2005 Nevada Revised Statutes - Chapter 689B — Group and Blanket Health Insurance
CHAPTER 689B - GROUP AND BLANKET HEALTHINSURANCE
GENERAL PROVISIONS
NRS 689B.010 Shorttitle; scope.
NRS 689B.015 Contractsbetween insurer and provider of health care: Prohibiting insurer from chargingprovider of health care fee for inclusion on list of providers given toinsureds; form to obtain information on provider of health care; modification;schedule of fees.
GROUP POLICIES
NRS 689B.020 Grouphealth insurance defined; eligible groups and benefits.
NRS 689B.026 Deliveryof policy to group formed to purchase health insurance prohibited; exception.
NRS 689B.027 Summaryof coverage: Contents of disclosure; approval by Commissioner; copy to be madeavailable to employer or producer acting on behalf of employer.
NRS 689B.028 Summaryof coverage: Copy to be provided before policy issued; policy may not beoffered unless summary approved by Commissioner.
NRS 689B.0283 Coveragefor prescription drugs: Provision of notice and information regarding use offormulary.
NRS 689B.0285 Systemfor resolving complaints: Approval; requirements; examination.
NRS 689B.029 Annualreport regarding system for resolving complaints; insurer to maintain recordsof complaints concerning something other than health care services.
NRS 689B.0295 Writtennotice to insured explaining right to file complaint; notice to insuredrequired when insurer denies coverage of health care service.
NRS 689B.030 Requiredprovisions.
NRS 689B.0303 Requiredprovision concerning coverage for continued medical treatment.
NRS 689B.0306 Requiredprovision concerning coverage for treatment received as part of clinical trialor study.
NRS 689B.031 Requiredprovision concerning coverage of certain gynecological or obstetrical serviceswithout authorization or referral from primary care physician.
NRS 689B.033 Requiredprovision concerning coverage for newly born and adopted children and childrenplaced for adoption.
NRS 689B.034 Requiredprovision concerning effect of benefits under other valid group coverage;subrogation.
NRS 689B.0345 Requiredprovision concerning coverage for employee or member on leave without pay asresult of total disability.
NRS 689B.035 Requiredprovision concerning termination of coverage on dependent child.
NRS 689B.0353 Requiredprovision concerning coverage for treatment of certain inherited metabolicdiseases.
NRS 689B.0357 Requiredprovision concerning coverage for management and treatment of diabetes.
NRS 689B.0359 Requiredprovision concerning coverage for treatment of conditions relating to severemental illness.
NRS 689B.036 Requiredprovision concerning benefits for treatment of abuse of alcohol or drugs.
NRS 689B.0365 Requiredprovision concerning coverage for use of certain drugs for treatment of cancer.
NRS 689B.0367 Requiredprovision concerning coverage for screening for colorectal cancer.
NRS 689B.0368 Requiredprovision concerning coverage for prescription drug previously approved formedical condition of insured.
NRS 689B.0374 Requiredprovision concerning coverage for cytologic screening tests and mammograms forcertain women.
NRS 689B.0375 Requiredprovision concerning coverage relating to mastectomy.
NRS 689B.0376 Policycovering prescription drugs or devices to provide coverage for drug or devicefor contraception and of hormone replacement therapy in certain circumstances;prohibited actions by insurer; exceptions.
NRS 689B.0377 Policycovering outpatient care to provide coverage for health care services relatedto contraceptives and hormone replacement therapy; prohibited actions byinsurer; exceptions.
NRS 689B.0379 Requiredprovision concerning coverage for treatment of temporomandibular joint.
NRS 689B.038 Reimbursementfor treatments by licensed psychologist.
NRS 689B.0383 Reimbursementfor treatments by licensed marriage and family therapist.
NRS 689B.0385 Reimbursementfor treatments by licensed associate in social work, social worker, independentsocial worker or clinical social worker.
NRS 689B.039 Reimbursementfor treatments by chiropractor.
NRS 689B.040 Directpayment for hospital and medical services and home health care; payment toassignee.
NRS 689B.045 Reimbursementfor services provided by certain nurses; prohibited limitations; exception.
NRS 689B.047 Reimbursementto provider of medical transportation.
NRS 689B.049 Reimbursementfor acupuncture.
NRS 689B.050 Extendeddisability benefit.
NRS 689B.060 Readjustmentof premiums; dividends.
NRS 689B.061 Limitationson deductibles and copayments charged under policy which offers difference ofpayment between preferred providers of health care and providers who are notpreferred.
NRS 689B.063 Primaryand secondary policies: Determination of benefits.
NRS 689B.064 Primaryand secondary policies: Order of benefits.
NRS 689B.065 Policyissued to replace discontinued policy or coverage: Requirements; notice ofreduction of benefits; statement of benefits; applicability of section.
NRS 689B.067 Provisionin policy requiring binding arbitration for disputes with insurer authorized;procedure for arbitration; declaratory relief.
NRS 689B.068 Insurerprohibited from denying coverage solely because person was victim of domesticviolence.
NRS 689B.069 Insurerprohibited from requiring or using information concerning genetic testing;exceptions.
BLANKET POLICIES
NRS 689B.070 Blanketaccident and health insurance defined.
NRS 689B.080 Authorityto issue; required provisions.
NRS 689B.090 Applicationand certificates.
NRS 689B.100 Paymentof benefits.
NRS 689B.110 Legalliability of policyholders for death of or injury to insured member unaffected.
NRS 689B.115 Accessby Commissioner to information concerning rates; confidentiality ofinformation.
CONVERSION OF GROUP POLICIES TO INDIVIDUAL POLICIES
NRS 689B.120 Policiesof group health insurance to contain provision for conversion; exceptions;conditions.
NRS 689B.130 Conversionprivilege available to spouse and children; conditions.
NRS 689B.140 Denialof converted policy because of overinsurance; notice concerning cancellation ofother coverage.
NRS 689B.150 Choiceof plans for converted policy.
NRS 689B.170 Benefitspayable under converted policy may be reduced by amount payable under grouppolicy.
NRS 689B.180 Issuanceand effective date of converted policy; premiums; persons covered.
NRS 689B.190 Renewalof converted policy: Request for information on sources of other benefits;grounds for refusal to renew; notice concerning cancellation of other coverage.[Repealed.]
NRS 689B.200 Noticeof conversion privilege.
NRS 689B.210 Convertedpolicy delivered outside Nevada: Form.
CONTINUATION OF COVERAGE UNDER CERTAIN GROUP POLICIES
NRS 689B.245 Requiredprovision concerning continuation of coverage.
NRS 689B.246 Noticeof eligibility or election to continue coverage.
NRS 689B.247 Paymentof premium for continued coverage.
NRS 689B.248 Newinsurer to provide continued coverage.
NRS 689B.249 Terminationof continued coverage before end of period.
MISCELLANEOUS PROVISIONS
NRS 689B.250 Acceptanceof uniform forms for billing and claims.
NRS 689B.255 Approvalor denial of claims; payment of claims and interest; requests for additionalinformation; award of costs and attorneys fees; compliance with requirements.
NRS 689B.260 Requiredprovision concerning coverage relating to complications of pregnancy.
NRS 689B.270 Requiredprocedure for arbitration of disputes concerning independent medical evaluations.
NRS 689B.275 Contents,approval and provision of summary of coverage; provision of information aboutguaranteed availability of certain plans for benefits.
NRS 689B.280 Disclosureof information concerning medication of insured prohibited.
NRS 689B.283 Mandatoryrenewal of coverage under conversion health benefit plan.
NRS 689B.285 Offeringpolicy of health insurance for purposes of establishing health savings account.
NRS 689B.287 Insurerprohibited from denying coverage solely because insured was intoxicated orunder influence of controlled substance; exceptions. [Effective July 1, 2006.]
ELIGIBILITY FOR COVERAGE UNDER GROUP POLICY
NRS 689B.290 Definitions.
NRS 689B.300 Effectof eligibility for medical assistance under Medicaid; assignment of rights tostate agency.
NRS 689B.310 Insurerprohibited from asserting certain grounds to deny enrollment of child ofinsured pursuant to order.
NRS 689B.320 Certainaccommodations to be made when child is covered under policy of noncustodialparent.
NRS 689B.330 Insurerto authorize enrollment of child of parent who is required by order to providemedical coverage for child.
PORTABILITY AND ACCOUNTABILITY
NRS 689B.340 Definitions.
NRS 689B.350 Affiliationperiod defined.
NRS 689B.355 Blanketaccident and health insurance defined.
NRS 689B.360 Carrierdefined.
NRS 689B.370 Contributiondefined.
NRS 689B.380 Creditablecoverage defined.
NRS 689B.390 Grouphealth plan defined.
NRS 689B.400 Groupparticipation defined.
NRS 689B.410 Healthbenefit plan defined.
NRS 689B.420 Healthstatus-related factor defined.
NRS 689B.430 Openenrollment defined.
NRS 689B.440 Plansponsor defined.
NRS 689B.450 Preexistingcondition defined.
NRS 689B.460 Waitingperiod defined.
NRS 689B.470 Certainplan, fund or program to be treated as employee welfare benefit plan which isgroup health plan; partnership deemed employer of each partner.
NRS 689B.480 Determinationof applicable creditable coverage of person; determination of period ofcreditable coverage of person; required statement.
NRS 689B.490 Writtencertification of coverage required for purpose of determining period ofcreditable coverage accumulated by person.
NRS 689B.500 Coverageof preexisting conditions; when health maintenance organization may requireaffiliation period.
NRS 689B.510 Carrierauthorized to modify coverage for insurance product under certaincircumstances.
NRS 689B.520 Groupplan or coverage that includes coverage for maternity care and pediatric care:Required to allow minimum stay in hospital in connection with childbirth;prohibited acts.
NRS 689B.530 Carrierrequired to permit eligible employee or dependent of employee to enroll forcoverage under certain circumstances.
NRS 689B.540 Mannerand period for enrollment of dependent of covered employee; period of specialenrollment.
NRS 689B.550 Carrierprohibited from imposing restriction on participation inconsistent withchapter; restrictions on rules of eligibility that may be established; premiumsto be equitable.
NRS 689B.560 Carrierrequired to renew coverage at option of plan sponsor; exceptions;discontinuation of form of product of group health insurance; discontinuationof group health insurance through bona fide association.
NRS 689B.570 Carrierthat offers coverage through network plan not required to offer coverage toemployer that does not employ enrollees who reside or work in geographic areafor which carrier is authorized to transact insurance.
NRS 689B.575 Carrierthat offers coverage through network plan: Contracts with certain federallyqualified health centers.
NRS 689B.580 Plansponsor of governmental plan authorized to elect to exclude governmental planfrom compliance with certain statutes; duties of plan sponsor.
NRS 689B.590 Convertedpolicies: Carrier may only offer choice of basic and standard plans; electionof basic or standard plan; premium; rates must be same for persons with similarcase characteristics; losses must be spread across book.
_________
GENERAL PROVISIONS
NRS
1. This chapter may be cited as the Group or BlanketHealth Insurance Law.
2. This chapter applies only to group health insurancecontracts and to blanket accident and health insurance contracts as provided inthis chapter.
(Added to NRS by 1971, 1767; A
NRS
1. An insurer that issues a policy of group healthinsurance shall not charge a provider of health care a fee to include the nameof the provider on a list of providers of health care given by the insurer toits insureds.
2. An insurer specified in subsection 1 shall notcontract with a provider of health care to provide health care to an insuredunless the insurer uses the form prescribed by the Commissioner pursuant to
3. A contract between an insurer specified insubsection 1 and a provider of health care may be modified:
(a) At any time pursuant to a written agreementexecuted by both parties.
(b) Except as otherwise provided in this paragraph, bythe insurer upon giving to the provider 30 days written notice of themodification. If the provider fails to object in writing to the modificationwithin the 30-day period, the modification becomes effective at the end of thatperiod. If the provider objects in writing to the modification within the 30-dayperiod, the modification must not become effective unless agreed to by bothparties as described in paragraph (a).
4. If an insurer specified in subsection 1 contractswith a provider of health care to provide health care to an insured, theinsurer shall:
(a) If requested by the provider of health care at thetime the contract is made, submit to the provider of health care the scheduleof payments applicable to the provider of health care; or
(b) If requested by the provider of health care at anyother time, submit to the provider of health care the schedule of paymentsspecified in paragraph (a) within 7 days after receiving the request.
5. As used in this section, provider of health caremeans a provider of health care who is licensed pursuant to
(Added to NRS by
GROUP POLICIES
NRS
1. Group health insurance is hereby declared to bethat form of health insurance covering groups of two or more persons, formedfor a purpose other than obtaining insurance.
2. Any group health policy which contains provisionsfor the payment by the insurer of benefits for expenses incurred on account ofhospital, nursing, medical, dental or surgical services, home health care orhealth supportive services for members of the family or dependents of a personin the insured group may provide for the continuation of such benefitprovisions, or any part or parts thereof, after the death of the person in theinsured group.
3. The Commissioner may, in his discretion, requirethe form of each certificate proposed to be delivered in this state under agroup health policy not made under the laws of this state to be filed with himby the insurer for informational purposes only.
(Added to NRS by 1971, 1767; A 1971, 1954; 1975, 447)
NRS
1. Except as otherwise provided in this section, nopolicy of group health insurance may be delivered or issued for delivery inthis state to a group which was formed for the purpose of purchasing one ormore policies of group health insurance.
2. A policy of group health insurance may be deliveredto a group described in subsection 1 if the Commissioner approves the issuance.The Commissioner shall not grant his approval unless he finds that:
(a) The benefits of the policy are reasonable inrelation to the premiums charged; and
(b) The group to which the policy is issued isorganized and operated in a fiscally sound manner.
3. Upon approval by the Commissioner, an insurer mayexclude or limit the coverage in a policy issued pursuant to this section ofany person as to whom evidence of insurability is not satisfactory to theinsurer.
4. The provisions of this section apply to theoffering in this state of a policy issued in another state.
(Added to NRS by 1985, 1060; A 1995, 1628)
NRS
1. The Commissioner shall adopt regulations whichrequire an insurer to file with the Commissioner, for his approval, adisclosure summarizing the coverage provided by each policy of group healthinsurance offered by the insurer. The disclosure must include:
(a) Any significant exception, reduction or limitationthat applies to the policy;
(b) Any restrictions on payments for emergency care,including related definitions of an emergency and medical necessity;
(c) Any provisions concerning the insurers right to changepremium rates and the characteristics, other than claim experience, that affectchanges in premium rates;
(d) Any provisions relating to renewability;
(e) Any provisions relating to preexisting conditions;and
(f) Any other information,
that theCommissioner finds necessary to provide for full and fair disclosure of theprovisions of the policy.
2. The disclosure must be written in language which iseasily understood and include a statement that the disclosure is a summary ofthe policy only, and that the policy should be read to determine the governingcontractual provisions.
