NRS: CHAPTER 689C - HEALTH INSURANCE FOR SMALL EMPLOYERS

[Rev. 6/29/2024 5:00:22 PM--2023]

CHAPTER 689C - HEALTH INSURANCE FOR SMALL EMPLOYERS

HEALTH BENEFIT PLANS

NRS 689C.015 Definitions.

NRS 689C.017 “Affiliated” defined.

NRS 689C.019 “Affiliation period” defined.

NRS 689C.023 “Bona fide association” defined.

NRS 689C.025 “Carrier” defined.

NRS 689C.045 “Class of business” defined.

NRS 689C.047 “Control” defined.

NRS 689C.053 “Creditable coverage” defined.

NRS 689C.055 “Dependent” defined.

NRS 689C.065 “Eligible employee” defined.

NRS 689C.071 “Geographic rating area” defined.

NRS 689C.072 “Geographic service area” defined.

NRS 689C.073 “Group health plan” defined.

NRS 689C.075 “Health benefit plan” defined.

NRS 689C.077 “Network plan” defined.

NRS 689C.078 “Open enrollment” defined.

NRS 689C.079 “Plan for coverage of a bona fide association” defined.

NRS 689C.081 “Plan sponsor” defined.

NRS 689C.083 “Producer” defined.

NRS 689C.0835 “Professional employer organization” defined.

NRS 689C.085 “Rating period” defined.

NRS 689C.095 “Small employer” defined.

NRS 689C.104 “Voluntary purchasing group” defined.

NRS 689C.106 “Waiting period” defined.

NRS 689C.1065 Applicability.

NRS 689C.109 Certain plan, fund or program established or maintained by partnership required to be treated as employee welfare benefit plan which is group health plan; partnership deemed employer of each partner.

NRS 689C.111 Professional employer organization deemed large employer in certain circumstances.

NRS 689C.113 Requirements for employee welfare benefit plan for providing benefits for employees of more than one employer.

NRS 689C.115 Mandatory and optional coverage.

NRS 689C.125 Rating factors for determining premiums; rating periods.

NRS 689C.131 Contracts between carrier and providers of health care: Prohibiting carrier from charging provider of health care fee for inclusion on list of providers given to insureds; carrier required to use form to obtain information on provider of health care; modification; submission by carrier of schedule of payments to providers.

NRS 689C.135 Effect of provision in health benefit plan for restricted network on determination of rates.

NRS 689C.143 Offering of policy of health insurance for purposes of establishing health savings account.

NRS 689C.155 Regulations.

NRS 689C.156 Each health benefit plan marketed in this State required to be offered to small employers; issuance; carrier required to provide system for resolving complaints of employees if services provided or paid for through managed care.

NRS 689C.1565 Coverage to small employers not required under certain circumstances; notice required to Commissioner of and prohibition on writing new business after election not to offer new coverage required.

NRS 689C.159 Certain provisions inapplicable to plan that carrier makes available only through bona fide association.

NRS 689C.160 Carrier must uniformly apply requirements to determine whether to provide coverage.

NRS 689C.165 Carrier prohibited from modifying plan to restrict or exclude coverage or benefits for specific diseases, medical conditions or services otherwise covered by plan; exceptions.

NRS 689C.1652 Coverage for medically necessary treatment of conditions relating to gender dysphoria and gender incongruence required; restriction on refusal to cover certain treatments; authority of carrier to prescribe requirements for covering surgical treatments for minors; determination of medical necessity.

NRS 689C.1653 Coverage for testing, treatment and prevention of sexually transmitted diseases required; coverage for condoms for certain insureds required.

NRS 689C.1655 Coverage for autism spectrum disorders for certain persons required; prohibited acts.

NRS 689C.166 Coverage for alcohol or substance use disorder: Required in group health insurance policy.

NRS 689C.1665 Coverage for certain drugs and services related to substance use disorder and opioid use disorder required; reimbursement of pharmacists and pharmacies for certain services; prohibited acts.

NRS 689C.167 Coverage for alcohol or substance use disorders: Benefits provided by group health insurance policy.

NRS 689C.1671 Coverage for drugs, laboratory testing and certain services related to human immunodeficiency virus and hepatitis C required; reimbursement of certain providers of health care for certain services; prohibited acts.

NRS 689C.1672 Coverage for certain tests and vaccines relating to human papillomavirus required; prohibited acts.

NRS 689C.1673 Coverage for screening, genetic counseling and testing related to BRCA gene required in certain circumstances.

NRS 689C.1674 Coverage for certain screenings and tests for breast cancer required; prohibited acts.

NRS 689C.1675 Coverage for examination of person who is pregnant for certain diseases required.

NRS 689C.1676 Coverage for drug or device for contraception and related health services required; prohibited acts; exceptions.

NRS 689C.1678 Coverage for certain services, screenings and tests relating to wellness required; prohibited acts.

NRS 689C.1679 Plan covering prescription drugs: Required actions by carrier related to acquisition of prescription drugs for certain insureds residing in area for which emergency or disaster has been declared.

NRS 689C.168 Plan covering prescription drugs prohibited from limiting or excluding coverage for prescription drug previously approved for medical condition of insured; exception.

NRS 689C.1681 Plan covering prescription drug for treatment of medical condition that is part of step therapy protocol: Use of certain guidelines required; establishment of process to request exemption from step therapy protocol required; granting of request; applicability of provisions.

NRS 689C.1682 Plan covering prescription drugs: Submission to step therapy protocol for drug to treat psychiatric condition prohibited in certain circumstances.

NRS 689C.1683 Coverage for prescription drugs irregularly dispensed for purpose of synchronization of chronic medications required in plan covering prescription drugs; prohibited acts; exception.

NRS 689C.1684 Plan covering prescription drug for treatment of cancer or cancer symptom that is part of step therapy protocol: Carrier required to allow insured or attending practitioner to apply for exemption from step therapy protocol in certain circumstances; procedure for applying for and granting exemption.

NRS 689C.1685 Plan covering prescription drugs: Denial of coverage prohibited for early refills of otherwise covered topical ophthalmic products.

NRS 689C.1687 Coverage for management and treatment of sickle cell disease and its variants required; coverage for medically necessary prescription drugs to treat sickle cell disease and its variants required in plan covering prescription drugs.

NRS 689C.1688 Coverage for biomarker testing for diagnosis, treatment, management and monitoring of cancer required in certain circumstances; establishment of process to request exception or appeal denial of coverage; time for responding to request for prior authorization.

NRS 689C.169 Coverage for severe mental illness required under group health insurance policy.

NRS 689C.170 Authorized variation of minimum participation and contributions; denial of coverage based on industry prohibited.

NRS 689C.180 Carrier to offer same coverage to all eligible employees; denial of coverage to otherwise eligible employee.

NRS 689C.183 Plan and carrier required to permit employee or dependent of employee to enroll for coverage under certain circumstances.

NRS 689C.187 Manner and period for enrolling dependent of covered employee; period of special enrollment.

NRS 689C.190 Carrier required to offer and issue plan regardless of health status of employees; prohibited acts; authority to include wellness program in plan that offers discounts based on health status under certain circumstances.

NRS 689C.191 Determination of applicable creditable coverage of person; determining period of creditable coverage of person; required statement for certain election by carrier; applicability.

NRS 689C.192 Written certification of coverage required for purpose of determining period of creditable coverage accumulated by person.

NRS 689C.193 Carrier prohibited from imposing restriction on being participant of or beneficiary of plan inconsistent with certain provisions; restrictions on rules of eligibility that may be established.

NRS 689C.194 Plan covering maternity and pediatric care: Required to allow minimum stay in hospital in connection with childbirth; exceptions; prohibited acts.

NRS 689C.1945 Plan covering maternity care: Prohibited acts by carrier if insured is acting as gestational carrier; child deemed child of intended parent for purposes of plan.

NRS 689C.1947 Plan covering anatomical gifts, organ transplants or treatments or services related to organ transplants: Prohibited acts by carrier if insured is person with disability.

NRS 689C.195 Coverage for services provided through telehealth required to same extent as though provided in person or by other means; reimbursement for certain services provided through telehealth required in same amount as though provided in person or by other means; prohibited acts.

NRS 689C.196 Insurer prohibited from denying coverage solely because claim involves act that constitutes domestic violence or applicant or insured was victim of domestic violence.

NRS 689C.197 Carrier prohibited from denying coverage because applicant or insured was intoxicated or under influence of controlled substance; exceptions.

NRS 689C.1975 Carrier prohibited from discriminating against person with respect to participation or coverage on basis of gender identity or expression.

NRS 689C.198 Insurer prohibited from requiring or using information concerning genetic testing; exceptions.

NRS 689C.200 Circumstances in which carrier is not required to offer coverage.

NRS 689C.203 Requirement for denial of application for coverage from small employer; regulations setting standards for fair marketing and broad availability of plans.

NRS 689C.207 Regulations concerning reissuance of health benefit plan.

NRS 689C.220 Adjustment in rates required to be applied uniformly.

NRS 689C.265 Carrier authorized to modify coverage for insurance product under certain circumstances.

NRS 689C.281 Plan covering prescription drugs: Provision of notice and information regarding use of formulary.

NRS 689C.310 Renewal of plan; discontinuance of issuance or renewal of coverage or of plan offered only through bona fide association; discontinuance of product; applicability.

NRS 689C.320 Required notification when carrier discontinues transacting insurance in this State or particular geographic service area of state; restrictions on carrier that discontinues transacting insurance.

NRS 689C.335 Approval or denial of claims; payment of claims and interest; requests for additional information; award of costs and attorney’s fees; compliance with requirements; imposition of administrative fine or suspension or revocation of certificate of authority for failure to comply.

NRS 689C.355 Prohibited acts of carrier or producer related to encouraging or directing small employer to take certain actions; exceptions; prohibited acts by carrier related to contract or agreement with producer; violation may constitute unfair trade practice; applicability.

VOLUNTARY PURCHASING GROUPS

NRS 689C.360 Definitions.

NRS 689C.380 “Contract” defined.

NRS 689C.390 “Dependent” defined.

NRS 689C.420 “Voluntary purchasing group” defined. [Replaced in revision by NRS 689C.104.]

NRS 689C.425 Applicability of other provisions.

NRS 689C.430 Entities which are authorized to offer contracts to voluntary purchasing groups; compliance with provisions required.

NRS 689C.435 Contracts between carrier and providers of health care: Prohibiting carrier from charging provider of health care fee for inclusion on list of providers given to insureds; form to obtain information on provider of health care; modification; schedule of fees. [Replaced in revision by NRS 689C.131.]

NRS 689C.455 Coverage for prescription drugs: Provision of notice and information regarding use of formulary.

NRS 689C.460 Carrier to offer same coverage to all eligible employees; denial of coverage to otherwise eligible employee.

NRS 689C.470 Renewal of contract; discontinuance of product or issuance or renewal of plan offered only through bona fide association.

NRS 689C.480 Required notification when carrier ceases to renew all contracts; restrictions on carrier that ceases to renew all contracts.

