent reasonably applicable, a fraternal benefit society shall comply with the provisions of sections 60 to 88, inclusive, of this act and chapter 689C of NRS relating to the portability and availability of health insurance offered by the society to its members. If there is a conflict between the provisions of this chapter and the provisions of sections 60 to 88, inclusive, of this act and chapter 689C of NRS, the provisions of sections 60 to 88, inclusive, of this act and chapter 689C of NRS control.
2. For the purposes of subsection 1, unless the context requires that a provision apply only to a group health plan or a carrier that provides coverage under a group health plan, any reference in those sections to "group health plan" or "carrier" must be replaced by "fraternal benefit society."
Sec. 202 NRS 695A.159 is hereby amended to read as follows:
695A.1591. If a person:
(a) Adopts a dependent child; or
(b) Assumes and retains a legal obligation for the total or partial support of a dependent child in anticipation of adopting the child,
while the person is eligible for group coverage under a certificate for health benefits, the society issuing that certificate shall not restrict the coverage , in accordance with sections 60 to 88, inclusive, of this act and chapter 689C of NRS relating to the portability and availability of health insurance, of the child solely because of a preexisting condition the child has at the time he would otherwise become eligible for coverage pursuant to that policy.
2. For the purposes of this section, "child" means a person who is under 18 years of age at the time of his adoption or the assumption of a legal obligation for his support in anticipation of his adoption.
Sec. 203 Chapter 695B of NRS is hereby amended by adding thereto a new section to read as follows:
1. Nonprofit hospital and medical or dental service corporations are subject to the provisions of sections 60 to 88, inclusive, of this act and chapter 689C of NRS relating to the portability and availability of health insurance offered by such organizations. If there is a conflict between the provisions of this chapter and the provisions of sections 60 to 88, inclusive, of this act and chapter 689C of NRS, the provisions of sections 60 to 88, inclusive, of this act and chapter 689C of NRS control.
2. For the purposes of subsection 1, unless the context requires that a provision apply only to a group health plan or a carrier that provides coverage under a group health plan, any reference in those sections to:
(a) "Group health plan" must be replaced by "group contract for hospital, medical or dental services."
(b) "Carrier" must be replaced by "corporation."
Sec. 204 NRS 695B.187 is hereby amended to read as follows:
695B.187Except as otherwise provided by the provisions of sections 60 to 88, inclusive, of this act and chapter 689C of NRS relating to the portability and availability of health insurance:
1. A group contract for hospital, medical or dental services issued by a nonprofit hospital, medical or dental service corporation to replace any discontinued policy or coverage for group health insurance must:
(a) Provide coverage for all persons who were covered under the previous policy or coverage on the date it was discontinued; and
(b) Except as otherwise provided in subsection 2, provide benefits which are at least as extensive as the benefits provided by the previous policy or coverage, except that the benefits may be reduced or excluded to the extent that such a reduction or exclusion was permissible under the terms of the previous policy or coverage,
if that contract is issued within 60 days after the date on which the previous policy or coverage was discontinued.
2. If an employer obtains a replacement contract pursuant to subsection 1 to cover his employees, any benefits provided by the previous policy or coverage may be reduced if notice of the reduction is given to his employees pursuant to NRS 608.1577.
3. Any corporation which issues a replacement contract pursuant to subsection 1 may submit a written request to the insurer which provided the previous policy or coverage for a statement of benefits which were provided under that policy or coverage. Upon receiving such a request, the insurer shall give a written statement to the corporation which indicates what benefits were provided and what exclusions or reductions were in effect under the previous policy or coverage.
4. The provisions of this section apply to a self-insured employer who provides health benefits to his employees and replaces those benefits with a group contract for hospital, medical or dental services issued by a nonprofit hospital, medical or dental service corporation.
Sec. 205 NRS 695B.189 is hereby amended to read as follows:
695B.189A group contract issued by a corporation under the provisions of this chapter must contain a provision which permits the continuation of coverage pursuant to the provisions of NRS 689B.245 to 689B.249, inclusive [.] , sections 60 to 88, inclusive, of this act and chapter 689C of NRS relating to the portability and availability of health insurance.