3. The Commissioner shall not approve any proposeddisclosure submitted to him pursuant to this section which does not comply withthe requirements of this section and the applicable regulations.
4. The insurer shall make available to an employer ora producer acting on behalf of an employer upon request a copy of thedisclosure approved by the Commissioner pursuant to this section for eachpolicy of health insurance coverage for which that employer may be eligible.
(Added to NRS by 1989, 1249; A 1991, 1846; 1997,2913; 1999, 2806)
NRS
(Added to NRS by 1989, 1249)
NRS
1. An insurer that offers or issues a policy of grouphealth insurance which provides coverage for prescription drugs shall includewith any summary, certificate or evidence of that coverage provided to aninsured, notice of whether a formulary is used and, if so, of the opportunityto secure information regarding the formulary from the insurer pursuant tosubsection 2. The notice required by this subsection must:
(a) Be in a language that is easily understood and in aformat that is easy to understand;
(b) Include an explanation of what a formulary is; and
(c) If a formulary is used, include:
(1) An explanation of:
(I) How often the contents of theformulary are reviewed; and
(II) The procedure and criteria fordetermining which prescription drugs are included in and excluded from theformulary; and
(2) The telephone number of the insurer formaking a request for information regarding the formulary pursuant to subsection2.
2. If an insurer offers or issues a policy of grouphealth insurance which provides coverage for prescription drugs and a formularyis used, the insurer shall:
(a) Provide to any insured or participating provider ofhealth care, upon request:
(1) Information regarding whether a specificdrug is included in the formulary.
(2) Access to the most current list ofprescription drugs in the formulary, organized by major therapeutic category,with an indication of whether any listed drugs are preferred over other listeddrugs. If more than one formulary is maintained, the insurer shall notify therequester that a choice of formulary lists is available.
(b) Notify each person who requests informationregarding the formulary, that the inclusion of a drug in the formulary does notguarantee that a provider of health care will prescribe that drug for aparticular medical condition.
(Added to NRS by
NRS
1. Except as otherwise provided in subsection 4, eachinsurer that issues a policy of group health insurance in this State shallestablish a system for resolving any complaints of an insured concerning healthcare services covered under the policy. The system must be approved by theCommissioner in consultation with the State Board of Health.
2. A system for resolving complaints establishedpursuant to subsection 1 must include an initial investigation, a review of thecomplaint by a review board and a procedure for appealing a determinationregarding the complaint. The majority of the members on a review board must beinsureds who receive health care services pursuant to a policy of group healthinsurance issued by the insurer.
3. The Commissioner or the State Board of Health mayexamine the system for resolving complaints established pursuant to subsection1 at such times as either deems necessary or appropriate.
4. Each insurer that issues a policy of group healthinsurance in this State that provides, delivers, arranges for, pays for orreimburses any cost of health care services through managed care shall providea system for resolving any complaints of an insured concerning the health careservices that complies with the provisions of
(Added to NRS by 1997, 309; A
NRS
1. Each insurerthat issues a policy of group health insurance in this State shall submit tothe Commissioner and the State Board of Health an annual report regarding itssystem for resolving complaints established pursuant to subsection 1 of
(a) A description of the procedures used for resolvingany complaints of an insured;
(b) The total number of complaints and appeals handledthrough the system for resolving complaints since the last report and acompilation of the causes underlying the complaints filed;
(c) The current status of each complaint and appealfiled; and
(d) The average amount of time that was needed toresolve a complaint and an appeal, if any.
2. Each insurer shall maintain records of complaintsfiled with it which concern something other than health care services and shallsubmit to the Commissioner a report summarizing such complaints at such timesand in such format as the Commissioner may require.
(Added to NRS by 1997, 309; A
NRS
1. Followingapproval by the Commissioner, each insurer that issues a policy of group healthinsurance in this State shall provide written notice to an insured, in clearand comprehensible language that is understandable to an ordinary layperson, explainingthe right of the insured to file a written complaint. Such notice must be providedto an insured:
(a) At the time he receives his certificate of coverageor evidence of coverage;
(b) Any time that the insurer denies coverage of ahealth care service or limits coverage of a health care service to an insured;and
(c) Any other time deemed necessary by theCommissioner.
2. Any time that an insurer denies coverage of ahealth care service, including, without limitation, denying a claim relating toa policy of group health insurance or blanket insurance pursuant to
(a) The reason for denying coverage of the service;
(b) The criteria by which the insurer determineswhether to authorize or deny coverage of the health care service; and
(c) His right to file a written complaint and theprocedure for filing such a complaint.
3. A written notice which is approved by theCommissioner shall be deemed to be in clear and comprehensible language that isunderstandable to an ordinary layperson.
(Added to NRS by 1997, 309; A
NRS
1. A provision that, in the absence of fraud, allstatements made by applicants or the policyholders or by an insured person arerepresentations and not warranties, and that no statement made for the purposeof effecting insurance voids the insurance or reduces its benefits unless thestatement is contained in a written instrument signed by the policyholder orthe insured person, a copy of which has been furnished to him or hisbeneficiary.
2. A provision that the insurer will furnish to thepolicyholder for delivery to each employee or member of the insured group astatement in summary form of the essential features of the insurance coverageof that employee or member and to whom benefits thereunder are payable. Ifdependents are included in the coverage, only one statement need be issued foreach family.
3. A provision that to the group originally insuredmay be added from time to time eligible new employees or members or dependents,as the case may be, in accordance with the terms of the policy.
4. A provision for benefits for expense arising fromcare at home or health supportive services if the care or service wasprescribed by a physician and would have been covered by the policy if performedin a medical facility or facility for the dependent as defined in
5. A provision for benefits payable for expensesincurred for the treatment of the abuse of alcohol or drugs, as provided in
6. A provision for benefits for expenses arising fromhospice care.
(Added to NRS by 1971, 1767; A 1975, 448, 1850; 1979,1178; 1983, 1934, 2037; 1985, 1774; 1989, 1032)
NRS
1. The provisions of this section apply to a policy ofgroup health insurance offered or issued by an insurer if an insured covered bythe policy receives health care through a defined set of providers of healthcare who are under contract with the insurer.
2. Except as otherwise provided in this section, if aninsured who is covered by a policy described in subsection 1 is receivingmedical treatment for a medical condition from a provider of health care whosecontract with the insurer is terminated during the course of the medicaltreatment, the policy must provide that:
(a) The insured may continue to obtain medicaltreatment for the medical condition from the provider of health care pursuantto this section, if:
(1) The insured is actively undergoing amedically necessary course of treatment; and
(2) The provider of health care and the insuredagree that the continuity of care is desirable.
(b) The provider of health care is entitled to receivereimbursement from the insurer for the medical treatment he provides to theinsured pursuant to this section, if the provider of health care agrees:
(1) To provide medical treatment under the termsof the contract between the provider of health care and the insurer with regardto the insured, including, without limitation, the rates of payment forproviding medical service, as those terms existed before the termination of thecontract between the provider of health care and the insurer; and
(2) Not to seek payment from the insured for anymedical service provided by the provider of health care that the provider ofhealth care could not have received from the insured were the provider ofhealth care still under contract with the insurer.
3. The coverage required by subsection 2 must beprovided until the later of:
(a) The 120th day after the date the contract isterminated; or
(b) If the medical condition is pregnancy, the 45th dayafter:
(1) The date of delivery; or
(2) If the pregnancy does not end in delivery,the date of the end of the pregnancy.
4. The requirements of this section do not apply to aprovider of health care if:
(a) The provider of health care was under contract withthe insurer and the insurer terminated that contract because of the medicalincompetence or professional misconduct of the provider of health care; and
(b) The insurer did not enter into another contractwith the provider of health care after the contract was terminated pursuant toparagraph (a).
5. A policy subject to the provisions of this chapterthat is delivered, issued for delivery or renewed on or after October 1, 2003,has the legal effect of including the coverage required by this section, andany provision of the policy or renewal thereof that is in conflict with thissection is void.
6. The Commissioner shall adopt regulations to carryout the provisions of this section.
(Added to NRS by
NRS
1. A policy of group health insurance must providecoverage for medical treatment which a person insured under the group policyreceives as part of a clinical trial or study if:
(a) The medical treatment is provided in a Phase I,Phase II, Phase III or Phase IV study or clinical trial for the treatment ofcancer or in a Phase II, Phase III or Phase IV study or clinical trial for thetreatment of chronic fatigue syndrome;
(b) The clinical trial or study is approved by:
(1) An agency of the National Institutes ofHealth as set forth in 42 U.S.C. 281(b);
(2) A cooperative group;
(3) The Food and Drug Administration as anapplication for a new investigational drug;
(4) The United States Department of VeteransAffairs; or
(5) The United States Department of Defense;
(c) In the case of:
(1) A Phase I clinical trial or study for thetreatment of cancer, the medical treatment is provided at a facility authorizedto conduct Phase I clinical trials or studies for the treatment of cancer; or
(2) A Phase II, Phase III or Phase IV study orclinical trial for the treatment of cancer or chronic fatigue syndrome, themedical treatment is provided by a provider of health care and the facility andpersonnel for the clinical trial or study have the experience and training toprovide the treatment in a capable manner;
(d) There is no medical treatment available which isconsidered a more appropriate alternative medical treatment than the medicaltreatment provided in the clinical trial or study;
(e) There is a reasonable expectation based on clinicaldata that the medical treatment provided in the clinical trial or study will beat least as effective as any other medical treatment;
(f) The clinical trial or study is conducted in thisState; and
(g) The insured has signed, before his participation inthe clinical trial or study, a statement of consent indicating that he has beeninformed of, without limitation:
(1) The procedure to be undertaken;
(2) Alternative methods of treatment; and
(3) The risks associated with participation inthe clinical trial or study, including, without limitation, the general natureand extent of such risks.
2. Except as otherwise provided in subsection 3, thecoverage for medical treatment required by this section is limited to:
(a) Coverage for any drug or device that is approvedfor sale by the Food and Drug Administration without regard to whether theapproved drug or device has been approved for use in the medical treatment ofthe insured person.
(b) The cost of any reasonably necessary health careservices that are required as a result of the medical treatment provided in aPhase II, Phase III or Phase IV clinical trial or study or as a result of anycomplication arising out of the medical treatment provided in a Phase II, PhaseIII or Phase IV clinical trial or study, to the extent that such health careservices would otherwise be covered under the policy of group health insurance.
(c) The cost of any routine health care services thatwould otherwise be covered under the policy of group health insurance for aninsured participating in a Phase I clinical trial or study.
(d) The initial consultation to determine whether theinsured is eligible to participate in the clinical trial or study.
(e) Health care services required for the clinicallyappropriate monitoring of the insured during a Phase II, Phase III or Phase IVclinical trial or study.
(f) Health care services which are required for theclinically appropriate monitoring of the insured during a Phase I clinicaltrial or study and which are not directly related to the clinical trial orstudy.
Except asotherwise provided in NRS 689B.0303,the services provided pursuant to paragraphs (b), (c), (e) and (f) must becovered only if the services are provided by a provider with whom the insurerhas contracted for such services. If the insurer has not contracted for theprovision of such services, the insurer shall pay the provider the rate ofreimbursement that is paid to other providers with whom the insurer hascontracted for similar services and the provider shall accept that rate ofreimbursement as payment in full.
3. Particular medical treatment described insubsection 2 and provided to a person insured under the group policy is notrequired to be covered pursuant to this section if that particular medicaltreatment is provided by the sponsor of the clinical trial or study free ofcharge to the person insured under the group policy.
4. The coverage for medical treatment required by thissection does not include:
(a) Any portion of the clinical trial or study that iscustomarily paid for by a government or a biotechnical, pharmaceutical ormedical industry.
(b) Coverage for a drug or device described inparagraph (a) of subsection 2 which is paid for by the manufacturer,distributor or provider of the drug or device.
(c) Health care services that are specifically excludedfrom coverage under the insureds policy of group health insurance, regardlessof whether such services are provided under the clinical trial or study.
(d) Health care services that are customarily providedby the sponsors of the clinical trial or study free of charge to theparticipants in the trial or study.
(e) Extraneous expenses related to participation in theclinical trial or study including, without limitation, travel, housing andother expenses that a participant may incur.
(f) Any expenses incurred by a person who accompaniesthe insured during the clinical trial or study.
(g) Any item or service that is provided solely tosatisfy a need or desire for data collection or analysis that is not directlyrelated to the clinical management of the insured.
(h) Any costs for the management of research relatingto the clinical trial or study.
5. An insurer who delivers or issues for delivery apolicy of group health insurance specified in subsection 1 may require copiesof the approval or certification issued pursuant to paragraph (b) of subsection1, the statement of consent signed by the insured, protocols for the clinicaltrial or study and any other materials related to the scope of the clinicaltrial or study relevant to the coverage of medical treatment pursuant to thissection.
6. An insurer who delivers or issues for delivery apolicy of group health insurance specified in subsection 1 shall:
(a) Include in the disclosure required pursuant to
(b) Provide the coverage required by this sectionsubject to the same deductible, copayment, coinsurance and other suchconditions for coverage that are required under the policy.
7. A policy of group health insurance subject to theprovisions of this chapter that is delivered, issued for delivery or renewed onor after January 1, 2006, has the legal effect of including the coveragerequired by this section, and any provision of the policy that conflicts withthis section is void.
8. An insurer who delivers or issues for delivery apolicy of group health insurance specified in subsection 1 is immune fromliability for:
(a) Any injury to the insured caused by:
(1) Any medical treatment provided to theinsured in connection with his participation in a clinical trial or studydescribed in this section; or
(2) An act or omission by a provider of healthcare who provides medical treatment or supervises the provision of medicaltreatment to the insured in connection with his participation in a clinicaltrial or study described in this section.
(b) Any adverse or unanticipated outcome arising out ofan insureds participation in a clinical trial or study described in thissection.
9. As used in this section:
(a) Cooperative group means a network of facilitiesthat collaborate on research projects and has established a peer review programapproved by the National Institutes of Health. The term includes:
(1) The Clinical Trials Cooperative GroupProgram; and
(2) The Community Clinical Oncology Program.
(b) Facility authorized to conduct Phase I clinicaltrials or studies for the treatment of cancer means a facility or an affiliateof a facility that:
(1) Has in place a Phase I program which permitsonly selective participation in the program and which uses clear-cut criteriato determine eligibility for participation in the program;
(2) Operates a protocol review and monitoringsystem which conforms to the standards set forth in the Policies and GuidelinesRelating to the Cancer-Center Support Grant published by the Cancer CentersBranch of the National Cancer Institute;
(3) Employs at least two researchers and atleast one of those researchers receives funding from a federal grant;
(4) Employs at least three clinical investigatorswho have experience working in Phase I clinical trials or studies conducted ata facility designated as a comprehensive cancer center by the National CancerInstitute;
(5) Possesses specialized resources for use inPhase I clinical trials or studies, including, without limitation, equipmentthat facilitates research and analysis in proteomics, genomics andpharmacokinetics;
(6) Is capable of gathering, maintaining andreporting electronic data; and
(7) Is capable of responding to audits institutedby federal and state agencies.