NRS 689C.485 Approval or denial of claims; payment of claims and interest; requests for additional information; award of costs and attorney’s fees; compliance with requirements; imposition of administrative fine or suspension or revocation of certificate of authority for failure to comply. [Replaced in revision by NRS 689C.335.]

NRS 689C.490 Formation of voluntary purchasing group by small employers; requirements when affiliate of group ceases to qualify as small employer.

NRS 689C.500 Registration: Requirements; application.

NRS 689C.510 Registration: Fee for application; response to application; regulations.

NRS 689C.520 Registration: Additional requirements.

NRS 689C.530 Filing reports; annual renewal fee; regulations.

NRS 689C.540 Duties.

NRS 689C.550 Collection of premiums; trust account for deposit of premiums.

NRS 689C.560 Regulations governing bond or other security to be maintained by voluntary purchasing group.

NRS 689C.570 Organizer prohibited from acquiring financial interest in group’s business for specified period.

NRS 689C.580 Prohibited acts.

NRS 689C.590 Disciplinary or other action for violation of provisions.

NRS 689C.600 Regulations.

MISCELLANEOUS HEALTH BENEFIT PLANS

NRS 689C.610 Definitions.

NRS 689C.630 “Church plan” defined.

NRS 689C.660 “Individual carrier” defined.

NRS 689C.670 “Individual health benefit plan” defined.

NRS 689C.940 Regulations concerning determination of status of stop-loss policy.

_________

HEALTH BENEFIT PLANS

NRS 689C.015 Definitions. Except as otherwise provided in this chapter, as used in this chapter, unless the context otherwise requires, the words and terms defined in NRS 689C.017 to 689C.106, inclusive, have the meanings ascribed to them in those sections.

(Added to NRS by 1995, 978; A 1997, 1096, 2940; 2011, 3384; 2021, 1935)

NRS 689C.017 “Affiliated” defined. “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.

(Added to NRS by 1997, 2916)

NRS 689C.019 “Affiliation period” defined. “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 a dependent of the eligible employee, if the affiliation period is applied uniformly and without regard to any health status-related factors.

(Added to NRS by 1997, 2916)

NRS 689C.023 “Bona fide association” defined. “Bona fide association” has the meaning ascribed to it in NRS 689A.485.

(Added to NRS by 1997, 2916)

NRS 689C.025 “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.

(Added to NRS by 1995, 978)

NRS 689C.045 “Class of business” defined. “Class of business” means all or a distinct grouping of small employers as shown in the records of a carrier serving small employers.

(Added to NRS by 1995, 978)

NRS 689C.047 “Control” defined. “Control” has the meaning ascribed to it in NRS 692C.050.

(Added to NRS by 1997, 2916)

NRS 689C.053 “Creditable coverage” defined. “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, 42 U.S.C. §§ 1395c et seq., also known as Medicare;

4. Title XIX of the Social Security Act, 42 U.S.C. §§ 1396 et seq., also known as Medicaid, other than coverage consisting solely of benefits under section 1928 of that Title, 42 U.S.C. § 1396s;

5. The Civilian Health and Medical Program of Uniformed Services, CHAMPUS, 10 U.S.C. §§ 1071 et seq.;

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 the Federal Employees Health Benefits Program, FEHBP, 5 U.S.C. §§ 8901 et seq.;

9. A public health plan as defined in federal regulations authorized by the Public Health Service Act, 42 U.S.C. § 300gg(c)(1)(I);

10. A health benefit plan under section 5(e) of the Peace Corps Act, 22 U.S.C. § 2504(e);

11. The Children’s Health Insurance Program established pursuant to 42 U.S.C. §§ 1397aa to 1397jj, inclusive;

12. A short-term health insurance policy; or

13. A blanket student accident and health insurance policy.

(Added to NRS by 1997, 2916; A 1999, 2240, 2811)

NRS 689C.055 “Dependent” defined. “Dependent” means a spouse, a domestic partner as defined in NRS 122A.030, or a child on or before the last day of the month in which the child attains 26 years of age.

(Added to NRS by 1995, 978; A 2013, 3625)

NRS 689C.065 “Eligible employee” defined.

1. “Eligible employee” means a permanent employee who has a regular working week of 30 or more hours.

2. The term includes a sole proprietor, a partner of a partnership or an employee of a professional employer organization, if the sole proprietor, partner or employee of the professional employer organization is included as an employee under a health benefit plan of a small employer.

(Added to NRS by 1995, 978; A 2011, 3384; 2021, 1935)

NRS 689C.071 “Geographic rating area” defined. “Geographic rating area” means an area established by the Commissioner for use in adjusting the rates for a health benefit plan.

(Added to NRS by 1997, 2917; A 2013, 3625)

NRS 689C.072 “Geographic service area” defined. “Geographic service area” means a geographic area, as approved by the Commissioner, within which the carrier is authorized to provide coverage.

(Added to NRS by 1997, 2917; A 2013, 3625)

NRS 689C.073 “Group health plan” defined.

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 July 16, 1997, 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;

(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

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 July 16, 1997;

(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

(Added to NRS by 1997, 2917)

NRS 689C.075 “Health benefit plan” defined. “Health benefit plan” has the meaning ascribed to it in NRS 687B.470.

(Added to NRS by 1995, 978; A 1997, 2940; 1999, 2811; 2007, 3326; 2023, 2639)

NRS 689C.077 “Network plan” defined. “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.

(Added to NRS by 1997, 2918)

NRS 689C.078 “Open enrollment” defined. “Open enrollment” means the period designated for enrollment in a health benefit plan.

(Added to NRS by 1997, 2918)

NRS 689C.079 “Plan for coverage of a bona fide association” defined. “Plan for coverage of a bona fide association” has the meaning ascribed to it in NRS 689A.570.

(Added to NRS by 1997, 2918)

NRS 689C.081 “Plan sponsor” defined. “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 July 16, 1997.

(Added to NRS by 1997, 2918)

NRS 689C.083 “Producer” defined. “Producer” means an agent or broker licensed pursuant to this title.

(Added to NRS by 1997, 2918)

NRS 689C.0835 “Professional employer organization” defined. “Professional employer organization” has the meaning ascribed to it in NRS 611.400.

(Added to NRS by 2021, 1935)

NRS 689C.085 “Rating period” defined. “Rating period” means the period for which premium rates established by a carrier are assumed to be in effect.

(Added to NRS by 1995, 979)

NRS 689C.095 “Small employer” defined. “Small employer” has the meaning ascribed to it in 42 U.S.C. § 18024(b)(2).

(Added to NRS by 1995, 979; A 1997, 2941; 1999, 2812; 2013, 3625)

NRS 689C.104 “Voluntary purchasing group” defined. “Voluntary purchasing group” means the employers and their eligible employees and dependents who form a group pursuant to NRS 689C.360 to 689C.600, inclusive, and hold a certificate of registration issued by the Commissioner pursuant to NRS 689C.510.

(Added to NRS by 1995, 2677)—(Substituted in revision for NRS 689C.420)

NRS 689C.106 “Waiting period” defined. “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. The term includes the period from the date a person submits an application to an individual carrier for coverage under a health benefit plan until the first day of coverage under that health benefit plan.

(Added to NRS by 1997, 2919; A 1999, 2813)

NRS 689C.1065 Applicability. The provisions of this chapter apply to health benefit plans that provide coverage to the employees of small employers in this state and to carriers that offer those health benefit plans if:

1. A portion of the premium or benefits are paid by or on behalf of the small employer;

2. An eligible employee or a dependent of the eligible employee is reimbursed for a portion of the premium, whether by wage adjustments or otherwise, by or on behalf of the small employer; or

3. The health benefit plan is considered by the small employer or any of the small employer’s eligible employees or dependents as part of a plan or program for the purposes of section 106, 125 or 162 of the Internal Revenue Code, 26 U.S.C. § 106, 125 or 162.

(Added to NRS by 1999, 2810)

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 July 16, 1997, 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.

(Added to NRS by 1997, 2919)

NRS 689C.111 Professional employer organization deemed large employer in certain circumstances. A professional employer organization which has more than 50 employees, including leased employees at client locations, and which sponsors a fully insured health benefit plan for those employees shall be deemed to be a large employer for the purposes of this chapter.

(Added to NRS by 1997, 2919; A 2011, 3384; 2017, 2372; 2021, 1935)

NRS 689C.113 Requirements for employee welfare benefit plan for providing benefits for employees of more than one employer.

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.

(Added to NRS by 1997, 2928)

NRS 689C.115 Mandatory and optional coverage.

1. A health benefit plan offered by a carrier pursuant to this chapter must include coverage of basic medical and hospital care.

2. In addition to the coverage required by subsection 1, a carrier may offer additional coverage for an additional cost upon the approval of the Commissioner.

(Added to NRS by 1995, 979)

NRS 689C.125 Rating factors for determining premiums; rating periods.

1. A carrier serving small employers shall apply rating factors consistently with respect to all small employers. Rating factors must produce premiums for identical groups that differ only by the amounts attributable to the design of the plans and the terms of the coverage and do not reflect differences based on the nature of the groups that will select particular health benefit plans. As used in this subsection, “premium” means all money paid by a small employer and eligible employees to a carrier as a condition of receiving coverage from a carrier, including any fees or other contributions associated with the health benefit plan.

2. A carrier serving small employers shall treat all health benefit plans issued or renewed in the same calendar month as having the same rating period, if the terms of coverage provided in the plans are the same.

(Added to NRS by 1995, 979; A 2013, 3625)

1. A carrier serving small employers and a carrier that offers a contract to a voluntary purchasing group shall not charge a provider of health care a fee to include the name of the provider on a list of providers of health care given by the carrier to its insureds.

2. A carrier specified in subsection 1 shall not contract with a provider of health care to provide health care to an insured unless the carrier uses the form prescribed by the Commissioner pursuant to NRS 629.095 to obtain any information related to the credentials of the provider of health care.

3. A contract between a carrier specified in subsection 1 and a provider of health care may be modified:

(a) At any time pursuant to a written agreement executed by both parties.

(b) Except as otherwise provided in this paragraph, by the carrier upon giving to the provider 45 days’ written notice of the modification of the carrier’s schedule of payments, including any changes to the fee schedule applicable to the provider’s practice. If the provider fails to object in writing to the modification within the 45 day period, the modification becomes effective at the end of that period. If the provider objects in writing to the modification within the 45 day period, the modification must not become effective unless agreed to by both parties as described in paragraph (a).

4. If a carrier specified in subsection 1 contracts with a provider of health care to provide health care to an insured, the carrier shall:

(a) If requested by the provider of health care at the time the contract is made, submit to the provider of health care the schedule of payments applicable to the provider of health care; or

(b) If requested by the provider of health care at any other time, submit to the provider of health care the schedule of payments, including any changes to the fee schedule applicable to the provider’s practice, specified in paragraph (a) within 7 days after receiving the request.

5. As used in this section, “provider of health care” means a provider of health care who is licensed pursuant to chapter 630, 631, 632 or 633 of NRS.

(Added to NRS by 1999, 1648; A 2001, 2731; 2003, 3359; 2011, 2533)—(Substituted in revision for NRS 689C.435)

NRS 689C.135 Effect of provision in health benefit plan for restricted network on determination of rates.