Sec. 206 NRS 695B.192 is hereby amended to read as follows:
695B.1921. No hospital, medical or dental service contract issued by a corporation [under] pursuant to the provisions of this chapter may contain any exclusion, reduction or other limitation of coverage relating to complications of pregnancy, unless the provision applies generally to all benefits payable under the contract [.] and complies with the provisions of sections 60 to 88, inclusive, of this act and chapter 689C of NRS relating to the portability and availability of health insurance.
2. As used in this section, the term "complications of pregnancy" includes any condition which requires hospital confinement for medical treatment and:
(a) If the pregnancy is not terminated, is caused by an injury or sickness not directly related to the pregnancy or by acute nephritis, nephrosis, cardiac decompensation, missed abortion or similar medically diagnosed conditions; or
(b) If the pregnancy is terminated, results in nonelective cesarean section, ectopic pregnancy or spontaneous termination.
3. A contract subject to the provisions of this chapter which is issued or delivered on or after July 1, 1977, has the legal effect of including the coverage required by this section, and any provision of the contract which is in conflict with this section is void.
Sec. 207 NRS 695B.193 is hereby amended to read as follows:
695B.1931. All individual and group service or indemnity-type contracts issued by a nonprofit corporation which provide coverage for a family member of the subscriber must as to such coverage provide that the health benefits applicable for children are payable with respect to:
(a) A newly born child of the subscriber from the moment of birth;
(b) An adopted child from the date the adoption becomes effective, if the child was not placed in the home before adoption; and
(c) A child placed with the subscriber for the purpose of adoption from the moment of placement as certified by the public or private agency making the placement. The coverage of such a child ceases if the adoption proceedings are terminated as certified by the public or private agency making the placement.
The contracts must provide the coverage specified in subsection 3, and must not exclude premature births.
2. The contract may require that notification of:
(a) The birth of a newly born child;
(b) The effective date of adoption of a child; or
(c) The date of placement of a child for adoption,
and payments of the required fees, if any, must be furnished to the nonprofit service corporation within 31 days after the date of birth, adoption or placement for adoption in order to have the coverage continue beyond the 31-day period.
3. The coverage for newly born and adopted children and children placed for adoption consists of coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities and, within the limits of the policy, necessary transportation costs from place of birth to the nearest specialized treatment center under major medical policies, and with respect to basic policies to the extent such costs are charged by the treatment center.
4. A corporation shall not restrict the coverage of a dependent child adopted or placed for adoption solely because of a preexisting condition the child has at the time he would otherwise become eligible for coverage pursuant to that contract. Any provision relating to an exclusion for a preexisting condition must comply with NRS 689C.190.
5. For covered services provided to the child, the corporation shall reimburse noncontracted providers of health care to an amount equal to the average amount of payment for which the organization has agreements, contracts or arrangements for those covered services.
Sec. 208 NRS 695B.251 is hereby amended to read as follows:
695B.2511. Except as otherwise provided in [subsection 3,] the provisions of this section and sections 60 to 88, inclusive, of this act and chapter 689C of NRS relating to the portability and availability of health insurance, all group subscriber contracts delivered or issued for delivery in this state providing for hospital, surgical or major medical coverage, or any combination of these coverages, on a service basis or an expense-incurred basis, or both, must contain a provision that the employee or member is entitled to have issued to him a subscriber contract of health coverage when the employee or member is no longer covered by the group subscriber contract.
2. The requirement in subsection 1 does not apply to contracts providing benefits only for specific diseases or accidental injuries . [, and it applies to other contracts only if:
(a) The termination of coverage under the group contract is not due to termination of the group contract itself unless the termination of the group contract has resulted from failure of the contract holder or agent, or both, to remit the required premiums;
(b) The termination is not due to failure of the employee or member to remit any required contributions;
(c) The employee or member has been continuously covered under the group contract for at least 3 consecutive months immediately before the termination; and
(d) The employee or member applies in writing for the converted contract and pays his first premium to the medical service corporation no later than 31 days after the termination.]