(c) Provider of health care means:
(1) A hospital; or
(2) A person licensed pursuant to
(Added to NRS by
NRS
1. A policy of group health insurance must include aprovision authorizing a woman covered by the policy to obtain coveredgynecological or obstetrical services without first receiving authorization ora referral from her primary care physician.
2. The provisions of this section do not authorize awoman covered by a policy of group health insurance to designate anobstetrician or gynecologist as her primary care physician.
3. A policy subject to the provisions of this chapterthat is delivered, issued for delivery or renewed on or after October 1, 1999,has the legal effect of including the coverage required by this section, andany provision of the policy or the renewal which is in conflict with thissection is void.
4. As used in this section, primary care physicianhas the meaning ascribed to it in NRS695G.060.
(Added to NRS by
NRS
1. All group health insurance policies providingcoverage on an expense-incurred basis and all employee welfare plans providingmedical, surgical or hospital care or benefits established or maintained foremployees or their families or dependents, or for both, must as to the familymembers coverage provide that the health benefits applicable for children arepayable with respect to:
(a) A newly born child of the insured from the momentof birth;
(b) An adopted child from the date the adoption becomeseffective, if the child was not placed in the home before adoption; and
(c) A child placed with the insured for the purpose ofadoption from the moment of placement as certified by the public or privateagency making the placement. The coverage of such a child ceases if theadoption proceedings are terminated as certified by the public or privateagency making the placement.
The policiesmust provide the coverage specified in subsection 3 and must not excludepremature births.
2. The policy or contract may require thatnotification of:
(a) The birth of a newly born child;
(b) The effective date of adoption of a child; or
(c) The date of placement of a child for adoption,
and paymentsof the required premium or fees, if any, must be furnished to the insurer orwelfare plan within 31 days after the date of birth, adoption or placement foradoption in order to have the coverage continue beyond the 31-day period.
3. The coverage for newly born and adopted childrenand children placed for adoption consists of coverage of injury or sickness,including the necessary care and treatment of medically diagnosed congenitaldefects and birth abnormalities and, within the limits of the policy, necessarytransportation costs from place of birth to the nearest specialized treatmentcenter under major medical policies, and with respect to basic policies to theextent such costs are charged by the treatment center.
4. An insurer shall not restrict the coverage of adependent child adopted or placed for adoption solely because of a preexistingcondition the child has at the time he would otherwise become eligible forcoverage pursuant to the group health policy. Any provision relating to anexclusion for a preexisting condition must comply with
(Added to NRS by 1975, 1109; A 1989, 740; 1995, 2430;1997, 2914)
NRS
1. Every policy of group health insurance must containa provision which reduces the insurers liability because of benefits underother valid group coverage. To the extent authorized by the Commissioner, sucha provision may include subrogation.
2. A provision for subrogation may include a lien uponany recovery by an insured from a third person for the cost of medical benefitspaid by the insurer for injuries incurred as a result of the actions of thethird person. The lien may not exceed the amount paid by the insurer.
3. An insurer may not deny payment for servicesbecause of the inclusion of a provision required by this section.
(Added to NRS by 1985, 1060; A 1995, 1628)
NRS
1. As used in this section, total disability andtotally disabled mean the continuing inability of the employee or member,because of an injury or illness, to perform substantially the duties related tohis employment for which he is otherwise qualified.
2. No group policy of health insurance may bedelivered or issued for delivery in this state unless it provides continuingcoverage for an employee or member of the insured group, and his dependents whoare otherwise covered by the policy, while the employee or member is on leavewithout pay as a result of a total disability. The coverage must be for anyinjury or illness suffered by the employee or member which is not related tothe total disability or for any injury or illness suffered by his dependent.The coverage for such injury or illness must be equal to or greater than thecoverage otherwise provided by the policy.
3. The coverage required pursuant to subsection 2 mustcontinue until:
(a) The date on which the employment of the employee ormember is terminated;
(b) The date on which the employee or member obtainsanother policy of health insurance;
(c) The date on which the group policy of healthinsurance is terminated; or
(d) After a period of 12 months in which benefits undersuch coverage are provided to the employee or member,
whicheveroccurs first.
(Added to NRS by 1989, 1249)
NRS
1. A group health insurance policy delivered or issuedfor delivery after November 1, 1973, which provides for the termination ofcoverage on a dependent child of a member of the insured group, when such childattains a contractually specified limiting age, shall also provide that suchcoverage shall not terminate when the dependent child reaches such age if suchchild is and continues to be:
(a) Incapable of self-sustaining employment due to aphysical handicap or mental retardation; and
(b) Dependent on the member of the insured group forsupport and maintenance.
2. Proof of such childs incapacity and dependencyshall be furnished to the insurer by the member of the insured group within 31days after such child attains the specified limiting age and as often as theinsurer may thereafter require, but no more than once a year beginning 2 yearsafter such child attains the specified limiting age.
(Added to NRS by 1973, 548)
NRS
1. A policy of group health insurance must providecoverage for:
(a) Enteral formulas for use at home that areprescribed or ordered by a physician as medically necessary for the treatmentof inherited metabolic diseases characterized by deficient metabolism, ormalabsorption originating from congenital defects or defects arising shortlyafter birth, of amino acid, organic acid, carbohydrate or fat; and
(b) At least $2,500 per year for special food productswhich are prescribed or ordered by a physician as medically necessary for thetreatment of a person described in paragraph (a).
2. The coverage required by subsection 1 must beprovided whether or not the condition existed when the policy was purchased.
3. A policy subject to the provisions of this chapterthat is delivered, issued for delivery or renewed on or after January 1, 1998,has the legal effect of including the coverage required by this section, andany provision of the policy or the renewal which is in conflict with thissection is void.
4. As used in this section:
(a) Inherited metabolic disease means a diseasecaused by an inherited abnormality of the body chemistry of a person.
(b) Special food product means a food product that isspecially formulated to have less than one gram of protein per serving and isintended to be consumed under the direction of a physician for the dietarytreatment of an inherited metabolic disease. The term does not include a foodthat is naturally low in protein.
(Added to NRS by 1997, 1526)
NRS
1. No group policy of health insurance that providescoverage for hospital, medical or surgical expenses may be delivered or issuedfor delivery in this state unless the policy includes coverage for themanagement and treatment of diabetes, including, without limitation, coveragefor the self-management of diabetes.
2. An insurer who delivers or issues for delivery apolicy specified in subsection 1:
(a) Shall include in the disclosure required pursuantto NRS 689B.027 notice to eachpolicyholder and subscriber under the policy of the availability of thebenefits required by this section.
(b) Shall provide the coverage required by this sectionsubject to the same deductible, copayment, coinsurance and other suchconditions for coverage that are required under the policy.
3. A policy subject to the provisions of this chapterthat is delivered, issued for delivery or renewed on or after January 1, 1998,has the legal effect of including the coverage required by this section, andany provision of the policy that conflicts with this section is void.
4. As used in this section:
(a) Coverage for the management and treatment ofdiabetes includes coverage for medication, equipment, supplies and appliancesthat are medically necessary for the treatment of diabetes.
(b) Coverage for the self-management of diabetesincludes:
(1) The training and education provided to theemployee or member of the insured group after he is initially diagnosed withdiabetes which is medically necessary for the care and management of diabetes,including, without limitation, counseling in nutrition and the proper use ofequipment and supplies for the treatment of diabetes;
(2) Training and education which is medicallynecessary as a result of a subsequent diagnosis that indicates a significantchange in the symptoms or condition of the employee or member of the insuredgroup and which requires modification of his program of self-management ofdiabetes; and
(3) Training and education which is medicallynecessary because of the development of new techniques and treatment fordiabetes.
(c) Diabetes includes type I, type II and gestationaldiabetes.
(Added to NRS by 1997, 743)
NRS
1. Notwithstanding any provisions of this title to thecontrary, a policy of group health insurance delivered or issued for deliveryin this state pursuant to this chapter must provide coverage for the treatmentof conditions relating to severe mental illness.
2. The coverage required by this section:
(a) Must provide:
(1) Benefits for at least 40 days ofhospitalization as an inpatient per policy year and 40 visits for treatment asan outpatient per policy year, excluding visits for the management ofmedication; and
(2) That two visits for partial or respite care,or a combination thereof, may be substituted for each 1 day of hospitalizationnot used by the insured. In no event is the policy required to provide coveragefor more than 40 days of hospitalization as an inpatient per policy year.
(b) Is not required to provide benefits forpsychosocial rehabilitation or care received as a custodial inpatient.
3. Any deductibles and copayments required to be paidfor the coverage required by this section must not be greater than 150 percentof the out-of-pocket expenses required to be paid for medical and surgicalbenefits provided pursuant to the policy of group health insurance.
4. The provisions of this section do not apply to apolicy of group health insurance:
(a) Delivered or issued for delivery to an employer toprovide coverage for his employees if the employer has no more than 25employees.
(b) If, at the end of the policy year, the premiumscharged for that policy, or a standard grouping of policies, increase by morethan 2 percent as a result of providing the coverage required by this sectionand the insurer obtains an exemption from the Commissioner pursuant tosubsection 5.
5. To obtain the exemption required by paragraph (b)of subsection 4, an insurer must submit to the Commissioner a written requesttherefor that is signed by an actuary and sets forth the reasons and actuarialassumptions upon which the request is based. To determine whether an exemptionmay be granted, the Commissioner shall subtract from the amount of premiumscharged during the policy year the amount of premiums charged during the periodimmediately preceding the policy year and the amount of any increase in thepremiums charged that is attributable to factors that are unrelated toproviding the coverage required by this section. The Commissioner shall verifythe information within 30 days after receiving the request. The request shallbe deemed approved if the Commissioner does not deny the request within thattime.
6. The provisions of this section do not:
(a) Limit the provision of specialized services coveredby Medicaid for persons with conditions relating to mental health or substanceabuse.
(b) Supersede any provision of federal law, any federalor state policy relating to Medicaid, or the terms and conditions imposed onany Medicaid waiver granted to this state with respect to the provisions ofservices to persons with conditions relating to mental health or substanceabuse.
7. A policy of group health insurance subject to theprovisions of this chapter which is delivered, issued for delivery or renewedon or after January 1, 2000, has the legal effect of including the coveragerequired by this section, and any provision of the policy or the renewal whichis in conflict with this section is void, unless the policy is otherwise exemptfrom the provisions of this section pursuant to subsection 4.
8. As used in this section, severe mental illnessmeans any of the following mental illnesses that are biologically based and forwhich diagnostic criteria are prescribed in the Diagnostic and StatisticalManual of Mental Disorders, Fourth Edition, published by the AmericanPsychiatric Association:
(a) Schizophrenia.
(b) Schizoaffective disorder.
(c) Bipolar disorder.
(d) Major depressive disorders.
(e) Panic disorder.
(f ) Obsessive-compulsivedisorder.
(Added to NRS by
NRS
1. The benefits provided by a group policy for healthinsurance, as required in subsection 5 of NRS689B.030, for treatment of the abuse of alcohol or drugs must consist of:
(a) Treatment for withdrawal from the physiologicaleffects of alcohol or drugs, with a minimum benefit of $1,500 per calendaryear.
(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 notadmitted to a facility, with a minimum benefit of $2,500 per calendar year.
2. These benefits must be paid in the same manner asbenefits for any other illness covered by a similar policy are paid.
3. The insured person is entitled to these benefits iftreatment is received in any:
(a) Facility for the treatment of abuse of alcohol ordrugs which is certified by the Health Division of the Department of Health andHuman Services.
(b) Hospital or other medical facility or facility forthe dependent which is licensed by the Health Division of the Department ofHealth and Human Services, accredited by the Joint Commission on Accreditationof Healthcare Organizations and provides a program for the treatment of abuseof alcohol or drugs as part of its accredited activities.
(Added to NRS by 1979, 1178; A 1983, 2038; 1985,1570, 1775; 1993, 1918; 1997, 1301;
NRS
1. No group policy of health insurance that providescoverage for a drug approved by the Food and Drug Administration for use in thetreatment of an illness, disease or other medical condition may be delivered orissued for delivery in this state unless the policy includes coverage for any otheruse of the drug for the treatment of cancer, if that use is:
(a) Specified in the most recent edition of orsupplement to:
(1) The United States Pharmacopoeia DrugInformation; or
(2) The American Hospital Formulary ServiceDrug Information; or
(b) Supported by at least two articles reporting theresults of scientific studies that are published in scientific or medicaljournals, as defined in 21 C.F.R. 99.3.
2. The coverage required pursuant to this section:
(a) Includes coverage for any medical servicesnecessary to administer the drug to the employee or member of the insuredgroup.
(b) Does not include coverage for any:
(1) Experimental drug used for the treatment ofcancer if that drug has not been approved by the Food and Drug Administration;or
(2) Use of a drug that is contraindicated by theFood and Drug Administration.
3. A policy subject to the provisions of this chapterthat is delivered, issued for delivery or renewed on or after October 1, 1999,has the legal effect of including the coverage required by this section, andany provision of the policy that conflicts with the provisions of this sectionis void.
(Added to NRS by
NRS
1. A policy of group health insurance that providescoverage for the treatment of colorectal cancer must provide coverage forcolorectal cancer screening in accordance with:
(a) The guidelines concerning colorectal cancerscreening which are published by the American Cancer Society; or
(b) Other guidelines or reports concerning colorectalcancer screening which are published by nationally recognized professional organizationsand which include current or prevailing supporting scientific data.
2. A policy of group health insurance subject to theprovisions of this chapter that is delivered, issued for delivery or renewed onor after October 1, 2003, has the legal effect of including the coveragerequired by this section, and any provision of the policy that conflicts withthe provisions of this section is void.
(Added to NRS by
NRS
1. Except as otherwise provided in this section, apolicy of group health insurance which provides coverage for prescription drugsmust not limit or exclude coverage for a drug if the drug:
(a) Had previously been approved for coverage by theinsurer for a medical condition of an insured and the insureds provider ofhealth care determines, after conducting a reasonable investigation, that noneof the drugs which are otherwise currently approved for coverage are medicallyappropriate for the insured; and
(b) Is appropriately prescribed and considered safe andeffective 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 prescribedfor a use that is different from the use for which that drug has been approvedfor marketing by the Food and Drug Administration;
(b) Prohibit:
(1) The insurer from charging a deductible,copayment or coinsurance for the provision of benefits for prescription drugsto the insured or from establishing, by contract, limitations on the maximumcoverage for prescription drugs;
(2) A provider of health care from prescribinganother drug covered by the policy that is medically appropriate for theinsured; or
(3) The substitution of another drug pursuant toNRS 639.23286 or
(c) Require any coverage for a drug after the term ofthe policy.