1. For the purposes of determining rates charged for health benefit plans, a health benefit plan that contains a provision for a restricted network is not similar coverage to a health benefit plan that does not contain such a provision if the restriction of benefits results in material differences in cost of claims.

2. As used in this section, “provision for a restricted network” means any provision of a group health benefit plan that conditions the payment of benefits, in whole or in part, on the use of providers of health care who have entered into a contractual arrangement with the carrier to provide health care to persons covered by the plan.

(Added to NRS by 1995, 980)

NRS 689C.143 Offering of policy of health insurance for purposes of establishing health savings account. A carrier may, subject to regulation by the Commissioner, offer a policy of health insurance that has a high deductible and is in compliance with 26 U.S.C. § 223 for the purposes of establishing a health savings account.

(Added to NRS by 2005, 2137)

NRS 689C.155 Regulations. The Commissioner may adopt regulations to carry out the provisions of NRS 689C.109 to 689C.143, inclusive, 689C.156 to 689C.159, inclusive, 689C.165, 689C.183, 689C.187, 689C.191 to 689C.198, inclusive, 689C.203, 689C.207, 689C.265, 689C.325, 689C.355 and 689C.610 to 689C.940, inclusive, 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 rating factors may be used by such carriers.

(Added to NRS by 1995, 980; A 1997, 2942; 2013, 3626; 2015, 640)

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. 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.355, inclusive, and 689C.610 to 689C.940, inclusive, 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.

3. If a health benefit plan marketed pursuant to this section provides, delivers, arranges for, pays for or reimburses any cost of health care services through managed care, the carrier shall provide a system for resolving any complaints of an employee concerning those health care services that complies with the provisions of NRS 695G.200 to 695G.310, inclusive.

(Added to NRS by 1997, 2920; A 2003, 775; 2011, 3384; 2013, 3626; 2015, 640)

1. A carrier is not required to provide coverage to small employers pursuant to NRS 689C.156:

(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.

(Added to NRS by 1997, 2920)

NRS 689C.158 Producer authorized only to market to or sign up small employers and eligible employees in bona fide associations if employers and employees are actively engaged in or directly related to bona fide association. 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.

(Added to NRS by 1997, 2919)

NRS 689C.159 Certain provisions inapplicable to plan that carrier makes available only through bona fide association. The provisions of NRS 689C.156 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.

(Added to NRS by 1997, 2921; A 2013, 3627; 2019, 302)

NRS 689C.160 Carrier must uniformly apply requirements to determine whether to provide coverage. The requirements used by a carrier serving small employers to determine whether to provide coverage to a small employer, including, without limitation, requirements for minimum participation of eligible employees and minimum employer’s contributions, must be applied uniformly among all small employers with the same number of eligible employees applying for coverage or receiving coverage from the carrier.

(Added to NRS by 1995, 980; A 2013, 3627)

NRS 689C.165 Carrier prohibited from modifying plan to restrict or exclude coverage or benefits for specific diseases, medical conditions or services otherwise covered by plan; exceptions. 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.

(Added to NRS by 1997, 2921)

1. Except as otherwise provided in this section, a carrier that issues a health benefit plan shall include in the health benefit plan coverage for the medically necessary treatment of conditions relating to gender dysphoria and gender incongruence. Such coverage must include coverage of medically necessary psychosocial and surgical intervention and any other medically necessary treatment for such disorders provided by:

(a) Endocrinologists;

(b) Pediatric endocrinologists;

(d) Psychiatrists;

(e) Psychologists;

(f) Gynecologists;

(g) Speech-language pathologists;

(h) Primary care physicians;

(i) Advanced practice registered nurses;

(j) Physician assistants; and

(k) Any other providers of medically necessary services for the treatment of gender dysphoria or gender incongruence.

2. This section does not require a health benefit plan to include coverage for cosmetic surgery performed by a plastic surgeon or reconstructive surgeon that is not medically necessary.

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

4. A carrier that issues a health benefit plan may prescribe requirements that must be satisfied before the carrier covers surgical treatment of conditions relating to gender dysphoria or gender incongruence for an insured who is less than 18 years of age. Such requirements may include, without limitation, requirements that:

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

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

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

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

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

6. A carrier shall make a reasonable effort to ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the carrier. If, after a reasonable effort, the carrier is unable to make such benefits available through such a provider of health care, the carrier may treat the treatment that the carrier is unable to make available through such a provider of health care in the same manner as other services provided by a provider of health care who does not participate in the network plan of the carrier.

7. If an insured appeals the denial of a claim or coverage under this section on the grounds that the treatment requested by the insured is not medically necessary, the carrier must consult with a provider of health care who has experience in prescribing or delivering gender-affirming treatment concerning the medical necessity of the treatment requested by the insured when considering the appeal.

8. A health benefit plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2023, has the legal effect of including the coverage required by subsection 1, and any provision of the plan or renewal which is in conflict with the provisions of this section is void.

9. As used in this section:

(a) “Cosmetic surgery”:

(1) Means a surgical procedure that:

(I) Does not meaningfully promote the proper function of the body;

(II) Does not prevent or treat illness or disease; and

(III) Is primarily directed at improving the appearance of a person.

(2) Includes, without limitation, cosmetic surgery directed at preserving beauty.

(b) “Gender dysphoria” means distress or impairment in social, occupational or other areas of functioning caused by a marked difference between the gender identity or expression of a person and the sex assigned to the person at birth which lasts at least 6 months and is shown by at least two of the following:

(1) A marked difference between gender identity or expression and primary or secondary sex characteristics or anticipated secondary sex characteristics in young adolescents.

(2) A strong desire to be rid of primary or secondary sex characteristics because of a marked difference between such sex characteristics and gender identity or expression or a desire to prevent the development of anticipated secondary sex characteristics in young adolescents.

(3) A strong desire for the primary or secondary sex characteristics of the gender opposite from the sex assigned at birth.

(4) A strong desire to be of the opposite gender or a gender different from the sex assigned at birth.

(5) A strong desire to be treated as the opposite gender or a gender different from the sex assigned at birth.

(6) A strong conviction of experiencing typical feelings and reactions of the opposite gender or a gender different from the sex assigned at birth.

(c) “Medically necessary” means health care services or products that a prudent provider of health care would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that are necessary and:

(1) Provided in accordance with generally accepted standards of medical practice;

(2) Clinically appropriate with regard to type, frequency, extent, location and duration;

(3) Not provided primarily for the convenience of the patient or provider of health care;

(4) Required to improve a specific health condition of a patient or to preserve the existing state of health of the patient; and

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

Ê A provider of health care prescribing, ordering, recommending or approving a health care service or product does not, by itself, make that health care service or product medically necessary.

(d) “Network plan” means a health benefit plan offered by a 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.

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

(Added to NRS by 2023, 2032)

NRS 689C.1653 Coverage for testing, treatment and prevention of sexually transmitted diseases required; coverage for condoms for certain insureds required.

1. A carrier that offers or issues a health benefit plan shall include in the plan:

(a) Coverage of testing for and the treatment and prevention of sexually transmitted diseases, including, without limitation, Chlamydia trachomatis, gonorrhea, syphilis, human immunodeficiency virus and hepatitis B and C, for all insureds, regardless of age. Such coverage must include, without limitation, the coverage required by NRS 689C.1671 and 689C.1675.

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

2. A health benefit plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2024, has the legal effect of including the coverage required by subsection 1, and any provision of the plan that conflicts with the provisions of this section is void.

(Added to NRS by 2023, 3516)

NRS 689C.1655 Coverage for autism spectrum disorders for certain persons required; prohibited acts.

1. A health benefit plan must provide coverage for screening for and diagnosis of autism spectrum disorders and for treatment of autism spectrum disorders to persons covered by the health benefit plan under the age of 18 years or, if enrolled in high school, until the person reaches the age of 22 years.

2. Coverage provided under this section is subject to:

(a) A maximum benefit of the actuarial equivalent of $72,000 per year for applied behavior analysis treatment; and

(b) Copayment, deductible and coinsurance provisions and any other general exclusion or limitation of a health benefit plan to the same extent as other medical services or prescription drugs covered by the plan.

3. A health benefit plan that offers or issues a policy of group health insurance which provides coverage for outpatient care shall not:

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

(b) Refuse to issue a health benefit plan or cancel a health benefit plan solely because the person applying for or covered by the plan uses or may use in the future any of the services listed in subsection 1.

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

5. Treatment of autism spectrum disorders must be identified in a treatment plan and may include medically necessary habilitative or rehabilitative care, prescription care, psychiatric care, psychological care, behavioral therapy or therapeutic care that is:

(a) Prescribed for a person diagnosed with an autism spectrum disorder by a licensed physician or licensed psychologist; and

(b) Provided for a person diagnosed with an autism spectrum disorder by a licensed physician, licensed psychologist, licensed behavior analyst or other provider that is supervised by the licensed physician, psychologist or behavior analyst.

Ê A carrier may request a copy of and review a treatment plan created pursuant to this subsection.

6. A health benefit plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2011, has the legal effect of including the coverage required by subsection 1, and any provision of the plan or the renewal which is in conflict with subsection 1 or 2 is void.

7. Nothing in this section shall be construed as requiring a carrier to provide reimbursement to a school for services delivered through school services.

8. As used in this section:

(a) “Applied behavior analysis” means the design, implementation and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including, without limitation, the use of direct observation, measurement and functional analysis of the relations between environment and behavior.

(b) “Autism spectrum disorder” has the meaning ascribed to it in NRS 427A.875.

(c) “Behavioral therapy” means any interactive therapy derived from evidence-based research, including, without limitation, discrete trial training, early intensive behavioral intervention, intensive intervention programs, pivotal response training and verbal behavior provided by a licensed psychologist, licensed behavior analyst, licensed assistant behavior analyst or registered behavior technician.

(d) “Evidence-based research” means research that applies rigorous, systematic and objective procedures to obtain valid knowledge relevant to autism spectrum disorders.

(e) “Habilitative or rehabilitative care” means counseling, guidance and professional services and treatment programs, including, without limitation, applied behavior analysis, that are necessary to develop, maintain and restore, to the maximum extent practicable, the functioning of a person.

(f) “Licensed assistant behavior analyst” has the meaning ascribed to the term “assistant behavior analyst” in NRS 641D.020.

(g) “Licensed behavior analyst” has the meaning ascribed to the term “behavior analyst” in NRS 641D.030.

(h) “Prescription care” means medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need or effectiveness of the medications.

(i) “Psychiatric care” means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.

(j) “Psychological care” means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.

(k) “Registered behavior technician” has the meaning ascribed to it in NRS 641D.100.

(l) “Screening for autism spectrum disorders” means medically necessary assessments, evaluations or tests to screen and diagnose whether a person has an autism spectrum disorder.

(m) “Therapeutic care” means services provided by licensed or certified speech-language pathologists, occupational therapists and physical therapists.

(n) “Treatment plan” means a plan to treat an autism spectrum disorder that is prescribed by a licensed physician or licensed psychologist and may be developed pursuant to a comprehensive evaluation in coordination with a licensed behavior analyst.