3. If an employee or member was a recipient of benefits under the coverage provided pursuant to NRS 695B.1944, he is not entitled to have issued to him by a replacement insurer a subscriber contract of health coverage unless he has reported for his normal employment for a period of 90 consecutive days after last being eligible to receive any benefits under the coverage provided pursuant to NRS 695B.1944.
Sec. 209 NRS 695B.320 is hereby amended to read as follows:
695B.320Nonprofit hospital and medical or dental service corporations are subject to the provisions of this chapter, and to the provisions of chapters 679A and 679B of NRS, NRS 686A.010 to 686A.315, inclusive, [689C.015 to 689C.350, inclusive,] and chapters 692C and 696B of NRS, to the extent applicable and not in conflict with the express provisions of this chapter.
Sec. 210 Chapter 695C of NRS is hereby amended by adding thereto the provisions set forth as sections 211 and 212 of this act.
Sec. 211 A health maintenance organization may offer to a small employer who has not less than 2 and not more than 50 employees, a health care plan that has a high deductible and that is in compliance with 26 U.S.C. § 220 for the purposes of establishing medical savings accounts for any person insured by the health care plan.
Sec. 212 1. A health maintenance organization is subject to the provisions of sections 60 to 88, inclusive, of this act and chapter 689C of NRS relating to the portability and availability of health insurance offered by such organizations. If there is a conflict between the provisions of this chapter and the provisions of sections 60 to 88, inclusive, of this act and chapter 689C of NRS, the provisions of sections 60 to 88, inclusive, of this act and chapter 689C of NRS control.
2. For the purposes of subsection 1, unless the context requires that a provision apply only to a group health plan or a carrier that provides coverage under a group health plan, any reference in those sections to "group health plan" or "carrier" must be replaced by "health maintenance organization."
Sec. 213 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, and subsections 2, 4, 18, 19 and 32 of NRS 680B.010 [and NRS 689C.015 to 689C.350, inclusive,] 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. 214 NRS 695C.1705 is hereby amended to read as follows:
695C.1705Except as otherwise provided in the provisions of sections 60 to 88, inclusive, of this act and chapter 689C of NRS relating to the portability and accountability of health insurance:
1. A group health care plan issued by a health maintenance organization to replace any discontinued policy or coverage for group health insurance must:
(a) Provide coverage for all persons who were covered under the previous policy or coverage on the date it was discontinued; and
(b) Except as otherwise provided in subsection 2, provide benefits which are at least as extensive as the benefits provided by the previous policy or coverage, except that benefits may be reduced or excluded to the extent that such a reduction or exclusion was permissible under the terms of the previous policy or coverage,
if that plan is issued within 60 days after the date on which the previous policy or coverage was discontinued.
2. If an employer obtains a replacement plan pursuant to subsection 1 to cover his employees, any benefits provided by the previous policy or coverage may be reduced if notice of the reduction is given to his employees pursuant to NRS 608.1577.
3. Any health maintenance organization which issues a replacement plan pursuant to subsection 1 may submit a written request to the insurer which provided the previous policy or coverage for a statement of benefits which were provided under that policy or coverage. Upon receiving such a request, the insurer shall give a written statement to the organization indicating what benefits were provided and what exclusions or reductions were in effect under the previous policy or coverage.
4. If an employee or enrollee was a recipient of benefits under the coverage provided pursuant to NRS 695C.1709, he is not entitled to have issued to him by a health maintenance organization a replacement plan unless he has reported for his normal employment for a period of 90 consecutive days after last being eligible to receive any benefits under the coverage provided pursuant to NRS 695C.1709.
5. The provisions of this section apply to a self-insured employer who provides health benefits to his employees and replaces those benefits with a group health care plan issued by a health maintenance organization.