3. Any provision of a policy subject to the provisionsof this chapter that is delivered, issued for delivery or renewed on or afterOctober 1, 2001, which is in conflict with this section is void.
(Added to NRS by
NRS
1. A policy of group health insurance must providecoverage for benefits payable for expenses incurred for:
(a) An annual cytologic screening test for women 18years of age or older;
(b) A baseline mammogram for women between the ages of35 and 40; and
(c) An annual mammogram for women 40 years of age orolder.
2. A policy of group health insurance must not requirean insured to obtain prior authorization for any service provided pursuant tosubsection 1.
3. A policy subject to the provisions of this chapterwhich is delivered, issued for delivery or renewed on or after October 1, 1989,has the legal effect of including the coverage required by subsection 1, andany provision of the policy or the renewal which is in conflict with subsection1 is void.
(Added to NRS by 1989, 1889; A 1997, 1730)
NRS
1. A policy of group health insurance which providescoverage for the surgical procedure known as a mastectomy must also providecommensurate coverage for:
(a) Reconstruction of the breast on which themastectomy has been performed;
(b) Surgery and reconstruction of the other breast toproduce a symmetrical structure; and
(c) Prostheses and physical complications for allstages of mastectomy, including lymphedemas.
2. The provision of services must be determined by theattending physician and the patient.
3. The plan or issuer may require deductibles andcoinsurance payments if they are consistent with those established for otherbenefits.
4. Written notice of the availability of the coveragemust be given upon enrollment and annually thereafter. The notice must be sentto all participants:
(a) In the next mailing made by the plan or issuer tothe participant or beneficiary; or
(b) As part of any annual information packet sent tothe participant or beneficiary,
whichever isearlier.
5. A plan or issuer may not:
(a) Deny eligibility, or continued eligibility, toenroll or renew coverage, in order to avoid the requirements of subsections 1to 4, inclusive; or
(b) Penalize, or limit reimbursement to, a provider ofcare, or provide incentives to a provider of care, in order to induce theprovider not to provide the care listed in subsections 1 to 4, inclusive.
6. A plan or issuer may negotiate rates ofreimbursement with providers of care.
7. If reconstructive surgery is begun within 3 yearsafter a mastectomy, the amount of the benefits for that surgery must equalthose amounts provided for in the policy at the time of the mastectomy. If thesurgery is begun more than 3 years after the mastectomy, the benefits providedare subject to all of the terms, conditions and exclusions contained in thepolicy at the time of the reconstructive surgery.
8. A policy subject to the provisions of this chapterwhich is delivered, issued for delivery or renewed on or after October 1, 2001,has the legal effect of including the coverage required by this section, andany provision of the policy or the renewal which is in conflict with thissection is void.
9. For the purposes of this section, reconstructivesurgery means a surgical procedure performed following a mastectomy on onebreast or both breasts to reestablish symmetry between the two breasts. Theterm includes augmentation mammoplasty, reduction mammoplasty and mastopexy.
(Added to NRS by 1983, 615; A 1989, 1889;
NRS
1. Except as otherwise provided in subsection 5, aninsurer that offers or issues a policy of group health insurance which providescoverage for prescription drugs or devices shall include in the policy coveragefor:
(a) Any type of drug or device for contraception; and
(b) Any type of hormone replacement therapy,
which islawfully prescribed or ordered and which has been approved by the Food and DrugAdministration.
2. An insurer that offers or issues a policy of grouphealth insurance that provides coverage for prescription drugs shall not:
(a) Require an insured to pay a higher deductible,copayment or coinsurance or require a longer waiting period or other conditionfor coverage for a prescription for a contraceptive or hormone replacementtherapy than is required for other prescription drugs covered by the policy;
(b) Refuse to issue a policy of group health insuranceor cancel a policy of group health insurance solely because the person applyingfor or covered by the policy uses or may use in the future any of the serviceslisted in subsection 1;
(c) Offer or pay any type of material inducement orfinancial incentive to an insured to discourage the insured from accessing anyof the services listed in subsection 1;
(d) Penalize a provider of health care who provides anyof the services listed in subsection 1 to an insured, including, withoutlimitation, reducing the reimbursement of the provider of health care; or
(e) Offer or pay any type of material inducement, bonusor other financial incentive to a provider of health care to deny, reduce,withhold, limit or delay any of the services listed in subsection 1 to aninsured.
3. Except as otherwise provided in subsection 5, apolicy subject to the provisions of this chapter that is delivered, issued fordelivery or renewed on or after October 1, 1999, has the legal effect ofincluding the coverage required by subsection 1, and any provision of thepolicy or the renewal which is in conflict with this section is void.
4. The provisions of this section do not:
(a) Require an insurer to provide coverage forfertility drugs.
(b) Prohibit an insurer from requiring an insured topay a deductible, copayment or coinsurance for the coverage required byparagraphs (a) and (b) of subsection 1 that is the same as the insured isrequired to pay for other prescription drugs covered by the policy.
5. An insurer which offers or issues a policy of grouphealth insurance and which is affiliated with a religious organization is notrequired to provide the coverage required by paragraph (a) of subsection 1 ifthe insurer objects on religious grounds. Such an insurer shall, before theissuance of a policy of group health insurance and before the renewal of such apolicy, provide to the group policyholder or prospective insured, asapplicable, written notice of the coverage that the insurer refuses to providepursuant to this subsection. The insurer shall provide notice to each insured,at the time the insured receives his certificate of coverage or evidence ofcoverage, that the insurer refused to provide coverage pursuant to thissubsection.
6. If an insurer refuses, pursuant to subsection 5, toprovide the coverage required by paragraph (a) of subsection 1, an employer mayotherwise provide for the coverage for his employees.
7. As used in this section, provider of health carehas the meaning ascribed to it in NRS629.031.
(Added to NRS by
NRS
1. Except as otherwise provided in subsection 5, aninsurer that offers or issues a policy of group health insurance which providescoverage for outpatient care shall include in the policy coverage for anyhealth care service related to contraceptives or hormone replacement therapy.
2. An insurer that offers or issues a policy of grouphealth insurance that 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 or other conditionfor coverage for outpatient care related to contraceptives or hormonereplacement therapy than is required for other outpatient care covered by thepolicy;
(b) Refuse to issue a policy of group health insuranceor cancel a policy of group health insurance solely because the person applyingfor or covered by the policy uses or may use in the future any of the serviceslisted in subsection 1;
(c) Offer or pay any type of material inducement orfinancial incentive to an insured to discourage the insured from accessing anyof the services listed in subsection 1;
(d) Penalize a provider of health care who provides anyof the services listed in subsection 1 to an insured, including, withoutlimitation, reducing the reimbursement of the provider of health care; or
(e) Offer or pay any type of material inducement, bonusor other financial incentive to a provider of health care to deny, reduce,withhold, limit or delay any of the services listed in subsection 1 to aninsured.
3. Except as otherwise provided in subsection 5, apolicy subject to the provisions of this chapter that is delivered, issued fordelivery or renewed on or after October 1, 1999, has the legal effect ofincluding the coverage required by subsection 1, and any provision of thepolicy or the renewal which is in conflict with this section is void.
4. The provisions of this section do not prohibit aninsurer from requiring an insured to pay a deductible, copayment or coinsurancefor the coverage required by subsection 1 that is the same as the insured isrequired to pay for other outpatient care covered by the policy.
5. An insurer which offers or issues a policy of grouphealth insurance and which is affiliated with a religious organization is notrequired to provide the coverage for health care service related tocontraceptives required by this section if the insurer objects on religiousgrounds. Such an insurer shall, before the issuance of a policy of group healthinsurance and before the renewal of such a policy, provide to the grouppolicyholder or prospective insured, as applicable, written notice of thecoverage that the insurer refuses to provide pursuant to this subsection. Theinsurer shall provide notice to each insured, at the time the insured receiveshis certificate of coverage or evidence of coverage, that the insurer refusedto provide coverage pursuant to this subsection.
6. If an insurer refuses, pursuant to subsection 5, toprovide the coverage required by paragraph (a) of subsection 1, an employer mayotherwise provide for the coverage for his employees.
7. As used in this section, provider of health carehas the meaning ascribed to it in NRS629.031.
(Added to NRS by
NRS
1. Except as otherwise provided in this section, nopolicy of group health insurance may be delivered or issued for delivery inthis state if it contains an exclusion of coverage of the treatment of thetemporomandibular joint whether by specific language in the policy or by aclaims settlement practice. A policy may exclude coverage of those methods oftreatment which are recognized as dental procedures, including, but not limitedto, the extraction of teeth and the application of orthodontic devices andsplints.
2. The insurer may limit its liability on thetreatment of the temporomandibular joint to:
(a) No more than 50 percent of the usual and customarycharges for such treatment actually received by an insured, but in no case morethan 50 percent of the maximum benefits provided by the policy for suchtreatment; and
(b) Treatment which is medically necessary.
3. Any provision of a policy subject to the provisionsof this chapter and issued or delivered on or after January 1, 1990, which isin conflict with this section is void.
(Added to NRS by 1989, 2138)
NRS
(Added to NRS by 1981, 575; A 1989, 1553)
NRS
(Added to NRS by 1987, 2133)
NRS
(Added to NRS by 1987, 1123)
NRS
1. If any group policy of health insurance providescoverage for treatment of an illness which is within the authorized scope ofpractice of a qualified chiropractor, the insured is entitled to reimbursementfor treatments by a chiropractor who is licensed pursuant to
2. The terms of the policy must not limit:
(a) Coverage for treatments by a chiropractor to anumber less than for treatments by other physicians.
(b) Reimbursement for treatments by a chiropractor toan amount less than that charged for similar treatments by other physicians.
(Added to NRS by 1981, 930; A 1983, 327)
NRS
1. Any group health policy may provide that all or anyportion of any indemnities provided by any such policy on account of hospital,nursing, medical or surgical services, home health care or supportive services:
(a) May, at the insurers option; or
(b) Must, upon the written request of the insured,
be paiddirectly to the hospital or person rendering the services. Payments made inthis manner discharge the insurers obligation.
2. If the insured assigns his benefits pursuant tothis section but the insurer after receiving a copy of the assignment pays thebenefits to the insured, the insurer shall also pay the benefits to theassignee as soon as the insurer receives the notice of the incorrect payment.
(Added to NRS by 1971, 1767; A 1975, 448; 1983, 880)
NRS
1. If any group policy of health insurance providescoverage for services which are within the authorized scope of practice of aregistered nurse who is authorized pursuant to chapter632 of NRS to perform additional acts in an emergency or under otherspecial conditions as prescribed by the State Board of Nursing, and which arereimbursed when provided by another provider of health care, the insured isentitled to reimbursement for services provided by such a registered nurse.
2. The terms of the policy must not limit:
(a) Coverage for services provided by such a registerednurse to a number of occasions less than for services provided by anotherprovider of health care.
(b) Reimbursement for services provided by such aregistered nurse to an amount less than that reimbursed for similar servicesprovided by another provider of health care.
3. An insurer is not required to pay for servicesprovided by such a registered nurse which duplicate services provided byanother provider of health care.
(Added to NRS by 1985, 1447)
NRS
1. Except as otherwise provided in subsection 3, everypolicy of group health insurance amended, delivered or issued for delivery inthis State after October 1, 1989, that provides coverage for medicaltransportation, must contain a provision for the direct reimbursement of aprovider of medical transportation for covered services if that provider doesnot receive reimbursement from any other source.
2. The insured or the provider may submit the claimfor reimbursement. The provider shall not demand payment from the insured untilafter that reimbursement has been granted or denied.
3. Subsection 1 does not apply to any agreementbetween an insurer and a provider of medical transportation for the directpayment by the insurer for the providers services.
(Added to NRS by 1989, 1273)
NRS
(Added to NRS by 1991, 1134)
NRS
(Added to NRS by 1971, 1768; A 1993, 1982)
NRS
1. Any contract of group health insurance may providefor the readjustment of the rate of premium based upon the experiencethereunder. If a policy dividend is declared after January 1, 1972, or areduction in rate is made after January 1, 1972, or continued for the first orany subsequent year of insurance under any policy of group health insuranceissued before, on or after January 1, 1972, to any policyholder, the excess, ifany, of the aggregate dividends or rate reductions under such a policy and allother group insurance policies of the policyholder over the aggregateexpenditure for insurance under such policies made from money contributed bythe policyholder, or by an employer of insured persons, or by a union orassociation to which the insured persons belong, including expenditures made inconnection with administration of such policies, must be applied by thepolicyholder for the sole benefit of insured employees or members.
2. This section does not apply as to debtor groups.
(Added to NRS by 1971, 1768; A 1997, 1627)
NRS
1. May not require a deductible of more than $600 differenceper admission to a facility for inpatient treatment which is not a preferredprovider of health care.
2. May not require a deductible of more than $500difference per treatment, other than inpatient treatment at a hospital, by aprovider which is not preferred.
3. May not require an insured, another insurer whoissues policies of group health insurance, a nonprofit medical servicecorporation or a health maintenance organization to pay any amount in excess ofthe deductible or coinsurance due from the insured based on the rates agreedupon with a provider.
4. May not provide for a difference in percentagerates of payment for coinsurance of more than 30 percentage points between thepayment for coinsurance required to be paid by the insured to a preferredprovider of health care and the payment for coinsurance required to be paid bythe insured to a provider of health care who is not preferred.
5. Must require that the deductible and payment forcoinsurance paid by the insured to a preferred provider of health care beapplied to the negotiated reduced rates of that provider.
6. Must include for providers of health care who arenot preferred a provision establishing the point at which an insureds paymentfor coinsurance is no longer required to be paid if such a provision isincluded for preferred providers of health care. Such provisions must be basedon a calendar year. The point at which an insureds payment for coinsurance isno longer required to be paid for providers of health care who are notpreferred must not be greater than twice the amount for preferred providers ofhealth care, regardless of the method of payment.
7. Must provide that if there is a particular servicewhich a preferred provider of health care does not provide and the provider ofhealth care who is treating the insured requests the service and the insurerdetermines that the use of the service is necessary for the health of theinsured, the service shall be deemed to be provided by the preferred providerof health care.
8. Must require the insurer to process a claim of aprovider of health care who is not preferred not later than 30 working daysafter the date on which proof of the claim is received.
(Added to NRS by 1987, 1781; A 1991, 1329; 1995,1629)
NRS
1. When a policy of group insurance is primary, itsbenefits are determined before those of another policy and the benefits ofanother policy are not considered. When a policy of group insurance issecondary, its benefits are determined after those of another policy. Secondarybenefits may not be reduced because of benefits under the primary policy. Whenthere are more than two policies, a policy may be primary as to one and may besecondary as to another.