(Added to NRS by 2009, 1469; A 2015, 685, 687; 2017, 1500, 4256; 2019, 2561; 2021, 1651)

NRS 689C.166 Coverage for alcohol or substance use disorder: Required in group health insurance policy. Each group health insurance policy must contain in substance a provision for benefits payable for expenses incurred for the treatment of alcohol or substance use disorder, as provided in NRS 689C.1665 and 689C.167.

(Added to NRS by 2009, 1811; A 2023, 2374, 3516)

1. A carrier that offers or issues a health benefit plan shall include in the plan coverage for:

(a) All drugs approved by the United States Food and Drug Administration to support safe withdrawal from substance use disorder, including, without limitation, lofexidine.

(b) All drugs approved by the United States Food and Drug Administration to provide medication-assisted treatment for opioid use disorder, including, without limitation, buprenorphine, methadone and naltrexone.

(c) The services described in NRS 639.28079 when provided by a pharmacist or pharmacy that participates in the network plan of the carrier. The Commissioner shall adopt regulations governing the provision of reimbursement for such services.

(d) Any service for the treatment of substance use disorder provided by a provider of primary care if the service is covered when provided by a specialist and:

(1) The service is within the scope of practice of the provider of primary care; or

(2) The provider of primary care is capable of providing the service safely and effectively in consultation with a specialist and the provider engages in such consultation.

2. A carrier that offers or issues a health benefit plan shall reimburse a pharmacist or pharmacy that participates in the network plan of the carrier for the services described in NRS 639.28079 at a rate equal to the rate of reimbursement provided to a physician, physician assistant or advanced practice registered nurse for similar services.

3. A carrier shall provide the coverage required by paragraphs (a) and (b) of subsection 1 regardless of whether the drug is included in the formulary of the carrier.

4. Except as otherwise provided in this subsection, a carrier shall not subject the benefits required by paragraphs (a), (b) and (c) of subsection 1 to medical management techniques, other than step therapy. A carrier may subject the benefits required by paragraphs (b) and (c) of subsection 1 to other reasonable medical management techniques when the benefits are provided by a pharmacist in accordance with NRS 639.28079.

5. A carrier shall not:

(a) Limit the covered amount of a drug described in paragraph (a) or (b) of subsection 1; or

(b) Refuse to cover a drug described in paragraph (a) or (b) of subsection 1 because the drug is dispensed by a pharmacy through mail order service.

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

7. A health benefit plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2024, has the legal effect of including the coverage required by subsection 1, and any provision of the plan that conflicts with the provisions of this section is void.

8. As used in this section:

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

(b) “Network plan” means a health benefit plan offered by a 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.

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

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

(Added to NRS by 2023, 2373, 3515)

NRS 689C.167 Coverage for alcohol or substance use disorders: Benefits provided by group health insurance policy.

1. In addition to the benefits required by NRS 689C.1665, the benefits provided by a group policy for health insurance, as required by NRS 689C.166, for the treatment of alcohol or substance use disorders must include, without limitation:

(a) Treatment for withdrawal from the physiological effects of alcohol or drugs, with a minimum benefit of $1,500 per calendar year.

(b) Treatment for a patient admitted to a facility, with a minimum benefit of $9,000 per calendar year.

(c) Counseling for a person, group or family who is not admitted to a facility, with a minimum benefit of $2,500 per calendar year.

2. Except as otherwise provided in NRS 687B.409, these benefits must be paid in the same manner as benefits for any other illness covered by a similar policy are paid.

3. The insured person is entitled to these benefits if treatment is received in any:

(a) Facility for the treatment of alcohol or substance use disorders which is certified by the Division of Public and Behavioral Health of the Department of Health and Human Services.

(b) Hospital or other medical facility or facility for the dependent which is licensed by the Division of Public and Behavioral Health of the Department of Health and Human Services, is accredited by The Joint Commission or CARF International and provides a program for the treatment of alcohol or substance use disorders as part of its accredited activities.

(Added to NRS by 2009, 1812; A 2017, 2210; 2023, 2374, 3516)

1. A carrier that offers or issues a health benefit plan shall include in the plan coverage for:

(a) All drugs approved by the United States Food and Drug Administration for preventing the acquisition of human immunodeficiency virus or treating human immunodeficiency virus or hepatitis C in the form recommended by the prescribing practitioner, regardless of whether the drug is included in the formulary of the carrier;

(b) Laboratory testing that is necessary for therapy that uses a drug to prevent the acquisition of human immunodeficiency virus;

(c) Any service to test for, prevent or treat human immunodeficiency virus or hepatitis C provided by a provider of primary care if the service is covered when provided by a specialist and:

(1) The service is within the scope of practice of the provider of primary care; or

(2) The provider of primary care is capable of providing the service safely and effectively in consultation with a specialist and the provider engages in such consultation; and

(d) The services described in NRS 639.28085, when provided by a pharmacist who participates in the health benefit plan of the carrier.

2. A carrier that offers or issues a health benefit plan shall reimburse:

(a) A pharmacist who participates in the health benefit plan of the carrier for the services described in NRS 639.28085 at a rate equal to the rate of reimbursement provided to a physician, physician assistant or advanced practice registered nurse for similar services.

(b) An advanced practice registered nurse or a physician assistant who participates in the network plan of the carrier for any service to test for, prevent or treat human immunodeficiency virus or hepatitis C at a rate equal to the rate of reimbursement provided to a physician for similar services.

3. A carrier shall not:

(a) Subject the benefits required by subsection 1 to medical management techniques, other than step therapy;

(b) Limit the covered amount of a drug described in paragraph (a) of subsection 1;

(c) Refuse to cover a drug described in paragraph (a) of subsection 1 because the drug is dispensed by a pharmacy through mail order service; or

(d) Prohibit or restrict access to any service or drug to treat human immunodeficiency virus or hepatitis C on the same day on which the insured is diagnosed.

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

5. A health benefit plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2024, has the legal effect of including the coverage required by subsection 1, and any provision of the plan that conflicts with the provisions of this section is void.

6. As used in this section:

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

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

(Added to NRS by 2021, 3208; A 2023, 3517)

NRS 689C.1672 Coverage for certain tests and vaccines relating to human papillomavirus required; prohibited acts.

1. A health benefit plan must provide coverage for benefits payable for expenses incurred for:

(a) Deoxyribonucleic acid testing for high-risk strains of human papillomavirus every 3 years for women 30 years of age or older; and

(b) Administering the human papillomavirus vaccine as recommended for vaccination by a competent authority, including, without limitation, the Centers for Disease Control and Prevention of the United States Department of Health and Human Services, the Food and Drug Administration or the manufacturer of the vaccine.

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

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

(a) Require an insured to pay a higher deductible, any copayment or coinsurance or require a longer waiting period or other condition to obtain any benefit provided in the health benefit plan pursuant to subsection 1;

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

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

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

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

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

4. A plan subject to the provisions of this chapter which is delivered, issued for delivery or renewed on or after January 1, 2018, has the legal effect of including the coverage required by subsection 1, and any provision of the plan or the renewal which is in conflict with this section is void.

5. Except as otherwise provided in this section and federal law, a carrier may use medical management techniques, including, without limitation, any available clinical evidence, to determine the frequency of or treatment relating to any benefit required by this section or the type of provider of health care to use for such treatment.

6. As used in this section:

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

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

(c) “Network plan” means a health benefit plan offered by a 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.

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

(Added to NRS by 2017, 1825)

NRS 689C.1673 Coverage for screening, genetic counseling and testing related to BRCA gene required in certain circumstances.

1. A carrier that issues a health benefit plan shall provide coverage for screening, genetic counseling and testing for harmful mutations in the BRCA gene for women under circumstances where such screening, genetic counseling or testing, as applicable, is required by NRS 457.301.

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

3. A health benefit plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2022, has the legal effect of including the coverage required by subsection 1, and any provision of the plan that conflicts with the provisions of this section is void.

4. As used in this section, “provider of health care” has the meaning ascribed to it in NRS 629.031.

(Added to NRS by 2021, 781)

NRS 689C.1674 Coverage for certain screenings and tests for breast cancer required; prohibited acts.

1. A health benefit plan must provide coverage for benefits payable for expenses incurred for:

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

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

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

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

(2) Detected by other means of examination.

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

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

(a) Except as otherwise provided in subsection 6, require an insured to pay a deductible, copayment, coinsurance or any other form of cost-sharing or require a longer waiting period or other condition to obtain any benefit provided in the health benefit plan pursuant to subsection 1;

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

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

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

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

4. A plan subject to the provisions of this chapter which is delivered, issued for delivery or renewed on or after January 1, 2024, has the legal effect of including the coverage required by subsection 1, and any provision of the plan or the renewal which is in conflict with this section is void.

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

7. As used in this section:

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

(d) “Qualified health benefit plan” means a health benefit plan that has a high deductible and is in compliance with 26 U.S.C. § 223 for the purposes of establishing a health savings account.

(Added to NRS by 2017, 1827; A 2023, 1346)

NRS 689C.1675 Coverage for examination of person who is pregnant for certain diseases required.

1. A carrier that issues a health benefit plan shall provide coverage for the examination of a person who is pregnant for the discovery of:

(a) Chlamydia trachomatis, gonorrhea, hepatitis B and hepatitis C in accordance with NRS 442.013.

(b) Syphilis in accordance with NRS 442.010.

2. The coverage required by this section must be provided:

(a) Regardless of whether the benefits are provided to the insured by a provider of health care, facility or medical laboratory that participates in the network plan of the carrier; and

(b) Without prior authorization.

3. A health benefit plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2021, has the legal effect of including the coverage required by subsection 1, and any provision of the plan that conflicts with the provisions of this section is void.

4. As used in this section:

(a) “Medical laboratory” has the meaning ascribed to it in NRS 652.060.

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

(Added to NRS by 2021, 2579)

NRS 689C.1676 Coverage for drug or device for contraception and related health services required; prohibited acts; exceptions.

1. Except as otherwise provided in subsection 8, a carrier that offers or issues a health benefit plan shall include in the plan coverage for:

(a) Up to a 12-month supply, per prescription, of any type of drug for contraception or its therapeutic equivalent which is:

(1) Lawfully prescribed or ordered;

(2) Approved by the Food and Drug Administration;

(3) Listed in subsection 11; and

(4) Dispensed in accordance with NRS 639.28075;

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

(1) Lawfully prescribed or ordered;

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

(3) Listed in subsection 11;

(d) Insertion of a device for contraception or removal of such a device if the device was inserted while the insured was covered by the same health benefit plan;

(e) Education and counseling relating to the initiation of the use of contraception and any necessary follow-up after initiating such use;

(f) Management of side effects relating to contraception; and

(g) Voluntary sterilization for women.

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

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

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

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

4. If a covered therapeutic equivalent listed in subsection 1 is not available or a provider of health care deems a covered therapeutic equivalent to be medically inappropriate, an alternate therapeutic equivalent prescribed by a provider of health care must be covered by the carrier.