Sec. 215 NRS 695C.1707 is hereby amended to read as follows:
695C.1707Any policy of group insurance to which an enrollee is entitled under a health care plan provided by a health maintenance organization must contain a provision which permits the continuation of coverage pursuant to the provisions of NRS 689B.245 to 689B.249, inclusive [.] , sections 60 to 88, inclusive, of this act and chapter 689C of NRS relating to the portability and accountability of health insurance.
Sec. 216 NRS 695C.172 is hereby amended to read as follows:
695C.1721. No health maintenance organization may issue evidence of coverage under a health care plan to any enrollee in this state if it contains any exclusion, reduction or other limitation of coverage relating to complications of pregnancy unless the provision applies generally to all benefits payable under the policy [.] and complies with the provisions of sections 60 to 88, inclusive, of this act and chapter 689C of NRS relating to the portability and accountability of health insurance.
2. As used in this section, the term "complications of pregnancy" includes any condition which requires hospital confinement for medical treatment and:
(a) If the pregnancy is not terminated, is caused by an injury or sickness not directly related to the pregnancy or by acute nephritis, nephrosis, cardiac decompensation, missed abortion or similar medically diagnosed conditions; or
(b) If the pregnancy is terminated, results in nonelective cesarean section, ectopic pregnancy or spontaneous termination.
3. Evidence of coverage under a health care plan subject to the provisions of this chapter which is issued on or after July 1, 1977, has the legal effect of including the coverage required by this section, and any provision which is in conflict with this section is void.
Sec. 217 NRS 695C.173 is hereby amended to read as follows:
695C.1731. All individual and group health care plans which provide coverage for a family member of the enrollee must , as to such coverage , provide that the health care services applicable for children are payable with respect to:
(a) A newly born child of the enrollee from the moment of birth;
(b) An adopted child from the date the adoption becomes effective, if the child was not placed in the home before adoption; and
(c) A child placed with the enrollee for the purpose of adoption from the moment of placement as certified by the public or private agency making the placement. The coverage of such a child ceases if the adoption proceedings are terminated as certified by the public or private agency making the placement.
The plans must provide the coverage specified in subsection 3, and must not exclude premature births.
2. The evidence of coverage may require that notification of:
(a) The birth of a newly born child;
(b) The effective date of adoption of a child; or
(c) The date of placement of a child for adoption,
and payments of the required charge, if any, must be furnished to the health maintenance organization within 31 days after the date of birth, adoption or placement for adoption in order to have the coverage continue beyond the 31-day period.
3. The coverage for newly born and adopted children and children placed for adoption consists of preventive health care services as well as coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities and, within the limits of the policy, necessary transportation costs from place of birth to the nearest specialized treatment center under major medical policies, and with respect to basic policies to the extent such costs are charged by the treatment center.
4. A health maintenance organization shall not restrict the coverage of a dependent child adopted or placed for adoption solely because of a preexisting condition the child has at the time he would otherwise become eligible for coverage pursuant to that plan. Any provision relating to an exclusion for a preexisting condition must comply with section 78 of this act or NRS 689C.190, as appropriate.
5. For covered services provided to the child, the health maintenance organization shall reimburse noncontracted providers of health care to an amount equal to the average amount of payment for which the organization has agreements, contracts or arrangements for those covered services.
Sec. 218 NRS 695F.090 is hereby amended to read as follows:
695F.090Prepaid limited health service organizations are subject to the provisions of this chapter and to the following provisions of this Title, to the extent reasonably applicable:
1. NRS 687B.310 to 687B.420, inclusive, concerning cancellation and nonrenewal of policies.
2. NRS 687B.122 to 687B.128, inclusive, concerning readability of policies.
3. The requirements of NRS 679B.152.
4. The fees imposed pursuant to NRS 449.465.
5. NRS 686A.010 to 686A.310, inclusive, concerning trade practices and frauds.
6. The assessment imposed pursuant to subsection 3 of NRS 679B.158.
7. Chapter 683A of NRS.
8. To the extent applicable, the provisions of sections 60 to 88, inclusive, of this act and chapter 689C of NRS relating to the portability and availability of health insurance.