2. The benefits payable under a policy of group healthinsurance may not be reduced because of any benefits payable under anindividual health insurance policy, health insurance on a franchise plan orfirst-party coverage under an automobile insurance policy.
3. As used in this section, a policy of groupinsurance includes Medicare.
(Added to NRS by 1987, 848; A 1989, 1250; 1995, 1629)
NRS
1. A policy that does not coordinate with otherpolicies is always the primary policy.
2. The benefits of the policy which covers a person asan employee, member or subscriber, other than a dependent, is the primarypolicy. The policy which covers the person as a dependent is the secondarypolicy.
3. When more than one policy covers the same child asa dependent of different parents who are not divorced or separated, the primarypolicy is the policy of the parent whose birthday falls earlier in the year.The secondary policy is the policy of the parent whose birthday falls later inthe year. If both parents have the same birthday, the benefits of the policywhich covered the parent the longer is the primary policy. The policy whichcovered the parent the shorter time is the secondary policy.
4. If more than one policy covers a person as adependent child of divorced or separated parents, benefits for the child aredetermined in the following order:
(a) First, the policy of the parent with custody of thechild;
(b) Second, the policy of the spouse of the parent withcustody; and
(c) Third, the policy of the parent without custody ofthe child,
unless thespecific terms of a court decree state that one parent is responsible for thehealth care expenses of the child, in which case, the policy of that parent isthe primary policy. A parent responsible for the health care pursuant to acourt decree must notify the insurer of the terms of the decree.
5. The primary policy is the policy which covers aperson as an employee who is neither laid off or retired, or that employeesdependent. The secondary policy is the policy which covers that person as alaid off or retired employee, or that employees dependent.
6. If none of the rules in subsections 1 to 5,inclusive, determines the order of benefits, the primary policy is the policywhich covered an employee, member or subscriber longer. The secondary policy isthe policy which covered that person the shorter time.
When apolicy is determined to be a secondary policy it acts to provide benefits inexcess of those provided by the primary policy. The secondary policy may not reducebenefits based upon payments by the primary policy, except that this provisiondoes not require duplication of benefits.
(Added to NRS by 1987, 848)
NRS
1. A policy of group health insurance issued toreplace any discontinued policy or coverage for group health insurance must:
(a) Provide coverage for all persons who were coveredunder the previous policy or coverage on the date it was discontinued; and
(b) Except as otherwise provided in subsection 2,provide benefits which are at least as extensive as the benefits provided bythe previous policy or coverage, except that benefits may be reduced orexcluded to the extent that such a reduction or exclusion was permissible underthe terms of the previous policy or coverage,
if thatreplacement policy is issued within 60 days after the date on which the previouspolicy or coverage was discontinued.
2. If an employer obtains a replacement policypursuant to subsection 1 to cover his employees, any benefits provided by theprevious policy or coverage may be reduced if notice of the reduction is givento his employees pursuant to NRS 608.1577.
3. Any insurer which issues a replacement policypursuant to subsection 1 may submit a written request to the insurer whoprovided the previous policy or coverage for a statement of benefits which wereprovided under that policy or coverage. Upon receiving such a request, theinsurer who provided the previous policy or coverage shall give a writtenstatement to the insurer providing the replacement policy which indicates whatbenefits were provided and what exclusions or reductions were in effect underthe previous policy or coverage.
4. The provisions of this section:
(a) Apply to a self-insured employer who provideshealth benefits to his employees and replaces those benefits with a policy ofgroup health insurance.
(b) Do not apply to the Public Employees BenefitsProgram established pursuant to NRS287.0402 to 287.049, inclusive.
(Added to NRS by 1987, 849; A 1991, 251;
NRS
1. Except as otherwise provided in
(a) A member and any dependent of the member must begiven the opportunity to decline to participate in binding arbitration at thetime they elect to be covered by the policy.
(b) It must clearly state that the insurer and a memberor dependent of a member of the insured group who has not declined toparticipate in binding arbitration agree to forego their right to resolve anysuch dispute in a court of law or equity.
2. Except as otherwise provided in subsection 3, thearbitration must be conducted pursuant to the rules for commercial arbitrationestablished by the American Arbitration Association. The insurer is responsiblefor any administrative fees and expenses relating to the arbitration, exceptthat the insurer is not responsible for attorneys fees and fees for expertwitnesses unless those fees are awarded by the arbitrator.
3. If a dispute required to be submitted to bindingarbitration requires an immediate resolution to protect the physical health ofa member or a dependent of a member, any party to the dispute may waivearbitration and seek declaratory relief in a court of competent jurisdiction.
4. If a provision described in subsection 1 isincluded in a policy of group health insurance, the provision shall not bedeemed unenforceable as an unreasonable contract of adhesion if the provisionis included in compliance with the provisions of subsection 1.
(Added to NRS by 1995, 2557)
NRS
(Added to NRS by 1997, 1096)
NRS
1. Except as otherwise provided in subsection 2, aninsurer who provides group health insurance shall not:
(a) Require an insured person or any member of hisfamily to take a genetic test;
(b) Require an insured person to disclose whether he orany member of his family has taken a genetic test or any genetic information ofthe insured person or a member of his family; or
(c) Determine the rates or any other aspect of thecoverage or benefits for health care provided to an insured person based on:
(1) Whether the insured person or any member ofhis family has taken a genetic test; or
(2) Any genetic information of the insuredperson or any member of his family.
2. The provisions of this section do not apply to aninsurer who issues a policy of group health insurance that provides coveragefor long-term care or disability income.
3. As used in this section:
(a) Genetic information means any information that isobtained from a genetic test.
(b) Genetic test means a test, including a laboratorytest that uses deoxyribonucleic acid extracted from the cells of a person or adiagnostic test, to determine the presence of abnormalities or deficiencies,including carrier status, that:
(1) Are linked to physical or mental disordersor impairments; or
(2) Indicate a susceptibility to illness,disease, impairment or any other disorder, whether physical or mental.
(Added to NRS by 1997, 1460)
BLANKET POLICIES
NRS
1. Any common carrier or to any operator, owner orlessee of a means of transportation, who or which shall be deemed thepolicyholder, covering a group of persons who may become passengers defined byreference to their travel status on the common carrier or means oftransportation.
2. An employer, who shall be deemed the policyholder,covering any group of employees, dependents or guests, defined by reference tospecified hazards incident to an activity or activities or operations of thepolicyholder.
3. A college, school or other institution of learning,a school district or districts, or school jurisdictional unit, or to the head,principal or governing board of any such educational unit, who or which shallbe deemed the policyholder, covering students, teachers or employees.
4. A religious, charitable, recreational, educationalor civic organization, or branch thereof, which shall be deemed thepolicyholder, covering any group of members or participants defined byreference to specified hazards incident to an activity or activities oroperations sponsored or supervised by the policyholder.
5. A sports team, camp or sponsor thereof, which shallbe deemed the policyholder, covering members, campers, employees, officials orsupervisors.
6. A volunteer fire department, organization providingfirst aid, organization for emergency management or other such volunteerorganization, which shall be deemed the policyholder, covering any group ofmembers or participants defined by reference to specified hazards incident toan activity or activities or operations sponsored or supervised by thepolicyholder.
7. A newspaper or other publisher, which shall bedeemed the policyholder, covering its carriers.
8. An association, including a labor union, which hasa constitution and bylaws and which has been organized and is maintained ingood faith for purposes other than that of obtaining insurance, which shall bedeemed the policyholder, covering any group of members or participants definedby reference to specified hazards incident to an activity or activities oroperations sponsored or supervised by the policyholder.
9. Cover any other risk or class of risks which, inthe discretion of the Commissioner, may be properly eligible for blanketaccident and health insurance. The discretion of the Commissioner may beexercised on the basis of an individual risk or class of risks, or both.
(Added to NRS by 1971, 1768; A 1983, 177;
NRS
1. A provision that the policy, including endorsementsand a copy of the application, if any, of the policyholder and the personsinsured constitutes the entire contract between the parties, and that anystatement made by the policyholder or by a person insured is in the absence offraud a representation and not a warranty, and that no such statements may beused in defense to a claim under the policy, unless contained in a writtenapplication. The insured, his beneficiary or assignee has the right to make awritten request to the insurer for a copy of an application, and the insurershall, within 15 days after the receipt of a request at its home office or anybranch office of the insurer, deliver or mail to the person making the requesta copy of the application. If a copy is not so delivered or mailed, the insureris precluded from introducing the application as evidence in any action basedupon or involving any statements contained therein.
2. A provision that written notice of sickness or ofinjury must be given to the insurer within 20 days after the date when thesickness or injury occurred. Failure to give notice within that time does notinvalidate or reduce any claim if it is shown that it was not reasonablypossible to give notice and that notice was given as soon as was reasonablypossible.
3. A provision that the insurer will furnish to theclaimant or to the policyholder for delivery to the claimant such forms as areusually furnished by it for filing proof of loss. If the forms are notfurnished before the expiration of 15 days after giving written notice ofsickness or injury, the claimant shall be deemed to have complied with therequirements of the policy as to proof of loss upon submitting, within the timefixed in the policy for filing proof of loss, written proof covering the occurrence,the character and the extent of the loss for which claim is made.
4. A provision that in the case of a claim for loss oftime for disability, written proof of the loss must be furnished to the insurerwithin 90 days after the commencement of the period for which the insurer isliable, and that subsequent written proofs of the continuance of the disabilitymust be furnished to the insurer at such intervals as the insurer mayreasonably require, and that in the case of a claim for any other loss, writtenproof of the loss must be furnished to the insurer within 90 days after thedate of the loss. Failure to furnish such proof within that time does not invalidateor reduce any claim if it is shown that it was not reasonably possible to furnishproof and that the proof was furnished as soon as was reasonably possible.
5. A provision that all benefits payable under thepolicy other than benefits for loss of time will be payable immediately uponreceipt of written proof of loss, and that, subject to proof of loss, allaccrued benefits payable under the policy for loss of time will be paid notless frequently than monthly during the continuance of the period for which theinsurer is liable, and that any balance remaining unpaid at the termination ofthat period will be paid immediately upon receipt of proof.
6. A provision that the insurer at its own expense hasthe right and opportunity to examine the person of the insured when and sooften as it may reasonably require during the pendency of claim under thepolicy and also the right and opportunity to make an autopsy where it is notprohibited by law.
7. A provision, if applicable, setting forth theprovisions of NRS 689B.035.
8. A provision for benefits for expense arising fromcare at home or health supportive services if that care or service wasprescribed by a physician and would have been covered by the policy ifperformed in a medical facility or facility for the dependent as defined in
9. A provision that no action at law or in equity maybe brought to recover under the policy before the expiration of 60 days afterwritten proof of loss has been furnished in accordance with the requirements ofthe policy and that no such action may be brought after the expiration of 3years after the time written proof of loss is required to be furnished.
(Added to NRS by 1971, 1769; A 1973, 548; 1975, 448;1985, 1775; 1993, 500; 2001,2221)
NRS
1. An individual application need not be required froma person covered under a blanket health policy or contract, nor shall it benecessary for the insurer to furnish each person a certificate, if such persondoes not pay all or part of the premium for such insurance.
2. The Commissioner may, by rule or regulation,require the delivery of an individual certificate or a statement of thecoverage to individuals insured under such a blanket policy or contract who areeither required to make an individual written application or pay part or all ofthe premium therefor, and applying to such classes of cases and circumstances,specified in such rule or regulation, as the Commissioner may find suchdelivery to be reasonably necessary and practicable.
(Added to NRS by 1971, 1770)
NRS
1. Except as provided in subsection 2, all benefitsunder any blanket health policy or contract must be payable to the personinsured, or to his designated beneficiary or beneficiaries, or to his estate,except that if the person insured is a minor or otherwise not competent to givea valid release, these benefits may be made payable to his parent, guardian orother person actually supporting him.
2. The policy may provide that all or a portion of anyindemnities provided by any such policy on account of hospital, nursing,medical or surgical services, home health care or supportive services:
(a) May, at the option of the insurer and unless theinsured requests otherwise in writing not later than the time of filing proofsof such loss; or
(b) Must, upon the written request of the insured,
be paiddirectly to the hospital or person rendering those services. The policy may notrequire that the service be rendered by a particular hospital or person.Payment so made discharges the obligation of the insurer with respect to theamount of insurance so paid.
3. If the insured assigns his benefits pursuant tothis section but the insurer after receiving a copy of the assignment pays thebenefits to the insured, the insurer shall also pay the benefits to theassignee as soon as the insurer receives the notice of the incorrect payment.
(Added to NRS by 1971, 1771; A 1975, 450; 1983, 880)
NRS
(Added to NRS by 1971, 1771)
NRS
(Added to NRS by
CONVERSION OF GROUP POLICIES TO INDIVIDUAL POLICIES
NRS
1. Except as otherwise provided in subsection 3, allpolicies of group health insurance delivered or issued for delivery in thisstate providing for hospital, surgical or major medical expense insurance, orany combination of these coverages, on an expense-incurred basis must contain aprovision that the employee or member is entitled to have issued to him by theinsurer a policy of health insurance when the employee or member is no longercovered by the group policy.
2. The requirement in subsection 1 does not apply topolicies providing benefits only for specific diseases or accidental injuries,and it applies to other policies only if:
(a) The termination of coverage under the group policyis not due to termination of the group policy itself unless the termination ofthe group policy has resulted from failure of the policyholder to remit therequired premiums;
(b) The termination is not due to failure of theemployee or member to remit any required contributions;
(c) The employee or member has been continuouslyinsured under any group policy of the employer for at least 3 consecutivemonths immediately before the termination; and
(d) The employee or member applies in writing for theconverted policy and pays his first premium to the insurer no later than 31days after the termination.
3. If an employee or member was a recipient ofbenefits under the coverage provided pursuant to
(Added to NRS by 1979, 1084; A 1985, 1060; 1989,1250)
NRS
1. To the surviving spouse, if any, upon the death ofthe employee or member, with respect to the spouse and any child whose coverageunder the group policy is terminated by reason of the death, or if there is nosurviving spouse, to each surviving child whose coverage under the group policyterminates by reason of the death, or, if the group policy provides forcontinuation of dependents coverage following the employees or membersdeath, at the end of the continued coverage;
2. To the spouse of the employee or member upontermination of coverage of the spouse while the employee or member remainsinsured under the group policy, if the spouse ceases to be a qualified familymember under the group policy, and to any child whose coverage under the grouppolicy terminates at the same time; or
3. To a child solely with respect to himself upontermination of his coverage because he ceases to be a qualified family memberunder the group policy, if a conversion privilege is not otherwise providedwith respect to the termination.