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

(a) Require an insured to pay a higher deductible, any copayment or coinsurance or require a longer waiting period or other condition to obtain any benefit included in the health benefit plan pursuant to subsection 1;

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

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

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

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

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

7. Except as otherwise provided in subsection 8, a health benefit plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2024, has the legal effect of including the coverage required by this section, and any provision of the plan or the renewal which is in conflict with this section is void.

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

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

10. For each of the 18 methods of contraception listed in subsection 11 that have been approved by the Food and Drug Administration, a health benefit plan must include at least one drug or device for contraception within each method for which no deductible, copayment or coinsurance may be charged to the insured, but the carrier may charge a deductible, copayment or coinsurance for any other drug or device that provides the same method of contraception. If the carrier charges a copayment or coinsurance for a drug for contraception, the carrier may only require an insured to pay the copayment or coinsurance:

(a) Once for the entire amount of the drug dispensed for the plan year; or

(b) Once for each 1-month supply of the drug dispensed.

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

(a) Voluntary sterilization for women;

(b) Surgical sterilization implants for women;

(d) Copper-based intrauterine devices;

(e) Progesterone-based intrauterine devices;

(f) Injections;

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

(h) Progestin-based drugs;

(i) Extended- or continuous-regimen drugs;

(j) Estrogen- and progestin-based patches;

(k) Vaginal contraceptive rings;

(l) Diaphragms with spermicide;

(m) Sponges with spermicide;

(n) Cervical caps with spermicide;

(o) Female condoms;

(p) Spermicide;

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

(r) Ulipristal acetate for emergency contraception.

12. Except as otherwise provided in this section and federal law, a carrier may use medical management techniques, including, without limitation, any available clinical evidence, to determine the frequency of or treatment relating to any benefit required by this section or the type of provider of health care to use for such treatment.

13. A carrier shall not:

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

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

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

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

15. As used in this section:

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

(d) “Provider network contract” means a contract between a carrier and a provider of health care or pharmacy specifying the rights and responsibilities of the carrier and the provider of health care or pharmacy, as applicable, for delivery of health care services pursuant to a network plan.

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

(f) “Therapeutic equivalent” means a drug which:

(1) Contains an identical amount of the same active ingredients in the same dosage and method of administration as another drug;

(2) Is expected to have the same clinical effect when administered to a patient pursuant to a prescription or order as another drug; and

(3) Meets any other criteria required by the Food and Drug Administration for classification as a therapeutic equivalent.

(Added to NRS by 2017, 1822, 3941; A 2021, 3278; 2023, 919, 2118)

NRS 689C.1678 Coverage for certain services, screenings and tests relating to wellness required; prohibited acts.

1. A carrier that offers or issues a health benefit plan shall include in the plan coverage for:

(a) Counseling, support and supplies for breastfeeding, including breastfeeding equipment, counseling and education during the antenatal, perinatal and postpartum period for not more than 1 year;

(b) Screening and counseling for interpersonal and domestic violence for women at least annually, with initial intervention services consisting of education, strategies to reduce harm, supportive services or a referral for any other appropriate services;

(c) Behavioral counseling concerning sexually transmitted diseases from a provider of health care for sexually active women who are at increased risk for such diseases;

(d) Hormone replacement therapy;

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

(f) Screening for blood pressure abnormalities and diabetes, including gestational diabetes, after at least 24 weeks of gestation or as ordered by a provider of health care;

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

(h) Screening for depression;

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

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

(k) All vaccinations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention of the United States Department of Health and Human Services or its successor organization; and

(l) Such well-woman preventative visits as recommended by the Health Resources and Services Administration, which must include at least one such visit per year beginning at 14 years of age.

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

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

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

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

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

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

4. A plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2018, has the legal effect of including the coverage required by subsection 1, and any provision of the plan or the renewal which is in conflict with this section is void.

6. As used in this section:

(Added to NRS by 2017, 1824)

1. If the Governor or the Legislature proclaims the existence of a state of emergency or issues a declaration of disaster pursuant to NRS 414.070, a carrier who has issued a health benefit plan which provides coverage for prescription drugs shall, notwithstanding any provision of the plan to the contrary:

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

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

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

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

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

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

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

(Added to NRS by 2021, 825)

NRS 689C.168 Plan covering prescription drugs prohibited from limiting or excluding coverage for prescription drug previously approved for medical condition of insured; exception.

1. Except as otherwise provided in this section, a health benefit plan which provides coverage for prescription drugs must not limit or exclude coverage for a drug if the drug:

(a) Had previously been approved for coverage by the carrier for a medical condition of an insured and the insured’s provider of health care determines, after conducting a reasonable investigation, that none of the drugs which are otherwise currently approved for coverage are medically appropriate for the insured; and

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

2. The provisions of subsection 1 do not:

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

(b) Prohibit:

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

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

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

3. Any provision of a health benefit plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 2001, which is in conflict with this section is void.

(Added to NRS by 2001, 859; A 2003, 2299; 2017, 637)

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

2. A carrier that offers or issues a health benefit plan which includes coverage for a prescription drug for the treatment of any medical condition that is part of a step therapy protocol shall:

(a) Establish a clear, convenient and readily accessible process by which an insured and his or her attending practitioner may:

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

(2) Appeal a decision made by the carrier concerning a request for an exemption from the step therapy protocol pursuant to subparagraph (1);

(b) Make the process described in paragraph (a) accessible through an Internet website maintained by the carrier; and

(c) Except as otherwise provided in this paragraph, respond to a request made or an appeal submitted pursuant to paragraph (a) not later than 2 business days after the request is made or the appeal is submitted, as applicable. If the attending practitioner indicates that exigent circumstances exist, the carrier shall respond to the request or appeal within 24 hours after the request is made or the appeal is submitted, as applicable.

3. A carrier shall grant a request to exempt an insured from a step therapy protocol made in accordance with the process established pursuant to subsection 2 if the attending practitioner for the insured submits to the carrier a statement which provides an adequate justification for the exemption and any documentation necessary to support the statement. The carrier shall determine whether such justification exists if the statement and documentation demonstrate that:

(a) Each prescription drug that is required to be used earlier in the step therapy protocol:

(1) Is contraindicated or will likely cause an adverse reaction or physical or mental harm to the insured;

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

(3) Has been tried by the insured, regardless of whether the insured was covered by the current health benefit plan at the time, and was discontinued due to lack of efficacy or effectiveness, diminished effect or an adverse event relating to the prescription drug; or

(4) Is not in the best interest of the insured, based on medical necessity; or

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

4. If a carrier does not respond to a request for an exemption from a step therapy protocol or an appeal concerning a decision relating to such a request within the time frame prescribed by paragraph (c) of subsection 2, the request shall be deemed to have been granted.

5. If a request for an exemption from a step therapy protocol is granted pursuant to subsection 3 or deemed granted pursuant to subsection 4, the carrier shall immediately authorize coverage for and dispensing of the drug chosen by the attending practitioner for the insured.

6. A health benefit plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2024, has the legal effect of including the coverage required by this section, and any provisions of the policy that conflict with the provisions of this section is void.

7. The provisions of this section do not apply to any prescription drug to which the provisions of NRS 689C.1684 apply.

8. As used in this section:

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

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

(Added to NRS by 2023, 810)

NRS 689C.1682 Plan covering prescription drugs: Submission to step therapy protocol for drug to treat psychiatric condition prohibited in certain circumstances.

1. A health benefit plan which provides coverage for prescription drugs must not require an insured to submit to a step therapy protocol before covering a drug approved by the Food and Drug Administration that is prescribed to treat a psychiatric condition of the insured, if:

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

(b) The drug is prescribed by:

(1) A psychiatrist;

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

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

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

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

2. Any provision of a health benefit plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2023, which is in conflict with this section is void.

3. As used in this section:

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

(b) “Network plan” means a health 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 health carrier. The term does not include an arrangement for the financing of premiums.

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

(Added to NRS by 2023, 1783)

NRS 689C.1683 Coverage for prescription drugs irregularly dispensed for purpose of synchronization of chronic medications required in plan covering prescription drugs; prohibited acts; exception.

1. A carrier who offers or issues a health benefit plan which provides coverage for prescription drugs:

(a) Must authorize coverage for and may apply a copayment and deductible to a prescription that is dispensed by a pharmacy for less than a 30-day supply if, for the purpose of synchronizing the insured’s chronic medications:

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

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

(b) May not deny coverage for a prescription described in paragraph (a) which is otherwise approved for coverage by the carrier.

(c) Unless otherwise provided by a contract or other agreement, may not prorate any pharmacy dispensing fees for a prescription described in paragraph (a).

2. A health benefit plan subject to the provisions of this chapter which provides coverage for prescription drugs and that is delivered, issued for delivery or renewed on or after January 1, 2017, has the legal effect of providing that coverage subject to the requirements of this section, and any provision of the health benefit plan or renewal which is in conflict with this section is void.

3. The provisions of this section do not apply to unit-of-use packaging for which synchronization is not practicable or to a controlled substance.

4. As used in this section:

(a) “Chronic medication” means any drug that is prescribed to treat any disease or other condition which is determined to be permanent, persistent or lasting indefinitely.

(b) “Synchronization” means the alignment of the dispensing of multiple medications by a single contracted pharmacy for the purpose of improving a patient’s adherence to a prescribed course of medication.

(c) “Unit-of-use packaging” means medication that is prepackaged by the manufacturer in blister packs, compliance packs, course-of-therapy packs or any other packaging which is designed and intended to be dispensed directly to the patient without modification by the dispensing pharmacy, except for the addition of a prescription label.

(Added to NRS by 2015, 2125)

1. A carrier that offers or issues a health benefit plan which provides coverage of a prescription drug for the treatment of cancer or any symptom of cancer that is part of a step therapy protocol shall allow an insured who has been diagnosed with stage 3 or 4 cancer or the attending practitioner of the insured to apply for an exemption from the step therapy protocol. The application process for such an exemption must:

(a) Allow the insured or attending practitioner, or a designated advocate for the insured or attending practitioner, to present to the carrier the clinical rationale for the exemption and any relevant medical information.

(b) Clearly prescribe the information and supporting documentation that must be submitted with the application, the criteria that will be used to evaluate the request and the conditions under which an expedited determination pursuant to subsection 4 is warranted.

2. The information and supporting documentation required pursuant to paragraph (b) of subsection 1:

(a) May include, without limitation:

(1) The medical history or other health records of the insured demonstrating that the insured has:

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

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

(2) Any other relevant clinical information.

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

3. Except as otherwise provided in subsection 4, a carrier that receives an application for an exemption pursuant to subsection 1 shall:

(a) Make a determination concerning the application if the application is complete or request additional information or documentation necessary to complete the application not later than 72 hours after receiving the application; and

(b) If it requests additional information or documentation, make a determination concerning the application not later than 72 hours after receiving the requested information or documentation.

4. If, in the opinion of the attending practitioner, a step therapy protocol may seriously jeopardize the life or health of the insured, a carrier that receives an application for an exemption pursuant to subsection 1 must make a determination concerning the application as expeditiously as necessary to avoid serious jeopardy to the life or health of the insured.