Sec. 219 NRS 695F.480 is hereby amended to read as follows:
695F.4801. If a person:
(a) Adopts a dependent child; or
(b) Assumes and retains a legal obligation for the total or partial support of a dependent child in anticipation of adopting the child,
while the person is eligible for group coverage under any evidence of coverage, the prepaid limited health service organization issuing that evidence of coverage shall not restrict the coverage of the child based solely on a preexisting condition the child has at the time he would otherwise become eligible for coverage pursuant to that evidence of coverage. Any provision relating to an exclusion for a preexisting condition must comply with section 78 of this act or NRS 689C.190, as appropriate.
2. For the purposes of this section, "child" means a person who is under 18 years of age at the time of his adoption or the assumption of a legal obligation for his support in anticipation of his adoption.
Sec. 220 NRS 287.045 is hereby amended to read as follows:
287.0451. Except as otherwise provided in [subsections 2, 4 and 5,] this section, every officer or employee of the state is eligible to participate in the program on the first day of the month following the completion of 90 days of full-time employment.
2. Professional employees of the University and Community College System of Nevada who have annual employment contracts are eligible to participate in the program on:
(a) The effective dates of their respective employment contracts, if those dates are on the first day of a month; or
(b) The first day of the month following the effective dates of their respective employment contracts, if those dates are not on the first day of a month.
3. Every officer or employee who is employed by a participating public agency on a permanent and full-time basis on the date the agency enters into an agreement to participate in the state's group insurance program, and every officer or employee who commences his employment after that date is eligible to participate in the program on the first day of the month following the completion of 90 days of full-time employment.
4. Every senator and assemblyman is eligible to participate in the program on the first day of the month following the 90th day after his initial term of office begins.
5. An officer or employee of the governing body of any county, school district, municipal corporation, political subdivision, public corporation or other public agency of the State of Nevada who retires under the conditions set forth in NRS 286.510 or 286.620 and was not participating in the state's group insurance program at the time of his retirement is eligible to participate in the program 30 days after notice of the selection to participate is given pursuant to NRS 287.023 or 287.0235. The committee on benefits shall make a separate accounting for these retired persons. For the first year following enrollment, the rates charged must be the full actuarial costs determined by the actuary based upon the expected claims experience with these retired persons. The claims experience of these retired persons must not be commingled with the retired persons who were members of the state's program before their retirement, nor with active employees of the state. After the first year following enrollment, the rates charged must be the full actuarial costs determined by the actuary based upon the past claims experience of these retired persons since enrolling.
6. Notwithstanding the provisions of subsections 1, 3 and 4, if the committee on benefits does not, pursuant to section 86 of this act, elect to exclude the program from compliance with sections 60 to 88, inclusive, of this act, and if the coverage under the program is provided by a health maintenance organization authorized to transact insurance in this state pursuant to chapter 695C of NRS, any affiliation period imposed by the program may not exceed the statutory limit for an affiliation period set forth in section 78 of this act.
Sec. 221 NRS 608.1577 is hereby amended to read as follows:
608.15771. An employer shall notify his employees of his intent to accept a policy of group life, dental or health insurance which covers the employees.
2. If an employer is the policyholder of a policy of group life, dental or health insurance which covers his employees, he shall notify the insurer and employees of his intent to terminate, reduce or modify substantially any benefit under the policy, or to change insurers.
3. If an employer is the policyholder or contract holder under a policy or contract issued pursuant to chapter 689B, 695A, 695B, 695C, 695D or 695F of NRS, or NRS 689C.015 to 689C.590, inclusive, and sections 94 to 182, inclusive, of this act which provides benefits for his employees, he shall, if applicable, notify the employees of:
(a) His inability to pay a premium when due; and
(b) His intention to stop paying premiums.
4. Any notice required pursuant to this section must be:
(a) Given at least 15 days before the:
(1) Acceptance of, change in or termination of benefits or insurers; or
(2) Next unpaid premium is due; and
(b) Conspicuously posted at the place of employment or given in another manner which ensures that all employees will receive the information.