(Added to NRS by 1979, 1086; A
NRS
1. The insurer is not required to issue a convertedpolicy to any person who:
(a) Is covered for similar benefits by anotherhospital, surgical, medical or major medical expense insurance policy, a hospitalor medical service subscriber contract, a medical practice or other prepaymentplan, or by any other kind of plan or program;
(b) Is eligible to be covered for similar benefitsunder any arrangement of coverage for individuals in a group, whether on aninsured on uninsured basis; or
(c) Has similar benefits provided for or availableunder the requirements of any state or federal law,
if anybenefits provided under the sources listed in this subsection, together withthe benefits to be provided by the converted policy, would result inoverinsurance according to the insurers standards.
2. Before denying a converted policy to an applicantbecause he has coverage as described in paragraph (a) of subsection 1, theinsurer shall notify him that the converted policy will be issued only if theother coverage is cancelled.
(Added to NRS by 1979, 1085)
NRS
(Added to NRS by 1979, 1085; A 1981, 907;
NRS
1. A converted policy must not exclude a preexistingcondition not excluded by the group policy, but a converted policy may providethat any hospital, surgical or medical benefits payable under it may be reducedby the amount of any benefits payable under the group policy after itstermination. A converted policy may provide that during the first policy yearthe benefits payable under it, together with the benefits payable under thegroup policy, must not exceed those that would have been payable if thepolicyholders insurance under the group policy had remained in effect.
2. Any exclusion for a preexisting condition providedby a converted policy must comply with NRS689B.500.
(Added to NRS by 1979, 1085; A 1997, 2915)
NRS
1. Issue the converted policy, as described in
2. Establish the premium on the converted policies inthe manner provided in subsections 3, 4 and 5, or pursuant to subsection 6, of
3. Provide that the effective date of the convertedpolicy is 12:01 a.m. on the day after the termination of insurance under thegroup policy; and
4. Provide that the converted policy covers theemployee or member and his dependents who were covered by the group policy onthe date of its termination. A separate converted policy may be issued to coverany dependent.
(Added to NRS by 1979, 1084; A
NRS
NRS
(Added to NRS by 1979, 1086; A 1985, 1061)
NRS
(Added to NRS by 1979, 1086)
CONTINUATION OF COVERAGE UNDER CERTAIN GROUP POLICIES
NRS
1. If an employer who employs less than 20 employeesmaintains a policy of group health insurance which covers those employees, thepolicy must contain a provision which permits:
(a) An employee to elect to continue identical coverageunder the policy, excluding coverage provided for eye or dental care, if:
(1) His employment is terminated for any reasonother than gross misconduct; or
(2) The number of his working hours is reducedso that he ceases to be eligible for coverage.
(b) The spouse or dependent child of an employee toelect to continue coverage, excluding coverage provided for eye or dental care,if:
(1) The employees employment is terminated forany reason other than gross misconduct or the number of his working hours isreduced so that he ceases to be eligible for coverage;
(2) The employee dies;
(3) The employee and his spouse are divorced orlegally separated;
(4) The dependent child ceases to be eligiblefor coverage under the terms of the policy; or
(5) The spouse ceases to be eligible forcoverage after becoming eligible for Medicare.
2. The period of continued coverage is limited to:
(a) Eighteen months for an employee.
(b) Thirty-six months for an employees spouse ordependent child.
3. An employee who voluntarily leaves his employment,or the spouse or dependent child of that employee, is not eligible to continuecoverage pursuant to this section.
4. An employee, spouse or dependent child who has notbeen covered under any group policy of the employer for at least 12 consecutivemonths before the termination of his coverage is not eligible to continuecoverage pursuant to this section.
5. A provision for continued coverage must includecoverage for any child born to, legally adopted by or placed for adoption withthe employee during the period of continued coverage. Such a child is eligiblefor continued coverage only to the end of the period of continued coverage asestablished pursuant to subsection 2.
(Added to NRS by 1987, 2233; A 1997, 2915)
NRS
1. An employee, spouse or dependent child shall notifythe employer that he is eligible to continue his coverage pursuant to
2. The employer shall, within 14 days after receipt ofthe notification given pursuant to subsection 1, provide adequate informationto the employee, spouse or dependent child regarding the election to continuecoverage and the premium required to be paid.
3. If the employee, spouse or dependent child electsto continue coverage, he shall notify the insurer of his election and pay tothe insurer the premium required by NRS689B.247 within 60 days after receipt of the information provided pursuantto subsection 2.
(Added to NRS by 1987, 2234)
NRS
1. Any person who elects to continue coverage pursuantto NRS 689B.245 shall pay the premiumfor that coverage in an amount not to exceed 125 percent of the premium chargedto the employer by the insurer on the date on which that person became eligiblefor continued coverage.
2. If there is a change in the rate charged orbenefits provided under the policy during the time of continued coverage, thepremium may not exceed 125 percent of the new rate charged to the employer.
3. The premiums must be paid to the insurer on aquarterly basis.
4. If the payment of a premium is not received by theinsurer within 30 days after the date on which it is due, continued coveragemust be terminated.
(Added to NRS by 1987, 2234)
NRS
(Added to NRS by 1987, 2234)
NRS
1. The employer discontinues group health insurancefor his employees;
2. The employee, spouse or dependent child fails topay the required premiums;
3. The employee, spouse or dependent child becomescovered under any other policy of group health insurance;
4. The employee or spouse qualifies for Medicare; or
5. The spouse remarries and becomes eligible forcoverage under the new spouses policy of group health insurance.
(Added to NRS by 1987, 2234)
MISCELLANEOUS PROVISIONS
NRS
1. A hospital the Uniform Billing and Claims Formsestablished by the American Hospital Association in lieu of its individualbilling and claims forms.
2. An individual who is licensed to practice one ofthe health professions regulated by title 54 of NRS such uniform healthinsurance claims forms as the Commissioner shall prescribe, except in thosecases where the Commissioner has excused uniform reporting.
(Added to NRS by 1975, 897; A
NRS
1. Except as otherwise provided in subsection 2, aninsurer shall approve or deny a claim relating to a policy of group healthinsurance or blanket insurance within 30 days after the insurer receives theclaim. If the claim is approved, the insurer shall pay the claim within 30 daysafter it is approved. Except as otherwise provided in this section, if theapproved claim is not paid within that period, the insurer shall pay intereston the claim at a rate of interest equal to the prime rate at the largest bankin Nevada, as ascertained by the Commissioner of Financial Institutions, onJanuary 1 or July 1, as the case may be, immediately preceding the date onwhich the payment was due, plus 6 percent. The interest must be calculated from30 days after the date on which the claim is approved until the date on whichthe claim is paid.
2. If the insurer requires additional information todetermine whether to approve or deny the claim, it shall notify the claimant ofits request for the additional information within 20 days after it receives theclaim. The insurer shall notify the provider of health care of all the specificreasons for the delay in approving or denying the claim. The insurer shallapprove or deny the claim within 30 days after receiving the additionalinformation. If the claim is approved, the insurer shall pay the claim within30 days after it receives the additional information. If the approved claim isnot paid within that period, the insurer shall pay interest on the claim in themanner prescribed in subsection 1.
3. An insurer shall not request a claimant to resubmitinformation that the claimant has already provided to the insurer, unless theinsurer provides a legitimate reason for the request and the purpose of therequest is not to delay the payment of the claim, harass the claimant ordiscourage the filing of claims.
4. An insurer shall not pay only part of a claim thathas been approved and is fully payable.
5. A court shall award costs and reasonable attorneysfees to the prevailing party in an action brought pursuant to this section.
6. The payment of interest provided for in thissection for the late payment of an approved claim may be waived only if thepayment was delayed because of an act of God or another cause beyond thecontrol of the insurer.
7. The Commissioner may require an insurer to provideevidence which demonstrates that the insurer has substantially complied withthe requirements set forth in this section, including, without limitation,payment within 30 days of at least 95 percent of approved claims or at least 90percent of the total dollar amount for approved claims.
8. If the Commissioner determines that an insurer isnot in substantial compliance with the requirements set forth in this section,the Commissioner may require the insurer to pay an administrative fine in anamount to be determined by the Commissioner. Upon a second or subsequentdetermination that an insurer is not in substantial compliance with therequirements set forth in this section, the Commissioner may suspend or revokethe certificate of authority of the insurer.
(Added to NRS by 1991, 1328; A
NRS
1. No group health or blanket health policy may bedelivered or issued for delivery in this state if it contains any exclusion,reduction or other limitation of coverage relating to complications ofpregnancy, unless the provision applies generally to all benefits payable underthe policy.
2. As used in this section, the term complications ofpregnancy includes any condition which requires hospital confinement formedical treatment and:
(a) If the pregnancy is not terminated, is caused by aninjury or sickness not directly related to the pregnancy or by acute nephritis,nephrosis, cardiac decompensation, missed abortion or similar medicallydiagnosed conditions; or
(b) If the pregnancy is terminated, results innonelective cesarean section, ectopic pregnancy or spontaneous termination.
3. A policy subject to the provisions of this chapterwhich is delivered or issued for delivery on or after July 1, 1977, has thelegal effect of including the coverage required by this section, and anyprovision of the policy which is in conflict with this section is void.
(Added to NRS by 1977, 415)(Substituted in revisionfor NRS 689B.032)
NRS
1. Each policy of group or blanket health insurancemust include a procedure for binding arbitration to resolve disputes concerningindependent medical evaluations pursuant to the rules of the AmericanArbitration Association.
2. If an insurer, for any final determination ofbenefits or care, requires an independent evaluation of the medical orchiropractic care of any person for whom such care is covered under the termsof a policy of group or blanket health insurance, only a physician orchiropractor who is certified to practice in the same field of practice as theprimary treating physician or chiropractor or who is formally educated in thatfield may conduct the independent evaluation.
3. The independent evaluation must include a physicalexamination of the patient, unless he is deceased, and a personal review of allX rays and reports prepared by the primary treating physician or chiropractor.A certified copy of all reports of findings must be sent to the primarytreating physician or chiropractor and the insured person within 10 workingdays after the evaluation. If the insured person disagrees with the finding ofthe evaluation, he must submit an appeal to the insurer pursuant to theprocedure for binding arbitration set forth in the policy of insurance within30 days after he receives the finding of the evaluation. Upon its receipt of anappeal, the insurer shall so notify in writing the primary treating physicianor chiropractor.
4. The insurer shall not limit or deny coverage forcare related to a disputed claim while the dispute is in arbitration, exceptthat, if the insurer prevails in the arbitration, the primary treatingphysician or chiropractor may not recover any payment from either the insurer,insured person or the patient for services that he provided to the patientafter receiving written notice from the insurer pursuant to subsection 3concerning the appeal of the insured person.
(Added to NRS by 1989, 2114)
NRS
1. An insurer shall provide to each policyholder, orproducer of insurance acting on behalf of a policyholder, on a form approved bythe Commissioner, a summary of the coverage provided by each policy of group orblanket health insurance offered by the insurer. The summary must disclose any:
(a) Significant exception, reduction or limitation thatapplies to the policy;
(b) Restriction on payment for care in an emergency,including related definitions of emergency and medical necessity;
(c) Right of the insurer to change the rate of premiumand the factors, other than claims experienced, which affect changes in rate;
(d) Provisions relating to renewability;
(e) Provisions relating to preexisting conditions; and
(f) Other information that the Commissioner findsnecessary for full and fair disclosure of the provisions of the policy.
2. The language of the disclosure must be easilyunderstood. The disclosure must state that it is only a summary of the policyand that the policy should be read to ascertain the governing contractualprovisions.
3. The Commissioner shall not approve a proposed disclosurethat does not satisfy the requirements of this section and of applicableregulations.
4. In addition to the disclosure, the insurer shallprovide information about guaranteed availability of basic and standard plansfor benefits to an eligible person.
5. The insurer shall provide the summary before thepolicy is issued.
(Added to NRS by
NRS
1. Except as otherwise provided in subsection 2, aninsurer or any agent or employee of an insurer who delivers or issues fordelivery a policy of group health or blanket health insurance in this stateshall not disclose to the policyholder or any agent or employee of thepolicyholder:
(a) The fact that an insured is taking a prescribeddrug or medicine; or
(b) The identity of that drug or medicine.
2. The provisions of subsection 1 do not prohibitdisclosure to an administrator who acts as an intermediary for claims forinsurance coverage.
(Added to NRS by 1989, 1978)
NRS
1. The person failed to pay premiums or contributionsin accordance with the terms of the health benefit plan or the individualcarrier has not received timely premium payments;
2. The person committed an act or practice thatconstitutes fraud or has made an intentional misrepresentation of material factunder the terms of the coverage; or
3. The carrier who is obligated to offer a conversionhealth benefit plan pursuant to NRS689B.590 or a health maintenance organization organized pursuant to
(a) Provide notice of its intention to the Commissionerand the chief regulatory officer for insurance in each state in which thecarrier or health maintenance organization is licensed to transact insurance atleast 60 days before the date on which notice of cancellation or nonrenewal isdelivered or mailed to the persons covered by the insurance to be discontinued;
(b) Provide notice of its intention at least 180 daysbefore the renewal of any conversion health benefit plan to all persons coveredunder its conversion health benefit plans and to the Commissioner and the chiefregulatory officer for insurance in each state in which the carrier or healthmaintenance organization is licensed to transact insurance; and
(c) Discontinue all group health insurance delivered orissued for delivery to persons in this State and not renew coverage under anypolicy of group health insurance issued to those persons.
(Added to NRS by
NRS
(Added to NRS by
NRS
1. Except as otherwise provided in subsection 2, aninsurer shall not:
(a) Deny a claim under a policy of health insurance solelybecause the claim involves an injury sustained by an insured as a consequenceof being intoxicated or under the influence of a controlled substance.
(b) Cancel a policy of health insurance solely becausean insured has made a claim involving an injury sustained by the insured as aconsequence of being intoxicated or under the influence of a controlledsubstance.
(c) Refuse to issue a policy of health insurance to aneligible applicant solely because the applicant has made a claim involving an injurysustained by the applicant as a consequence of being intoxicated or under theinfluence of a controlled substance.
2. The provisions of this section do not prohibit aninsurer from enforcing a provision included in a policy of group healthinsurance to:
(a) Deny a claim which involves an injury to which acontributing cause was the insureds commission of or attempt to commit afelony;
(b) Cancel a policy of group health insurance solelybecause of such a claim; or
(c) Refuse to issue a policy of group health insuranceto an eligible applicant solely because of such a claim.
(Added to NRS by
ELIGIBILITY FOR COVERAGE UNDER GROUP POLICY
NRS
1. Medicaid means a program established in any statepursuant to Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) toprovide assistance for part or all of the cost of medical care rendered onbehalf of indigent persons.
2. Order for medical coverage means an order of acourt or administrative tribunal to provide coverage under a group healthpolicy to a child pursuant to the provisions of 42 U.S.C. 1396g-1.
(Added to NRS by 1995, 2428)
NRS
1. An insurer shall not, when considering eligibilityfor coverage or making payments under a group health policy, consider theavailability of, or eligibility of a person for, medical assistance underMedicaid.
