2005 Nevada Revised Statutes - Chapter 689A — Individual Health Insurance

CHAPTER 689A - INDIVIDUAL HEALTH INSURANCE

GENERAL PROVISIONS

NRS 689A.010 Shorttitle.

NRS 689A.020 Scope.

NRS 689A.030 Generalrequirements.

NRS 689A.035 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;providing schedule of fees.

REQUIRED PROVISIONS

NRS 689A.040 Contentsof policy; substitution of provisions; captions; omission or modification ofprovisions.

NRS 689A.0403 Procedurefor arbitration of disputes concerning independent medical evaluations.

NRS 689A.04033 Coveragefor treatment received as part of clinical trial or study.

NRS 689A.04036 Coveragefor continued medical treatment.

NRS 689A.0404 Coveragefor use of certain drugs for treatment of cancer.

NRS 689A.04042 Coveragefor screening for colorectal cancer.

NRS 689A.04045 Coveragefor prescription drug previously approved for medical condition of insured.

NRS 689A.0405 Coveragefor cytologic screening test and mammograms for certain women.

NRS 689A.041 Coveragerelating to mastectomy.

NRS 689A.0413 Coveragefor certain gynecological or obstetrical services without authorization orreferral from primary care physician.

NRS 689A.0415 Coveragefor drug or device for contraception and for hormone replacement therapy incertain circumstances; prohibited actions by insurer; exceptions.

NRS 689A.0417 Coveragefor health care services related to contraceptives and hormone replacementtherapy in certain circumstances; prohibited actions by insurer; exceptions.

NRS 689A.042 Coveragerelating to complications of pregnancy.

NRS 689A.0423 Coveragefor treatment of certain inherited metabolic diseases.

NRS 689A.0425 Individualhealth benefit plan that includes coverage for maternity care and pediatriccare: Requirement to allow minimum stay in hospital in connection withchildbirth; prohibited acts.

NRS 689A.0427 Coveragefor management and treatment of diabetes.

NRS 689A.043 Coverageof newly born and adopted children and children placed for adoption.

NRS 689A.045 Terminationof coverage on dependent child.

NRS 689A.0455 Coveragefor treatment of conditions relating to severe mental illness.

NRS 689A.046 Benefitsfor treatment of abuse of alcohol or drugs.

NRS 689A.0465 Coverageof treatment of temporomandibular joint.

REIMBURSEMENT FOR CERTAIN MEDICALLY RELATED TREATMENT ANDSERVICES

NRS 689A.0475 Acupuncture.

NRS 689A.048 Treatmentby licensed psychologist.

NRS 689A.0483 Treatmentby licensed marriage and family therapist.

NRS 689A.0485 Treatmentby licensed associate in social work, social worker, independent social workeror clinical social worker.

NRS 689A.049 Treatmentby licensed chiropractor; restriction on policy limitations.

NRS 689A.0495 Servicesprovided by certain registered nurses; restriction on policy limitations;exception.

NRS 689A.0497 Providerof medical transportation.

MISCELLANEOUS PROVISIONS

NRS 689A.050 Entirecontract; changes.

NRS 689A.060 Timelimit on certain defenses.

NRS 689A.070 Graceperiod.

NRS 689A.080 Reinstatement.

NRS 689A.090 Noticeof claim.

NRS 689A.100 Claimforms: Required provision.

NRS 689A.105 Claimforms: Uniform billing, claims forms.

NRS 689A.110 Claimforms: Acceptance of uniform forms.

NRS 689A.120 Timeof payment of claims.

NRS 689A.130 Paymentof claims.

NRS 689A.135 Assignmentof benefits to provider of health care.

NRS 689A.140 Physicalexamination and autopsy.

NRS 689A.150 Legalactions.

NRS 689A.160 Changeof beneficiary.

NRS 689A.170 Rightto examine and return policy.

NRS 689A.180 Optionalprovisions. [Effective through June 30, 2006.]

NRS 689A.180 Optionalprovisions. [Effective July 1, 2006.]