Sec. 221.5. Section 42 of Assembly Bill No. 156 of this session is hereby amended to read as follows:
Sec. 42. NRS 695C.055 is hereby amended to read as follows:
695C.055
1. The provisions of NRS 449.465, 679B.158 and 680B.025 to 680B.060, inclusive, and subsections 2, 4, 18, 19 and 32 of NRS 680B.010 and sections 2 to 27, 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. 222 NRS 689C.370, 689C.400 and 689C.410 are hereby repealed.
Sec. 223 If the Secretary of the United States Department of Health and Human Services determines that the State of Nevada is not in compliance with the provisions of the Health Insurance Portability and Accountability Act of 1996, the commissioner of insurance may adopt such regulations, not otherwise inconsistent with the provisions of this act, as may be necessary to bring this state into compliance with the Health Insurance Portability and Accountability Act of 1996.
Sec. 224 Not later than 60 days after the effective date of this act, each carrier and individual carrier shall file with the commissioner of insurance a plan of operation established pursuant to the program of reinsurance established pursuant to sections 145 to 182, inclusive, of this act that contains the net health insurance premium of the carrier derived from health benefit plans delivered or issued for delivery to small employers and eligible persons in this state during the previous calendar year.
Sec. 225 1. For the initial term of the members of the board of directors of the program of reinsurance established pursuant to section 160 of this act, the commissioner of insurance shall appoint:
(a) Two members to 2-year terms;
(b) Three members to 4-year terms; and
(c) Three members to 6-year terms.
2. For the initial term of the members of the committee on health benefit plans established pursuant to section 179 of this act, the commissioner of insurance shall appoint:
(a) Two members to 2-year terms;
(b) Three members to 4-year terms; and
(c) Three members to 6-year terms.
Sec. 226 1. There is hereby appropriated from the state general fund to the division of insurance of the department of business and industry to carry out the provisions of this act:
For the fiscal year 1997-1998 $286,968
For the fiscal year 1998-1999 $259,323
2. Any balance of the sums appropriated by subsection 1 remaining at the end of the respective fiscal years must not be committed for expenditure after June 30 of the respective fiscal years and reverts to the state general fund as soon as all payments of money committed have been made.
Sec. 227 The amendatory provisions of this act do not apply to offenses that are committed before the effective date of this act.
Sec. 228 The provisions of subsection 1 of NRS 354.599 do not apply to any additional expenses of a local government that are related to the provisions of this act.
Sec. 229 1. This section and sections 1 to 87, inclusive, and 89 to 228, inclusive, of this act become effective upon passage and approval.
2. Section 88 of this act becomes effective on January 1, 1998, and expires by limitation on September 30, 2001.
TEXT OF REPEALED SECTIONS
689C.370"Carrier" defined. "Carrier" means any person who provides health insurance in this state, including a fraternal benefit society, a health maintenance organization, a nonprofit hospital and health service corporation, a health insurance company and any other person providing a plan of health insurance or health benefits subject to this Title.
689C.400"Eligible employee" defined. "Eligible employee" means an employee who has a regular working week of 30 or more hours. The term includes a sole proprietor, a partner of a partnership and an independent contractor if the sole proprietor, partner or independent contractor is included as an employee under a contract. The term does not include an employee who works temporarily or as a substitute.
689C.410"Small employer" defined.
1. "Small employer" means any person actively engaged in a business which, on at least one-half of its working days during the preceding year, employed no fewer than 2 and no more than 25 employees, which was not formed primarily for the purpose of purchasing insurance, and in which a relationship between the employer and the employees exists in good faith. For the purposes of determining the number of eligible employees, organizations which are affiliated or which are eligible to file a combined tax return for the purposes of taxation constitute one employer.
2. For the purposes of this section, organizations are "affiliated" if an organization, directly or indirectly, through one or more intermediaries, controls or is controlled by, or is under common control with, another organization, as determined pursuant to the provisions of NRS 692C.050.