2. To the extent that payment has been made byMedicaid for health care, an insurer, group health plan as defined in section607(1) of the Employee Retirement Income Security Act of 1974 (29 U.S.C.A. 1167(1)), health maintenance organization or other organization that has issueda group health policy:
(a) Shall treat Medicaid as having a valid andenforceable assignment of an insureds benefits regardless of any exclusion ofMedicaid or the absence of a written assignment; and
(b) May, as otherwise allowed by the policy, evidenceof coverage or contract and applicable law or regulation concerningsubrogation, seek to enforce any rights of a recipient of Medicaid toreimbursement against any other liable party if:
(1) It is so authorized pursuant to a contractwith Medicaid for managed care; or
(2) It has reimbursed Medicaid in full for thehealth care provided by Medicaid to its insured.
3. If a state agency is assigned any rights of aperson who is:
(a) Eligible for medical assistance under Medicaid; and
(b) Covered by a group health policy,
the insurerthat issued the policy shall not impose any requirements upon the state agencyexcept requirements it imposes upon the agents or assignees of other personscovered by the policy.
(Added to NRS by 1995, 2429)
NRS
1. Was born out of wedlock;
2. Has not been claimed as a dependent on the parentsfederal income tax return; or
3. Does not reside with the parent or within theinsurers geographic area of service.
(Added to NRS by 1995, 2429)
NRS
1. Provide to the custodial parent such information asnecessary for the child to obtain any benefits under that coverage.
2. Allow the custodial parent or, with the approval ofthe custodial parent, a provider of health care to submit claims for coveredservices without the approval of the noncustodial parent.
3. Make payments on claims submitted pursuant tosubsection 2 directly to the custodial parent, the provider of health care oran agency of this or another state responsible for the administration ofMedicaid.
(Added to NRS by 1995, 2429)
NRS
1. Shall, if the child is otherwise eligible for thatcoverage, allow the parent to enroll the child in that coverage without regardto any restrictions upon periods for enrollment.
2. Shall, if:
(a) The child is otherwise eligible for that coverage;and
(b) The parent is enrolled in that coverage but failsto apply for enrollment of the child,
enroll thechild in that coverage upon application by the other parent of the child, or byan agency of this or another state responsible for the administration of Medicaidor a state program for the enforcement of child support established pursuant to42 U.S.C. 651 et seq., without regard to any restrictions upon periods forenrollment.
3. Shall not terminate the enrollment of the child inthat coverage or otherwise eliminate that coverage of the child unless theinsurer has written proof that:
(a) The order for medical coverage is no longer ineffect; or
(b) The child is or will be enrolled in comparablecoverage through another insurer on or before the effective date of thetermination of enrollment or elimination of coverage.
(Added to NRS by 1995, 2429)
PORTABILITY AND ACCOUNTABILITY
NRS
(Added to NRS by 1997, 2900; A
NRS
(Added to NRS by 1997, 2900)
NRS
(Added to NRS by
NRS
(Added to NRS by 1997, 2900)
NRS
(Added to NRS by 1997, 2900)
NRS
1. A group health plan;
2. A health benefit plan;
3. Part A or Part B of Title XVIII of the SocialSecurity 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 ofbenefits under section 1928 of that Title, 42 U.S.C. 1396s;
5. The Civilian Health and Medical Program ofUniformed Services, CHAMPUS, 10 U.S.C. 1071 et seq.;
6. A medical care program of the Indian Health Serviceor of a tribal organization;
7. A state health benefit risk pool;
8. A health plan offered pursuant to the FederalEmployees Health Benefits Program, FEHBP, 5 U.S.C. 8901 et seq.;
9. A public health plan as defined in 45 C.F.R. 146.113, 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 thePeace Corps Act, 22 U.S.C. 2504(e);
11. The Childrens Health Insurance Programestablished pursuant to 42 U.S.C. 1397aa to 1397jj, inclusive;
12. A short-term health insurance policy; or
13. A blanket accident and health insurance policy.
(Added to NRS by 1997, 2900; A
NRS
1. Group health plan means an employee welfarebenefit plan, as defined in section 3(1) of the Employee Retirement IncomeSecurity Act of 1974, as that section existed on July 16, 1997, to the extentthat the plan provides medical care to employees or their dependents as definedunder the terms of the plan directly, or through insurance, reimbursement orotherwise.
2. The term does not include:
(a) Coverage that is only for accident or disabilityincome insurance, or any combination thereof;
(b) Coverage issued as a supplement to liabilityinsurance;
(c) Liability insurance, including general liabilityinsurance and automobile liability insurance;
(d) Workers compensation or similar insurance;
(e) Coverage for medical payments under a policy ofautomobile insurance;
(f) Credit insurance;
(g) Coverage for on-site medical clinics; and
(h) Other similar insurance coverage specified infederal regulations adopted pursuant to Public Law 104-191 under which benefitsfor medical care are secondary or incidental to other insurance benefits.
3. The term does not include the following benefits ifthe benefits are provided under a separate policy, certificate or contract ofinsurance or are otherwise not an integral part of a health benefit plan:
(a) Limited-scope dental or vision benefits;
(b) Benefits for long-term care, nursing home care,home health care or community-based care, or any combination thereof; and
(c) Such other similar benefits as are specified in anyfederal regulations adopted pursuant to Public Law 104-191.
4. The term does not include the following benefits ifthe benefits are provided under a separate policy, certificate or contract ofinsurance, there is no coordination between the provision of the benefits andany exclusion of benefits under any group health plan maintained by the sameplan sponsor, and such benefits are paid for a claim without regard to whetherbenefits are provided for such a claim under any group health plan maintainedby the same plan sponsor:
(a) Coverage that is only for a specified disease orillness; and
(b) Hospital indemnity or other fixed indemnityinsurance.
5. The term does not include any of the following, ifoffered as a separate policy, certificate or contract of insurance:
(a) Medicare supplemental health insurance as definedin section 1882(g)(1) of the Social Security Act, as that section existed onJuly 16, 1997;
(b) Coverage supplemental to the coverage providedpursuant to chapter 55 of Title 10, United States Code (Civilian Health andMedical Program of Uniformed Services (CHAMPUS)); and
(c) Similar supplemental coverage provided under agroup health plan.
(Added to NRS by 1997, 2900)
NRS
(Added to NRS by 1997, 2901)
NRS
1. Health benefit plan means a policy, contract,certificate or agreement offered by a carrier to provide for, arrange for thepayment of, pay for or reimburse any of the costs of health care services.Except as otherwise provided in this section, the term includes catastrophichealth insurance policies, and a policy that pays on a cost-incurred basis.
2. The term does not include:
(a) Coverage that is only for accident or disabilityincome insurance, or any combination thereof;
(b) Coverage issued as a supplement to liabilityinsurance;
(c) Liability insurance, including general liabilityinsurance and automobile liability insurance;
(d) Workers compensation or similar insurance;
(e) Coverage for medical payments under a policy ofautomobile insurance;
(f) Credit insurance;
(g) Coverage for on-site medical clinics;
(h) Other similar insurance coverage specified infederal regulations issued pursuant to the Health Insurance Portability andAccountability Act of 1996, Public Law 104-191, under which benefits formedical care are secondary or incidental to other insurance benefits;
(i) Coverage under a short-term health insurancepolicy; and
(j) Coverage under a blanket student accident andhealth insurance policy.
3. If the benefits are provided under a separatepolicy, certificate or contract of insurance or are otherwise not an integralpart of a health benefit plan, the term does not include the followingbenefits:
(a) Limited-scope dental or vision benefits;
(b) Benefits for long-term care, nursing home care,home health care or community-based care, or any combination thereof; and
(c) Such other similar benefits as are specified in anyfederal regulations adopted pursuant to the Health Insurance Portability andAccountability Act of 1996, Public Law 104-191.
4. For the purposes of
(a) Coverage that is only for a specified disease orillness; and
(b) Hospital indemnity or other fixed indemnityinsurance.
5. For the purposes of
(a) Medicare supplemental health insurance as definedin section 1882(g)(1) of the Social Security Act, 42 U.S.C. 1395ss, as thatsection existed on July 16, 1997;
(b) Coverage supplemental to the coverage providedpursuant to the Civilian Health and Medical Program of Uniformed Services,CHAMPUS, 10 U.S.C. 1071 et seq.; and
(c) Similar supplemental coverage provided under agroup health plan.
(Added to NRS by 1997, 2901; A
NRS
1. Health status;
2. Any medical conditions, including physical ormental illness, or both;
3. Claims experience;
4. Receipt of health care;
5. Medical history;
6. Genetic information;
7. Evidence of insurability, including conditionsarising out of acts of domestic violence; and
8. Disability.
(Added to NRS by 1997, 2902)
NRS
(Added to NRS by 1997, 2903)
NRS
(Added to NRS by 1997, 2903)
NRS
(Added to NRS by 1997, 2903)
NRS
(Added to NRS by 1997, 2903; A
NRS
1. Any plan, fund or program which would not be, butfor section 2721(e) of the Public Health Service Act, as amended by Public Law104-191, as that section existed on July 16, 1997, an employee welfare benefitplan and which is established or maintained by a partnership to the extent thatthe plan, fund or program provides medical care, including items and servicespaid for as medical care, to current or former partners in the partnership, orto 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 planthat is a group health plan.
2. In the case of a group health plan, a partnershipshall be deemed to be the employer of each partner.
(Added to NRS by 1997, 2903)
NRS
1. In determiningthe applicable creditable coverage of a person for the purposes of
2. In determining the period of creditable coverage ofa person for the purposes of NRS 689B.500,a carrier shall include each applicable period of creditable coverage withoutregard to the specific benefits covered during that period, except that thecarrier may elect to include applicable periods of creditable coverage based oncoverage of specific benefits as specified in the regulations of the UnitedStates Department of Health and Human Services, if such an election is made ona uniform basis for all participants and beneficiaries of the health benefitplan or coverage. Pursuant to such an election, the carrier shall include eachapplicable period of creditable coverage with respect to any class or categoryof benefits if any level of benefits is covered within that class or category,as specified by those regulations.
3. Regardless of whether coverage is actuallyprovided, if a carrier elects in accordance with subsection 2 to determinecreditable coverage based on specified benefits, a statement that such anelection has been made and a description of the effect of the election must be:
(a) Included prominently in any disclosure statementconcerning the health benefit plan; and
(b) Provided to each person at the time of enrollmentin the health benefit plan.
(Added to NRS by 1997, 2903)
NRS
1. For thepurpose of determining the period of creditable coverage of a personaccumulated under a health benefit plan, blanket accident and health insuranceor group health insurance, the insurer shall provide written certification on aform prescribed by the Commissioner of coverage to the person which certifiesthe length of:
(a) The period of creditable coverage that the personaccumulated under the plan and any coverage under any provision of theConsolidated Omnibus Budget Reconciliation Act of 1985, as that act existed onJuly 16, 1997, relating to the continuation of coverage; and
(b) Any waiting and affiliation period imposed on theperson pursuant to that coverage.
2. The certification of coverage must be provided tothe person who was insured:
(a) At the time that he ceases to be covered under theplan, if he does not otherwise become covered under any provision of theConsolidated Omnibus Budget Reconciliation Act of 1985, as that act existed onJuly 16, 1997, relating to the continuation of coverage;
(b) If he becomes covered under such a provision, atthe time that he ceases to be covered by that provision; and
(c) Upon request, if the request is made not later than24 months after the date on which he ceased to be covered as described inparagraphs (a) and (b).
(Added to NRS by 1997, 2904; A
NRS
1. Except as otherwise provided in this section, acarrier that issues a group health plan or coverage under blanket accident andhealth insurance or group health insurance shall not deny, exclude or limit abenefit for a preexisting condition for:
(a) More than 12 months after the effective date ofcoverage if the employee or other insured enrolls through open enrollment orafter the first day of the waiting period for that enrollment, whichever isearlier; or
(b) More than 18 months after the effective date ofcoverage for a late enrollee.
A carriermay not define a preexisting condition more restrictively than that term isdefined in NRS 689B.450.
2. The period of any exclusion for a preexistingcondition imposed by a group health plan or coverage under blanket accident andhealth insurance or group health insurance on a person to be insured inaccordance with the provisions of this chapter must be reduced by the aggregateperiod of creditable coverage of that person, if the creditable coverage wascontinuous to a date not more than 63 days before the effective date of thecoverage. The period of continuous coverage must not include:
(a) Any waiting period for the effective date of thenew coverage applied by the employer or the carrier; or
(b) Any affiliation period not to exceed 60 days for anew enrollee and 90 days for a late enrollee required before becoming eligibleto enroll in the group health plan.
3. A health maintenance organization authorized totransact insurance pursuant to chapter 695Cof NRS that does not restrict coverage for a preexisting condition may requirean affiliation period before coverage becomes effective under a plan ofinsurance if the affiliation period applies uniformly to all employees or otherpersons insured and without regard to any health status-related factors. Duringthe affiliation period, the carrier shall not collect any premiums for coverageof the employee or other insured.
4. An insurer that restricts coverage for preexistingconditions shall not impose an affiliation period.
5. A carrier shall not impose any exclusion for a preexistingcondition:
(a) Relating to pregnancy.
(b) In the case of a person who, as of the last day ofthe 30-day period beginning on the date of his birth, is covered undercreditable coverage.
(c) In the case of a child who is adopted or placed foradoption before attaining the age of 18 years and who, as of the last day ofthe 30-day period beginning on the date of adoption or placement for adoption,whichever is earlier, is covered under creditable coverage. The provisions ofthis paragraph do not apply to coverage before the date of adoption orplacement for adoption.
(d) In the case of a condition for which medicaladvice, diagnosis, care or treatment was recommended or received for the firsttime while the covered person held creditable coverage, and the medical advice,diagnosis, care or treatment was a benefit under the plan, if the creditablecoverage was continuous to a date not more than 63 days before the effectivedate of the new coverage.
Theprovisions of paragraphs (b) and (c) do not apply to a person after the end ofthe first 63-day period during all of which the person was not covered underany creditable coverage.
6. As used in this section, late enrollee means aneligible employee, or his dependent, who requests enrollment in a group healthplan following the initial period of enrollment, if that initial period ofenrollment is at least 30 days, during which the person is entitled to enrollunder the terms of the health benefit plan. The term does not include aneligible employee or his dependent if:
(a) The employee or dependent:
(1) Was covered under creditable coverage at thetime of the initial enrollment;
(2) Lost coverage under creditable coverage as aresult of cessation of contributions by his employer, termination of employmentor eligibility, reduction in the number of hours of employment, involuntarytermination of creditable coverage, or death of, or divorce or legal separationfrom, a covered spouse; and
(3) Requests enrollment not later than 30 daysafter the date on which his creditable coverage was terminated or on which thechange in conditions that gave rise to the termination of the coverageoccurred.