NRS 689A.190 Extendeddisability benefit.

NRS 689A.200 Changeof occupation.

NRS 689A.210 Misstatementof age.

NRS 689A.220 Coordinationof benefits: Same insurer.

NRS 689A.230 Coordinationof benefits: All coverages.

NRS 689A.240 Relationof earnings to insurance.

NRS 689A.250 Unpaidpremiums.

NRS 689A.260 Conformitywith state statutes.

NRS 689A.270 Illegaloccupation.

NRS 689A.280 Intoxicantsand narcotics. [Effective through June 30, 2006.]

NRS 689A.290 Renewability.

NRS 689A.300 Orderof certain provisions.

NRS 689A.310 Ownershipof policy by person other than insured.

NRS 689A.320 Requirementsof other jurisdictions.

NRS 689A.330 Policiesissued for delivery in another state.

NRS 689A.340 Limitationon provisions not subject to chapter; effect of violation.

NRS 689A.350 Agelimit.

NRS 689A.360 Filingof rates.

NRS 689A.370 Healthinsurance on franchise plan.

NRS 689A.380 Definitionsof terms used in policies.

NRS 689A.390 Summaryof coverage: Contents of disclosure; approval by Commissioner.

NRS 689A.400 Summaryof coverage: Copy to be provided before policy issued; policy may not be offeredunless summary approved by Commissioner.

NRS 689A.405 Coveragefor prescription drugs: Provision of notice and information regarding use offormulary.

NRS 689A.410 Approvalor denial of claims; payment of claims and interest; requests for additionalinformation; award of costs and attorneys fees; compliance with requirements.

NRS 689A.413 Insurerprohibited from denying coverage solely because person was victim of domesticviolence.

NRS 689A.415 Insurerprohibited from denying coverage solely because insured was intoxicated orunder influence of controlled substance; exceptions. [Effective July 1, 2006.]

NRS 689A.417 Insurerprohibited from requiring or using information concerning genetic testing;exceptions.

NRS 689A.419 Offeringpolicy of health insurance for purposes of establishing health savings account.

ELIGIBILITY FOR COVERAGE

NRS 689A.420 Definitions.

NRS 689A.430 Effectof eligibility for medical assistance under Medicaid; assignment of rights tostate agency.

NRS 689A.440 Insurerprohibited from asserting certain grounds to deny enrollment of child ofinsured pursuant to order.

NRS 689A.450 Certainaccommodations to be made when child is covered under policy of noncustodialparent.

NRS 689A.460 Insurerto authorize enrollment of child of parent who is required by order to providemedical coverage under certain circumstances; termination of coverage of child.

PORTABILITY AND ACCOUNTABILITY

General Provisions

NRS 689A.470 Definitions.

NRS 689A.475 Affiliateddefined.

NRS 689A.480 Basichealth benefit plan defined.

NRS 689A.485 Bonafide association defined.

NRS 689A.490 Churchplan defined.

NRS 689A.495 Controldefined.

NRS 689A.500 Convertedpolicy defined.

NRS 689A.505 Creditablecoverage defined.

NRS 689A.510 Dependentdefined.

NRS 689A.515 Eligibleperson defined.

NRS 689A.520 Establishedgeographic service area defined.

NRS 689A.523 Exclusionfor a preexisting condition defined.

NRS 689A.525 Geographicarea defined.

NRS 689A.530 Governmentalplan defined.

NRS 689A.535 Grouphealth plan defined.

NRS 689A.540 Healthbenefit plan defined.

NRS 689A.545 Healthstatus-related factor defined.

NRS 689A.550 Individualcarrier defined.

NRS 689A.555 Individualhealth benefit plan defined.

NRS 689A.560 Individualreinsuring carrier defined.

NRS 689A.565 Individualrisk-assuming carrier defined.

NRS 689A.570 Planfor coverage of a bona fide association defined.

NRS 689A.575 Planof operation defined.

NRS 689A.580 Plansponsor defined.