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

6. A carrier must grant an exemption from a step therapy protocol in response to an application submitted pursuant to subsection 1 if:

(a) Any treatment otherwise required under the step therapy or any drug in the same pharmacological class or having the same mechanism of action as the drug for which the exemption is requested has not been effective at treating the cancer or symptom of the insured when prescribed in accordance with clinical indications, clinical guidelines or other peer-reviewed evidence;

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

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

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

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

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

7. If a carrier approves an application for an exemption from a step therapy protocol pursuant to this section, the carrier must cover the prescription drug to which the exemption applies in accordance with the terms of the applicable health benefit plan. The carrier may initially limit the coverage to a 1-week supply of the drug for which the exemption is granted. If the attending practitioner determines after 1 week that the drug is effective at treating the cancer or symptom for which it was prescribed, the carrier must continue to cover the drug for as long as it is necessary to treat the insured for the cancer or symptom. The carrier may conduct a review not more frequently than once each quarter to determine, in accordance with available medical evidence, whether the drug remains necessary to treat the insured for the cancer or symptom. The carrier shall provide a report of the review to the insured.

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

9. A health benefit plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2022, has the legal effect of including the coverage required by this section, and any provision of the policy that conflicts with this section is void.

10. As used in this section, “attending practitioner” means the practitioner, as defined in NRS 639.0125, who has primary responsibility for the treatment of the cancer or any symptom of such cancer of an insured.

(Added to NRS by 2021, 2663)

NRS 689C.1685 Plan covering prescription drugs: Denial of coverage prohibited for early refills of otherwise covered topical ophthalmic products.

1. A carrier who offers or issues a health benefit plan which provides coverage for prescription drugs shall not deny coverage for a topical ophthalmic product which is otherwise approved for coverage by the carrier when the insured, pursuant to NRS 639.2395, receives a refill of the product:

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

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

2. The provisions of this section do not affect any deductibles, copayments or coinsurance established by the health benefit plan.

3. A health benefit plan subject to the provisions of this chapter which provides coverage for prescription drugs and that is delivered, issued for delivery or renewed on or after January 1, 2016, has the legal effect of including the coverage required by this section, and any provision of the plan or renewal which is in conflict with this section is void.

4. As used in this section, “topical ophthalmic product” means a liquid prescription drug which is applied directly to the eye from a bottle or by means of a dropper.

(Added to NRS by 2015, 207)

1. A carrier that issues a health benefit plan shall include in the plan coverage for:

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

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

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

3. A carrier may use medical management techniques, including, without limitation, any available clinical evidence, to determine the frequency of or treatment relating to any benefit required by this section or the type of provider of health care to use for such treatment.

4. As used in this section:

(a) “Case management services” means medical or other health care management services to assist patients and providers of health care, including, without limitation, identifying and facilitating additional resources and treatments, providing information about treatment options and facilitating communication between providers of services to a patient.

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

(d) “Sickle cell disease and its variants” has the meaning ascribed to it in NRS 439.4927.

(Added to NRS by 2019, 2170)

1. Subject to the limitations prescribed by subsection 4, a carrier that issues a health benefit plan shall include in the plan coverage for medically necessary biomarker testing for the diagnosis, treatment, appropriate management and ongoing monitoring of cancer when such biomarker testing is supported by medical and scientific evidence. Such evidence includes, without limitation:

(a) The labeled indications for a biomarker test or medication that has been approved or cleared by the United States Food and Drug Administration;

(b) The indicated tests for a drug that has been approved by the United States Food and Drug Administration or the warnings and precautions included on the label of such a drug;

(c) A national coverage determination or local coverage determination, as those terms are defined in 42 C.F.R. § 400.202; or

(d) Nationally recognized clinical practice guidelines or consensus statements.

2. A carrier shall:

(a) Provide the coverage required by subsection 1 in a manner that limits disruptions in care and the need for multiple specimens.

(b) Establish a clear and readily accessible process for an insured or provider of health care to:

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

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

3. If a carrier requires an insured to obtain prior authorization for a biomarker test described in subsection 1, the carrier shall respond to a request for such prior authorization:

(a) Within 24 hours after receiving an urgent request; or

(b) Within 72 hours after receiving any other request.

4. The provisions of this section do not require a carrier to provide coverage of biomarker testing:

(a) For screening purposes;

(b) Conducted by a provider of health care for whom the biomarker testing is not within his or her scope of practice, training and experience;

(d) That has not been determined to be medically necessary by a provider of health care for whom such a determination is within his or her scope of practice, training and experience.

5. A health benefit plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 2023, has the legal effect of including the coverage required by this section, and any provision of the plan or renewal which is in conflict with the provisions of this section is void.

6. As used in this section:

(a) “Biomarker” means a characteristic that is objectively measured and evaluated as an indicator of a normal biological process, a pathogenic process or a pharmacological response to a specific therapeutic intervention and includes, without limitation:

(1) An interaction between a gene and a drug that is being used by or considered for use by the patient;

(2) A mutation or characteristic of a gene; and

(3) The expression of a protein.

(b) “Biomarker testing” means the analysis of the tissue, blood or other biospecimen of a patient for the presentation of a biomarker and includes, without limitation, single-analyte tests, multiplex panel tests and whole genome, whole exome and whole transcriptome sequencing.

(1) Made for the purpose of optimizing the outcomes of clinical care;

(2) Made by an independent, multidisciplinary panel of experts that has established a policy to avoid conflicts of interest;

(3) Based on scientific evidence; and

(4) Made using a transparent methodology and reporting procedure.

(d) “Medically necessary” means health care services or products that a prudent provider of health care would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that are necessary and:

(1) Provided in accordance with generally accepted standards of medical practice;

(2) Not primarily provided for the convenience of the patient or provider of health care; and

(3) Significant in guiding and informing the provider of health care in providing the most appropriate course of treatment for the patient in order to prevent, delay or lessen the magnitude of an adverse health outcome.

(e) “Nationally recognized clinical practice guidelines” means evidence-based guidelines establishing standards of care that include, without limitation, recommendations intended to optimize care of patients and are:

(1) Informed by a systemic review of evidence and an assessment of the risks and benefits of alternative options for care; and

(2) Developed using a transparent methodology and reporting procedure by an independent organization or society of medical professionals that has established a policy to avoid conflicts of interest.

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

(Added to NRS by 2023, 2216)

NRS 689C.169 Coverage for severe mental illness required under group health insurance policy.

1. A policy of group health insurance delivered or issued for delivery in this State pursuant to this chapter must provide coverage for the treatment of conditions relating to severe mental illness.

2. As used in this section, “severe mental illness” means any of the following mental illnesses that are biologically based and for which diagnostic criteria are prescribed in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association:

(a) Schizophrenia.

(b) Schizoaffective disorder.

(d) Major depressive disorders.

(e) Panic disorder.

(f) Obsessive-compulsive disorder.

(Added to NRS by 2009, 1811; A 2013, 3627)

NRS 689C.170 Authorized variation of minimum participation and contributions; denial of coverage based on industry prohibited.

1. 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 or the product offered.

2. In applying requirements for minimum participation with respect to a small employer, a carrier shall not consider employees or dependents who have 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.

(Added to NRS by 1995, 980; A 1997, 2942; 2007, 3327)

NRS 689C.180 Carrier to offer same coverage to all eligible employees; denial of coverage to otherwise eligible employee.

1. 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 a dependent of the eligible employee, 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 creditable coverage at the time of the initial period for enrollment;

(2) Lost coverage under the other creditable coverage as a result of termination of employment or eligibility, the involuntary termination of the creditable coverage, the death of a spouse or divorce; and

(3) Requests enrollment within 30 days after termination of the other 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.

(Added to NRS by 1995, 981; A 1997, 2942)

NRS 689C.183 Plan and carrier required to permit employee or dependent of employee to enroll for coverage under certain circumstances. 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 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 or her insurance coverage was lost as a result of cessation of contributions by his or her 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.

(Added to NRS by 1997, 2921)

NRS 689C.187 Manner and period for enrolling dependent of covered employee; period of special enrollment.

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

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.

(Added to NRS by 1997, 2922)

1. A carrier that issues a health benefit plan shall offer and issue a health benefit plan to any small employer regardless of the health status of the employees of the small employer. Such health status includes, without limitation:

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

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

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

2. A carrier that offers or issues a health benefit plan shall not:

(a) Deny, limit or exclude a covered benefit based on the health status of an insured; or

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

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

4. A carrier that offers or issues a health benefit plan may include in the plan a wellness program that reduces a premium, deductible or copayment based on health status if:

(a) An insured who is eligible to participate in the wellness program is given the opportunity to qualify for the discount at least once each year;

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

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

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

(Added to NRS by 1995, 981; A 1997, 2943; 2013, 3628; 2019, 302)

NRS 689C.191 Determination of applicable creditable coverage of person; determining period of creditable coverage of person; required statement for certain election by carrier; applicability.

1. In determining the applicable creditable coverage of a person, 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 the eligible employee in accordance with NRS 689C.192 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, 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.

4. The provisions of this section apply only to grandfathered plans.

(Added to NRS by 1997, 2926; A 2013, 3630)

NRS 689C.192 Written certification of coverage required for purpose of determining period of creditable coverage accumulated by person.

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 July 16, 1997, 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 the person ceases to be covered under the plan, if the person does not otherwise become covered under any provision of the Consolidated Omnibus Budget Reconciliation Act of 1985, as that act existed on July 16, 1997, relating to the continuation of coverage;

(b) If the person becomes covered under such a provision, at the time that the person 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 the person ceased to be covered as described in paragraphs (a) and (b).

(Added to NRS by 1997, 2927)

1. A carrier shall not place any restriction on a small employer or an eligible employee or a dependent of the eligible employee 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.355, inclusive.

2. A carrier that offers health insurance coverage to small employers pursuant to this chapter shall not establish rules of eligibility which conflict with the provisions of NRS 689B.550, 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 a dependent of the eligible employee:

(a) Health status.

(b) Medical condition, including physical and mental illnesses, or both.

(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 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.

4. 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.

5. 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.

(Added to NRS by 1997, 2925; A 2013, 3630; 2019, 303)

NRS 689C.194 Plan covering maternity and pediatric care: Required to allow minimum stay in hospital in connection with childbirth; exceptions; prohibited acts.

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 pregnant or postpartum individual 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.

Ê If a different length of stay is provided in the guidelines established by the American College of Obstetricians and Gynecologists, or its successor organization, and the American Academy of Pediatrics, or its successor organization, the health benefit plan may follow such guidelines in lieu of following the length of stay set forth above. The provisions of this subsection do not apply to any health benefit plan in any case in which the decision to discharge the pregnant or postpartum individual or newborn infant before the expiration of the minimum length of stay set forth in this subsection is made by the attending physician of the pregnant or postpartum individual or newborn infant.

2. Nothing in this section requires a pregnant or postpartum individual to:

(a) Deliver the baby in a hospital; or

(b) Stay in a hospital for a fixed period following the birth of the child.

3. A health benefit plan that offers coverage for maternity care and pediatric care of newborn infants may not:

(a) Deny a pregnant or postpartum individual or the 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 pregnant or postpartum individual to encourage the individual 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 the attending provider of health care provided care to a pregnant or postpartum individual or newborn infant in accordance with the provisions of this section;

(d) Provide incentives of any kind to an attending physician to induce the attending physician to provide care to a pregnant or postpartum individual 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 pregnant or postpartum individual 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 pregnant or postpartum individual and the 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.