(b) The employee enrolls during the open enrollmentperiod, as provided in the contract or as otherwise specifically provided byspecific statute.
(c) The employer of the employee offers several healthbenefit plans and the employee elected a different plan during an openenrollment period.
(d) A court has ordered coverage to be provided to thespouse or a minor or dependent child of an employee under a health benefit planof the employee and a request for enrollment is made within 30 days after theissuance of the court order.
(e) The employee changes status from not being aneligible employee to being an eligible employee and requests enrollment,subject to any waiting period, within 30 days after the change in status.
(f) The person has continued coverage in accordancewith the Consolidated Omnibus Budget Reconciliation Act of 1985, Public Law99-272, and that coverage has been exhausted.
(Added to NRS by 1997, 2904; A
NRS
(Added to NRS by 1997, 2906)
NRS
1. Except asotherwise provided in this subsection, a group health plan or coverage offeredunder group health insurance issued pursuant to this chapter that includescoverage for maternity care and pediatric care for newborn infants may notrestrict benefits for any length of stay in a hospital in connection withchildbirth for a mother or newborn infant covered by the plan or coverage to:
(a) Less than 48 hours after a normal vaginal delivery;and
(b) Less than 96 hours after a cesarean section.
If adifferent length of stay is provided in the guidelines established by the AmericanCollege of Obstetricians and Gynecologists, or its successor organization, andthe American Academy of Pediatrics, or its successor organization, the grouphealth plan or health insurance coverage may follow such guidelines in lieu offollowing the length of stay set forth above. The provisions of this subsectiondo not apply to any group health plan or health insurance coverage in any casein which the decision to discharge the mother or newborn infant before theexpiration of the minimum length of stay set forth in this subsection is madeby the attending physician of the mother or newborn infant.
2. Nothing in this section requires a mother to:
(a) Deliver her baby in a hospital; or
(b) Stay in a hospital for a fixed period following thebirth of her child.
3. A group health plan or coverage under group healthinsurance that offers coverage for maternity care and pediatric care of newborninfants may not:
(a) Deny a mother or her newborn infant coverage orcontinued coverage under the terms of the plan or coverage if the sole purposeof the denial of coverage or continued coverage is to avoid the requirements ofthis section;
(b) Provide monetary payments or rebates to a mother toencourage her to accept less than the minimum protection available pursuant tothis section;
(c) Penalize, or otherwise reduce or limit, thereimbursement of an attending provider of health care because he provided careto a mother or newborn infant in accordance with the provisions of thissection;
(d) Provide incentives of any kind to an attendingphysician to induce him to provide care to a mother or newborn infant in amanner 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 theprovisions of this section in a manner that is less favorable than the benefitsprovided for any preceding portion of that stay.
4. Nothing in this section:
(a) Prohibits a group health plan or carrier fromimposing a deductible, coinsurance or other mechanism for sharing costsrelating to benefits for hospital stays in connection with childbirth for amother or newborn child covered by the plan, except that such coinsurance orother mechanism for sharing costs for any portion of a hospital stay requiredby this section may not be greater than the coinsurance or other mechanism forany preceding portion of that stay.
(b) Prohibits an arrangement for payment between agroup health plan or carrier and a provider of health care that uses capitationor other financial incentives, if the arrangement is designed to provideservices efficiently and consistently in the best interest of the mother andher newborn infant.
(c) Prevents a group health plan or carrier fromnegotiating with a provider of health care concerning the level and type ofreimbursement to be provided in accordance with this section.
(Added to NRS by 1997, 2906)
NRS
1. The employee or dependent was covered under adifferent group health insurance or had other health insurance coverage at thetime coverage was previously offered to the employee or dependent;
2. The employee stated in writing at that time thatthe other coverage was the reason for declining enrollment, but only if theplan sponsor or carrier required such a written statement and informed theemployee of that requirement and the consequences of the requirement; and
3. The employee or his dependent:
(a) Was covered under any provision of the ConsolidatedOmnibus Budget Reconciliation Act of 1985 relating to the continuation ofcoverage and such continuation of coverage was exhausted; or
(b) Was not covered under such a provision and hisinsurance coverage was lost as a result of cessation of contributions by hisemployer, termination of employment or eligibility, reduction in the number ofhours of employment, or the death of, or divorce or legal separation from, acovered spouse.
(Added to NRS by 1997, 2907)
NRS
1. A carrier thatoffers group health insurance which makes coverage available to the dependentof an employee covered by the group health plan shall permit the employee toenroll a dependent after the close of a period of open enrollment if:
(a) The employee is a participant in the group healthplan, or has met any waiting period applicable to becoming a participant and iseligible to be enrolled under the plan, except for a failure to enroll during aprevious period of open enrollment; and
(b) The person to be enrolled became a dependent of theemployee through marriage, birth, adoption or placement for adoption.
2. The group health plan or carrier shall provide aperiod of special enrollment for the enrollment of a dependent of an employeepursuant to this section. Such a period must be not less than 30 days and mustbegin on:
(a) The date specified by the group health plan orcarrier for the period of special enrollment; or
(b) The date of the marriage, birth, adoption orplacement for adoption, as appropriate.
3. If an employee seeks to enroll a dependent duringthe first 30 days of the period for special enrollment provided pursuant tosubsection 2, the coverage of the dependent becomes effective:
(a) In the case of a marriage, not later than the firstday of the first month beginning after the date on which the completed requestfor enrollment is received;
(b) In the case of a birth, on the date of the birth;and
(c) In the case of an adoption or placement foradoption, on the date of the adoption or the placement for adoption.
4. In the case of a birth, an adoption or a placementfor adoption of a child of an employee, the spouse of the employee may beenrolled as a dependent pursuant to this section if the spouse is otherwiseeligible for coverage under the group health plan.
(Added to NRS by 1997, 2908)
NRS
1. A carrier shall not place any restriction on aperson or his dependent as a condition of being a participant in or abeneficiary of a policy of blanket accident and health insurance or grouphealth insurance that is inconsistent with the provisions of this chapter.
2. A carrier that offers coverage under a policy ofblanket accident and health insurance or group health insurance pursuant tothis chapter shall not establish rules of eligibility, including rules whichdefine applicable waiting periods, for the initial or continued enrollmentunder a group health plan offered by the carrier that are based on thefollowing factors relating to the employee or his dependent:
(a) Health status.
(b) Medical condition, including physical and mentalillnesses, or both.
(c) Claims experience.
(d) Receipt of health care.
(e) Medical history.
(f) Genetic information.
(g) Evidence of insurability, including conditionswhich arise out of acts of domestic violence.
(h) Disability.
3. Except as otherwise provided in
(a) Require a carrier to provide particular benefitsother than those that would otherwise be provided under the terms of theblanket health and accident insurance or group health insurance or coverage; or
(b) Prevent a carrier from establishing limitations orrestrictions on the amount, level, extent or nature of the benefits or coveragefor similarly situated persons.
4. As a condition of enrollment or continuedenrollment under a policy of blanket accident and health insurance or grouphealth insurance, a carrier shall not require an employee to pay a premium orcontribution that is greater than the premium or contribution for a similarlysituated person covered by similar coverage on the basis of any factordescribed in subsection 2 in relation to the employee or his dependent.
5. This section does not:
(a) Restrict the amount that an employer or employeemay be charged for coverage by a carrier;
(b) Prevent a carrier from establishing premiumdiscounts or rebates or from modifying otherwise applicable copayments ordeductibles in return for adherence by the insured person to programs of healthpromotion and disease prevention; or
(c) Preclude a carrier from establishing rules relatingto employer contribution or group participation when offering health insurancecoverage to small employers in this state.
(Added to NRS by 1997, 2908; A
NRS
1. Except asotherwise provided in this section, coverage under a policy of group healthinsurance must be renewed by the carrier at the option of the plan sponsor,unless:
(a) The plan sponsor has failed to pay premiums orcontributions in accordance with the terms of the group health insurance or thecarrier has not received timely premium payments;
(b) The plan sponsor has performed an act or a practicethat constitutes fraud or has made an intentional misrepresentation of materialfact under the terms of the coverage;
(c) The plan sponsor has failed to comply with anymaterial provision of the group health insurance relating to employercontributions and group participation; or
(d) The carrier decides to discontinue offeringcoverage under group health insurance. If the carrier decides to discontinueoffering and renewing such insurance, the carrier shall:
(1) Provide notice of its intention to theCommissioner and the chief regulatory officer for insurance in each state inwhich the carrier is licensed to transact insurance at least 60 days before thedate on which notice of cancellation or nonrenewal is delivered or mailed tothe persons covered by the discontinued insurance pursuant to subparagraph (2).
(2) Provide notice of its intention to allpersons covered by the discontinued insurance and to the Commissioner and thechief regulatory officer for insurance in each state in which such a person isknown to reside. The notice must be made at least 180 days before thediscontinuance of any group health plan by the carrier.
(3) Discontinue all health insurance issued ordelivered for issuance for persons in this state and not renew coverage underany group health insurance issued to such persons.
2. A carrier may discontinue the issuance and renewalof a form of a product of group health insurance if the Commissioner finds thatthe form of the product offered by the carrier is obsolete and is beingreplaced with comparable coverage. A form of a product may be discontinued bythe carrier pursuant to this subsection only if:
(a) The carrier notifies the Commissioner and the chiefregulatory officer in each state in which it is licensed of its decisionpursuant to this subsection to discontinue the issuance and renewal of the formof the product at least 60 days before the individual carrier notifies thepersons covered by the discontinued insurance pursuant to paragraph (b).
(b) The carrier notifies each person covered by thediscontinued insurance and the Commissioner and the chief regulatory officer ineach state in which such a person is known to reside of the decision of thecarrier to discontinue offering the form of the product. The notice must bemade at least 180 days before the date on which the carrier will discontinueoffering the form of the product.
(c) The carrier offers to each person covered by thediscontinued insurance the option to purchase any other health benefit plancurrently offered by the carrier to large groups in this state.
(d) In exercising the option to discontinue the form ofthe product and in offering the option to purchase other coverage pursuant toparagraph (c), the carrier acts uniformly without regard to the claimexperience of the persons covered by the discontinued insurance or any healthstatus-related factor relating to those persons or beneficiaries covered by thediscontinued form of the product or any person or beneficiary who may becomeeligible for such coverage.
3. A carrier may discontinue the issuance and renewalof any type of group health insurance offered by the carrier in this state thatis made available pursuant to this chapter only to a member of a bona fideassociation if:
(a) The membership of the person in the bona fideassociation was the basis for the provision of coverage under the group healthinsurance;
(b) The membership of the person in the bona fideassociation ceases; and
(c) Coverage is terminated pursuant to this subsectionfor all such former members uniformly without regard to any healthstatus-related factor relating to the former member.
4. A carrier that elects not to renew group healthinsurance pursuant to paragraph (d) of subsection 1 shall not write newbusiness pursuant to this chapter for 5 years after the date on which notice isprovided to the Commissioner pursuant to subparagraph (2) of paragraph (d) ofsubsection 1.
5. If the carrier does business in only oneestablished geographic service area of this state, the provisions of thissection apply only to the operations of the carrier in that service area.
6. As used in this section, bona fide associationhas the meaning ascribed to it in NRS689A.485.
(Added to NRS by 1997, 2909)
NRS
1. A carrier that offers coverage through a networkplan is not required to offer coverage to or accept an application from anemployer that does not employ or no longer employs any enrollees who reside orwork in the established geographic service area of the carrier or thegeographic area for which the carrier is authorized to transact insurance,provided that such coverage is refused or terminated uniformly without regardto any health status-related factor for any employee of the employer.
2. As used in this section, network plan means ahealth benefit plan offered by a health carrier under which the financing anddelivery of medical care, including items and services paid for as medicalcare, are provided, in whole or in part, through a defined set of providersunder contract with the carrier. The term does not include an arrangement forthe financing of premiums.
(Added to NRS by 1997, 2911)
NRS
1. A carrier that offers coverage through a networkplan shall use its best efforts to contract with at least one health center ineach established geographic service area of the carrier or geographic area forwhich the carrier is authorized to transact insurance to provide medical carefor enrollees if the health center:
(a) Meets all conditions imposed by the carrier onsimilarly situated providers of health care with which the carrier contracts,including, without limitation:
(1) Certification for participation in theMedicaid or Medicare program; and
(2) Requirements relating to the appropriatecredentials for providers of health care; and
(b) Agrees to reasonable reimbursement rates that aregenerally consistent with those offered by the carrier to similarly situatedproviders of health care with which the carrier contracts.
2. As used in this section:
(a) Health center has the meaning ascribed to it in42 U.S.C. 254b.
(b) Network plan has the meaning ascribed to it in
(Added to NRS by
NRS
1. A plan sponsorof a governmental plan that is a group health plan to which the provisions of
(a) Must be made in such a form and in such a manner asthe Commissioner prescribes by regulation.
(b) Is effective for a single specified year of theplan or, if the plan is provided pursuant to a collective bargaining agreement,for the term of that agreement.
(c) May be extended by subsequent elections.
(d) Excludes the governmental plan from thoseprovisions in this chapter that apply only to group health plans.
2. If a plan sponsor of a governmental plan makes anelection pursuant to this section, the plan sponsor shall:
(a) Annually and at the time of enrollment, notify theenrollees in the plan of the election and the consequences of the election; and
(b) Provide certification and disclosure of creditablecoverage under the plan with respect to those enrollees pursuant to
3. As used in this section, governmental plan hasthe meaning ascribed to in section 3(32) of the Employee Retirement IncomeSecurity Act of 1974, as that section existed on July 16, 1997.
(Added to NRS by 1997, 2911)
NRS
1. Not later than180 days after the date on which the basic and standard health benefit plansare approved pursuant to NRS 689C.770as part of the plan of operation of the Program of Reinsurance, each carrierrequired to offer to a person a converted policy pursuant to
2. A person with a converted policy issued before theeffective date of the requirement set forth in subsection 1 may, at each annualrenewal of the converted policy elect a basic or standard health benefit planas a substitute converted policy, except that the carrier may, if the personhas not made an election within 3 years after first becoming eligible to do so,require the person to make such an election. Once a person has elected thebasic or standard health benefit plan as a substitute converted policy, he maynot elect another converted policy.
3. The premium for a converted policy may not exceedthe small group index rate, as defined in paragraph (b) of subsection 3 of
4. The rates for new and renewal converted policiesfor persons with the same converted policies whose case characteristics aresimilar must be the same.
5. Any losses suffered by a carrier on its convertedpolicies issued pursuant to this section must be spread across the entire bookof the health benefit coverage of the carrier issued or delivered for issuanceto small employers and large group employers in this state.
6. The Commissioner shall adopt such regulations asare necessary to carry out the provisions of this section.
(Added to NRS by 1997, 2911; A
Disclaimer: These codes may not be the most recent version. Nevada may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