(Added to NRS by 1997, 2924; A 2021, 2977)

NRS 689C.1945 Plan covering maternity care: Prohibited acts by carrier if insured is acting as gestational carrier; child deemed child of intended parent for purposes of plan.

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

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

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

(Added to NRS by 2019, 1006)

NRS 689C.1947 Plan covering anatomical gifts, organ transplants or treatments or services related to organ transplants: Prohibited acts by carrier if insured is person with disability.

1. A carrier that offers or issues a health benefit plan that includes coverage for anatomical gifts, organ transplants or treatments or services related to an organ transplant shall not:

(a) Deny, limit or seek reimbursement from an insured for care related to an organ transplant because the insured is a person with a disability;

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

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

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

2. As used in this section:

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

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

(Added to NRS by 2021, 1171)

1. A health benefit plan must include coverage for services provided to an insured through telehealth to the same extent as though provided in person or by other means.

2. A health benefit plan must provide reimbursement for services described in subsection 1 in the same amount as though provided in person or by other means:

(a) If the services:

(1) Are received at an originating site described in 42 U.S.C. § 1395m(m)(4)(C) or furnished by a federally-qualified health center or a rural health clinic;

(2) Except for services described in paragraph (b), are not provided through audio-only interaction; or

(b) For counseling or treatment relating to a mental health condition or a substance use disorder, including, without limitation, when such counseling or treatment is provided through audio-only interaction.

3. A carrier shall not:

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

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

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

(2) The technology used to provide the services;

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

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

4. A health benefit plan must not require an insured to obtain prior authorization for any service provided through telehealth that is not required for the service when provided in person. A health benefit plan may require prior authorization for a service provided through telehealth if such prior authorization would be required if the service were provided in person or by other means.

5. The provisions of this section do not require a carrier to:

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

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

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

6. A plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2023, has the legal effect of including the coverage required by this section, and any provision of the plan or the renewal which is in conflict with this section is void.

7. As used in this section:

(a) “Distant site” has the meaning ascribed to it in NRS 629.515.

(b) “Federally-qualified health center” has the meaning ascribed to it in 42 U.S.C. § 1396d(l)(2)(B).

(d) “Provider of health care” has the meaning ascribed to it in NRS 439.820.

(e) “Rural health clinic” has the meaning ascribed to it in 42 U.S.C. § 1395x(aa)(2).

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

(Added to NRS by 2015, 639; A 2021, 3024, 3025, 3026, 3027; 2023, 227, 237)

NRS 689C.196 Insurer prohibited from denying coverage solely because claim involves act that constitutes domestic violence or applicant or insured was victim of domestic violence. An insurer shall not deny a claim, refuse to issue a health benefit plan or cancel a health benefit plan solely because the claim involves an act that constitutes domestic violence pursuant to NRS 33.018, or because the person applying for or covered by the health benefit plan was the victim of such an act of domestic violence, regardless of whether the insured or applicant contributed to any loss or injury.

(Added to NRS by 1997, 1096)

NRS 689C.197 Carrier prohibited from denying coverage because applicant or insured was intoxicated or under influence of controlled substance; exceptions.

1. Except as otherwise provided in subsection 2, a carrier shall not:

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

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

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

2. The provisions of subsection 1 do not prohibit a carrier from enforcing a provision included in a health benefit plan to:

(a) Deny a claim which involves an injury to which a contributing cause was the insured’s commission of or attempt to commit a felony;

(b) Cancel participation in a health benefit plan solely because of such a claim; or

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

(Added to NRS by 2005, 2344; A 2007, 85)

NRS 689C.1975 Carrier prohibited from discriminating against person with respect to participation or coverage on basis of gender identity or expression. A carrier that issues a health benefit plan shall not discriminate against any person with respect to participation or coverage under the plan on the basis of actual or perceived gender identity or expression. Prohibited discrimination includes, without limitation:

1. Denying, cancelling, limiting or refusing to issue or renew a health benefit plan on the basis of the actual or perceived gender identity or expression of a person or a family member of the person;

2. Imposing a payment or premium that is based on the actual or perceived gender identity or expression of an insured or a family member of the insured;

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

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

(a) Related to gender transition, provided that there is coverage under the plan for the services when the services are not related to gender transition; or

(b) Ordinarily or exclusively available to persons of any sex.

(Added to NRS by 2023, 2035)

NRS 689C.198 Insurer prohibited from requiring or using information concerning genetic testing; exceptions.

1. Except as otherwise provided in subsection 2, a carrier serving small employers shall not:

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

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

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

2. The provisions of this section do not apply to a carrier serving small employers who issues a policy of health insurance that provides coverage for long-term care or disability income.

3. As used in this section:

(a) “Genetic information” means any information that is obtained from a genetic test.

(b) “Genetic test” means a test, including a laboratory test that uses deoxyribonucleic acid extracted from the cells of a person or a diagnostic test, to determine the presence of abnormalities or deficiencies, including carrier status, that:

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

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

(Added to NRS by 1997, 1460; A 2019, 304)

NRS 689C.200 Circumstances in which carrier is not required to offer coverage. A carrier serving small employers is not required to accept applications from or offer coverage to:

1. A small employer if the employer is not physically located in the carrier’s geographic service area; or

2. An employee if the employee does not work or reside within the carrier’s geographic service area.

(Added to NRS by 1995, 982; A 1997, 2946; 2013, 3631)

NRS 689C.203 Requirement for denial of application for coverage from small employer; regulations setting standards for fair marketing and broad availability of plans.

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.

(Added to NRS by 1997, 2924)

NRS 689C.207 Regulations concerning reissuance of health benefit plan. The Commissioner may adopt regulations to require a carrier, as a condition of transacting insurance with small employers in this state after July 16, 1997, 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 the Commissioner finds are reasonable and necessary to provide continuity of coverage to small employers.

(Added to NRS by 1997, 2924)

NRS 689C.220 Adjustment in rates required to be applied uniformly. A carrier serving small employers shall not charge adjustments in rates for duration of coverage or any reason prohibited by NRS 689C.190 to individual employees or dependents. Any such adjustment must be applied uniformly to the rates charged for all employees and dependents of a small employer.

(Added to NRS by 1995, 984; A 2019, 305)

NRS 689C.265 Carrier authorized to modify coverage for insurance product under certain circumstances. 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.

(Added to NRS by 1997, 2927)

NRS 689C.281 Plan covering prescription drugs: Provision of notice and information regarding use of formulary.

1. A carrier that offers or issues a health benefit plan which provides coverage for prescription drugs shall include with any summary, certificate or evidence of that coverage provided to an insured, notice of whether a formulary is used and, if so, of the opportunity to secure information regarding the formulary from the carrier pursuant to subsection 2. The notice required by this subsection must:

(a) Be in a language that is easily understood and in a format that is easy to understand;

(b) Include an explanation of what a formulary is; and

(1) An explanation of:

(I) How often the contents of the formulary are reviewed; and

(II) The procedure and criteria for determining which prescription drugs are included in and excluded from the formulary; and

(2) The telephone number of the carrier for making a request for information regarding the formulary pursuant to subsection 2.

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

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

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

(2) Access to the most current list of prescription drugs in the formulary, organized by major therapeutic category, with an indication of whether any listed drugs are preferred over other listed drugs. If more than one formulary is maintained, the carrier shall notify the requester that a choice of formulary lists is available.

(b) Notify each person who requests information regarding the formulary, that the inclusion of a drug in the formulary does not guarantee that a provider of health care will prescribe that drug for a particular medical condition.

(Added to NRS by 2001, 858)

NRS 689C.310 Renewal of plan; discontinuance of issuance or renewal of coverage or of plan offered only through bona fide association; discontinuance of product; applicability.

1. 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 service 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;

(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 a dependent of the particular employee from coverage under a health benefit plan as a condition to renewal of the plan if the employee or dependent of the employee commits fraud upon the carrier or misrepresents a material fact which affects his or her coverage under the plan.

4. 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 a product offered to small employers pursuant to this subsection only if:

(a) The carrier notifies the Commissioner of its decision pursuant to this subsection to discontinue 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 of the decision of the carrier to discontinue the product. The notice must be made at least 90 days before the date on which the carrier will discontinue offering 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 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 dependent of the eligible employee.

7. If a carrier does business in only one geographic service area of this state, the provisions of this section apply only to the operations of the carrier in that service area.

(Added to NRS by 1995, 986; A 1997, 2948; 2013, 3632; 2017, 2372)

1. A carrier that discontinues transacting insurance in this State or in a particular geographic service 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.

2. A carrier that cancels any health benefit plan because it has discontinued transacting insurance in this State or in a particular geographic service area of this State:

(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 service area for 5 years after it gives notice to the Commissioner pursuant to paragraph (b) of subsection 1.

(Added to NRS by 1995, 986; A 1997, 2949; 2013, 3633)

NRS 689C.325 Coverage offered through network plan not required to be offered to eligible employee who does not reside or work in geographic service area or if carrier lacks capacity to deliver adequate service to additional employers and employees. 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 geographic service area of the network plan.

2. For a small employer whose eligible employees reside or work in the 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 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.

(Added to NRS by 1997, 2921; A 2013, 3633)

1. Except as otherwise provided in subsection 2 and NRS 439B.754, a carrier serving small employers and a carrier that offers a contract to a voluntary purchasing group shall approve or deny a claim relating to a policy of health insurance within 30 days after the carrier receives the claim. If the claim is approved, the carrier shall pay the claim within 30 days after it is approved. Except as otherwise provided in this section, if the approved claim is not paid within that period, the carrier shall pay interest on the claim at a rate of interest equal to the prime rate at the largest bank in Nevada, as ascertained by the Commissioner of Financial Institutions, on January 1 or July 1, as the case may be, immediately preceding the date on which the payment was due, plus 6 percent. The interest must be calculated from 30 days after the date on which the claim is approved until the date on which the claim is paid.

2. If the carrier requires additional information to determine whether to approve or deny the claim, it shall notify the claimant of its request for the additional information within 20 days after it receives the claim. The carrier shall notify the provider of health care of all the specific reasons for the delay in approving or denying the claim. The carrier shall approve or deny the claim within 30 days after receiving the additional information. If the claim is approved, the carrier shall pay the claim within 30 days after it receives the additional information. If the approved claim is not paid within that period, the carrier shall pay interest on the claim in the manner prescribed in subsection 1.

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

4. A carrier shall not pay only part of a claim that has been approved and is fully payable.

5. A court shall award costs and reasonable attorney’s fees to the prevailing party in an action brought pursuant to this section.

6. The payment of interest provided for in this section for the late payment of an approved claim may be waived only if the payment was delayed because of an act of God or another cause beyond the control of the carrier.

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

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

(Added to NRS by 1999, 1648; A 2001, 2731; 2003, 3359; 2019, 331)—(Substituted in revision for NRS 689C.485)

NRS 689C.350 Health benefit plan which offers difference of payment between preferred providers of health care and providers who are not preferred: Limitations on deductibles and copayments; circumstances in which service is deemed to be provided by preferred provider. A health benefit plan which offers a difference of payment between preferred providers of health care and providers of health care who are not preferred:

1. Must require that the deductible and payment for coinsurance paid by the insured to a preferred provider of health care be applied to the negotiated reduced rates of that provider.

2. Must provide that if there is a particular service which a preferred provider of health care does not provide and the provider of health care who is treating the insured requests the service and the insurer determines that the use of the service is necessary for the health of the insured, the service shall be deemed to be provided by the preferred provider of health care.

(Added to NRS by 1995, 987; A 2013, 3634; 2017, 2374)

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 geographic service area or a provision for a restricted network of the carrier.

3. 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.

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 producer to advise and represent the best interests of a small employer who is seeking health insurance coverage from a small employer carrier.

(Added to NRS by 1997, 2923; A 2013, 3634)

VOLUNTARY PURCHASING GROUPS

NRS 689C.360 Definitions. As used in NRS 689C.360 to 689C.600, inclusive, unless the context otherwise requires, the words and terms defined in NRS 689C.380 and 689C.390 have the meanings ascribed to them in those sections.

(Added to NRS by 1995, 2677; A 1997, 2951)

NRS 689C.380 “Contract” defined. “Contract” 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 by or 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, coverage for a specified disease, hospital confinement indemnity or limited-benefit health insurance.

(Added to NRS by 1995, 2677)

NRS 689C.390 “Dependent” defined. “Dependent” means a spouse, a domestic partner as defined in NRS 122A.030, or a child on or before the last day of the month in which the child attains 26 years of age.

(Added to NRS by 1995, 2677; A 2013, 3635)

NRS 689C.420 “Voluntary purchasing group” defined. [Replaced in revision by NRS 689C.104.]

NRS 689C.425 Applicability of other provisions. A voluntary purchasing group and any contract issued to such a group pursuant to NRS 689C.360 to 689C.600, inclusive, are subject to the provisions of NRS 689C.015 to 689C.355, inclusive, to the extent applicable and not in conflict with the express provisions of NRS 687B.408 and 689C.360 to 689C.600, inclusive.

(Added to NRS by 1997, 2929; A 2001, 860; 2009, 1812; 2015, 207, 641, 2125; 2017, 1828, 3943; 2019, 1006, 2171; 2021, 782, 825, 1172, 1935, 2579, 2665, 3209; 2023, 812, 1784, 2035, 2217, 2374, 3518)

NRS 689C.430 Entities which are authorized to offer contracts to voluntary purchasing groups; compliance with provisions required. Every insurer, fraternal benefit society, corporation providing hospital or medical services or health maintenance organization, whose policies or activities relating to health insurance are governed by the provisions of chapter 689B, 695A, 695B or 695C of NRS, may offer contracts to voluntary purchasing groups and, if it does so, shall comply with the provisions of NRS 689C.360 to 689C.600, inclusive.

(Added to NRS by 1995, 2677)

NRS 689C.455 Coverage for prescription drugs: Provision of notice and information regarding use of formulary.

1. A carrier that offers or issues a contract which provides coverage for prescription drugs shall include with any summary, certificate or evidence of that coverage provided to an insured, notice of whether a formulary is used and, if so, of the opportunity to secure information regarding the formulary from the carrier pursuant to subsection 2. The notice required by this subsection must:

(a) Be in a language that is easily understood and in a format that is easy to understand;

(b) Include an explanation of what a formulary is; and

(1) An explanation of:

(I) How often the contents of the formulary are reviewed; and

(II) The procedure and criteria for determining which prescription drugs are included in and excluded from the formulary; and

(2) The telephone number of the carrier for making a request for information regarding the formulary pursuant to subsection 2.

2. If a carrier offers or issues a contract which provides coverage for prescription drugs and a formulary is used, the carrier shall:

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

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

(Added to NRS by 2001, 859)

NRS 689C.460 Carrier to offer same coverage to all eligible employees; denial of coverage to otherwise eligible employee.

1. 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 a dependent of the otherwise eligible employee, 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 creditable coverage at the time of the initial period for enrollment;

(3) Requests enrollment within 30 days after termination of the other 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.

(Added to NRS by 1995, 2678; A 1997, 2951)

NRS 689C.470 Renewal of contract; discontinuance of product or issuance or renewal of plan offered only through bona fide association.

1. Except as otherwise provided in NRS 689C.360 to 689C.600, inclusive, 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:

(a) Required premiums are not paid;

(b) The insured employer or other purchaser is guilty of fraud or misrepresentation;

(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;

(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

(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 a product offered to a small employer or purchasers pursuant to NRS 689C.360 to 689C.600, inclusive, only if:

(b) The carrier notifies each affected small employer and purchaser of the decision of the carrier to discontinue the product. The notice must be made at least 90 days before the date on which the carrier will discontinue offering 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 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 or her dependent.

(Added to NRS by 1995, 2679; A 1997, 2951; 2017, 2374)

NRS 689C.480 Required notification when carrier ceases to renew all contracts; restrictions on carrier that ceases to renew all contracts.

1. 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:

(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 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.

(Added to NRS by 1995, 2679; A 1997, 2953)

NRS 689C.490 Formation of voluntary purchasing group by small employers; requirements when affiliate of group ceases to qualify as small employer.

1. 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 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 employees of that employer and their dependents under any contract provided through the voluntary purchasing group.

(Added to NRS by 1995, 2679; A 1997, 2953)

NRS 689C.500 Registration: Requirements; application.

1. An organization seeking to be registered as a voluntary purchasing group:

(a) Must be incorporated as a Nevada corporation not for profit for the purpose of securing health benefits for its members and their eligible employees and dependents;

(b) Shall file articles of incorporation with the Secretary of State and provide a copy of the articles to the Commissioner in such a form as the Commissioner may require; and

(c) Must apply to the Commissioner for and obtain a certificate of registration to operate as a voluntary purchasing group.

2. The contents of the application must be established by the Commissioner and include at least:

(a) The name of the voluntary purchasing group and any agent for service of process;

(b) Provisions to govern the business and affairs of the group, including the management and organizational structure;

(c) An affidavit by an officer of the organization that the group is in compliance with the requirements of NRS 689C.490 to 689C.600, inclusive; and

(d) The names of managing personnel of the voluntary purchasing group.

(Added to NRS by 1995, 2680)

NRS 689C.510 Registration: Fee for application; response to application; regulations.

1. The application must be accompanied by a fee in an amount to be established by the Commissioner by regulation to cover the direct costs of examining the qualifications of an applicant.

2. The Commissioner shall respond to each application for a certificate of registration within 30 days after receipt. The Commissioner shall either approve the application or shall inform the organization of specific changes to the application necessary to permit approval.

(Added to NRS by 1995, 2680)

NRS 689C.520 Registration: Additional requirements.

1. Before the issuance of a certificate of registration, each voluntary purchasing group shall, to the satisfaction of the Commissioner:

(a) Establish the conditions of membership in the group and require as a condition of membership that all employers include all their eligible employees. The group may not differentiate among classes of membership on the basis of the kind of employment, race, religion, sex, sexual orientation, gender identity or expression, education, health or income. The group shall set reasonable fees for membership which will finance all reasonable and necessary costs incurred in administering the group.

(b) Provide to members of the group and their eligible employees any applicable disclosures of the coverage provided by any proposed contracts and any applicable information regarding available benefits and carriers provided by any proposed contracts.

2. In addition to the information required pursuant to subsection 1, a voluntary purchasing group shall provide annually to members of the group information regarding available benefits and carriers.

(Added to NRS by 1995, 2680; A 2017, 1080, 2375)

NRS 689C.530 Filing reports; annual renewal fee; regulations. A voluntary purchasing group shall:

1. File any reports required by the Commissioner; and

2. Pay a renewal fee established by the Commissioner by regulation to recover the direct costs to the Division to determine annually that a voluntary purchasing group is in compliance with NRS 689C.490 to 689C.600, inclusive.

(Added to NRS by 1995, 2680)

NRS 689C.540 Duties. A voluntary purchasing group shall:

1. Establish administrative and accounting procedures for the operation of the group and the provision of services to members, prepare an annual budget and annual operational fiscal reports;

2. Provide for internal and independent audits; and

3. Maintain all records, reports and other information of the group and may contract with qualified third-party administrators, licensed insurance agents or brokers as needed.

(Added to NRS by 1995, 2681)

NRS 689C.550 Collection of premiums; trust account for deposit of premiums. A voluntary purchasing group shall offer to collect premiums for contracts offered through the purchasing group and maintain a trust account for the deposit of premiums collected to be paid to carriers for coverage offered through the purchasing group. A voluntary purchasing group is a fiduciary with respect to any premiums so collected.

(Added to NRS by 1995, 2681)

NRS 689C.560 Regulations governing bond or other security to be maintained by voluntary purchasing group. A voluntary purchasing group shall post a bond for the benefit of members of the group and their eligible employees and dependents, or deposit a certificate of deposit or securities, which complies with NRS 679B.175 and is in an amount as determined by the Commissioner.

(Added to NRS by 1995, 2681; A 2021, 2979)

NRS 689C.570 Organizer prohibited from acquiring financial interest in group’s business for specified period. No person who organizes a voluntary purchasing group may acquire or attempt to acquire a financial interest in the group’s business for a period of 3 years after organization of the group.

(Added to NRS by 1995, 2681)

NRS 689C.580 Prohibited acts. A voluntary purchasing group shall not perform any activity included in the definition of transacting insurance in this state as defined in NRS 679A.130, perform any activity for which it is subject to regulation pursuant to NRS 685B.120 or establish or otherwise engage in the activities of a health maintenance organization as provided in chapter 695C of NRS.

(Added to NRS by 1995, 2681)

NRS 689C.590 Disciplinary or other action for violation of provisions. The Commissioner may deny, revoke or suspend a certificate of registration of any voluntary purchasing group found to be in violation of NRS 689C.490 to 689C.600, inclusive.

(Added to NRS by 1995, 2681)

NRS 689C.600 Regulations. The Commissioner shall adopt such regulations as are needed to carry out the requirements of NRS 689C.490 to 689C.600, inclusive.

(Added to NRS by 1995, 2681)

MISCELLANEOUS HEALTH BENEFIT PLANS

NRS 689C.610 Definitions. As used in NRS 689C.610 to 689C.940, inclusive, unless the context otherwise requires, the words and terms defined in NRS 689C.630, 689C.660 and 689C.670 have the meanings ascribed to them in those sections.

(Added to NRS by 1997, 2929; A 1999, 2814; 2013, 3635)

NRS 689C.630 “Church plan” defined. “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 July 16, 1997.

(Added to NRS by 1997, 2929)

NRS 689C.660 “Individual carrier” defined. “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.

(Added to NRS by 1997, 2929)

NRS 689C.670 “Individual health benefit plan” defined. “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.

(Added to NRS by 1997, 2929)

NRS 689C.940 Regulations concerning determination of status of stop-loss policy. 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.

(Added to NRS by 1997, 2938)