NRS 689A.585 Preexistingcondition defined.

NRS 689A.590 Producerdefined.

NRS 689A.595 Programof Reinsurance defined.

NRS 689A.600 Provisionfor a restricted network defined.

NRS 689A.605 Standardhealth benefit plan defined.

NRS 689A.610 Applicability;ceding arrangement prohibited in certain circumstances.

NRS 689A.615 Certainplan, fund or program to be treated as employee welfare benefit plan which isgroup health plan; partnership deemed employer of each partner.

NRS 689A.620 Certainperson with break in coverage deemed eligible person.

NRS 689A.625 Supplementalcoverage not health benefit plan if individual carrier files annualcertification with Commissioner.

 

Individual Carriers

NRS 689A.630 Requirementto renew coverage at option of individual; exceptions; discontinuation of formof product of health benefit plan; discontinuation of health benefit planavailable through bona fide association.

NRS 689A.635 Coverageoffered through network plan not required to be offered to eligible person whodoes not reside or work in established geographic service area.

NRS 689A.637 Coverageoffered through plan that provides for restricted network: Contracts withcertain federally qualified health centers.

NRS 689A.640 Eachhealth benefit plan marketed in this State required to be offered to eligiblepersons.

NRS 689A.645 Coverageto eligible person who does not reside in established geographic service areanot required; coverage within certain areas not required.

NRS 689A.650 Coverageto eligible persons not required under certain circumstances; notice toCommissioner of and prohibition on writing new business after election not tooffer new coverage required.

NRS 689A.655 Requirementto file basic and standard health benefit plans with Commissioner; disapprovalof plan.

NRS 689A.660 Prohibitedacts concerning preexisting conditions and modification of health benefit plan.

NRS 689A.665 Certainhealth carriers not required to offer health benefit insurance coverage toindividuals.

NRS 689A.670 Electionto operate as individual risk-assuming carrier or individual reinsuringcarrier: Notice to Commissioner; effective date; change in status.

NRS 689A.675 Electionto act as individual risk-assuming carrier: Suspension by Commissioner;applicable statutes.

NRS 689A.680 Ratesfor individual health benefit plans to be developed based on ratingcharacteristics: Prohibited characteristics; health status as rating factor.

NRS 689A.685 Amountof change in rate of single block of business; plan with provision for restrictednetwork; involuntary transfer of individual or dependent prohibited; premiumsadjusted for block of business.

NRS 689A.690 Informationrequired to be disclosed as part of solicitation and sales materials;information required to be maintained at place of business; actuarialcertification required to be filed with Commissioner.

NRS 689A.695 Informationand documents to be made available to Commissioner; proprietary information.

NRS 689A.700 Regulationsregarding rates.

NRS 689A.705 Regulationsconcerning reissuance of health benefit plan.

NRS 689A.710 Prohibitedacts; denial of application for coverage; regulations; violation may constituteunfair trade practice; applicability of section.

 

Individual Health Insurance Coverage

NRS 689A.715 Requirementsfor employee welfare benefit plan for providing benefits for employees of morethan one employer.

NRS 689A.720 Writtencertification of coverage required for determining period of creditablecoverage accumulated by person; provision of certificate to insured.

 

Bona Fide Associations

NRS 689A.725 Requirementsfor plan for coverage.

NRS 689A.730 Producermay only sign up eligible persons if eligible persons are actively engaged inor related to association.

 

Miscellaneous Provisions

NRS 689A.735 Reportto Commissioner by trustee of medical savings account.

NRS 689A.740 Regulations.

SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS

NRS 689A.745 Approval;requirements; examination.

NRS 689A.750 Annualreport; insurer to maintain records of complaints concerning something otherthan health care services.

NRS 689A.755 Writtennotice to insured explaining right to file complaint; notice to insuredrequired when insurer denies coverage of health care service.

_________

 

GENERAL PROVISIONS

NRS 689A.010 Shorttitle. This chapter may be cited as theUniform Health Policy Provision Law.

(Added to NRS by 1971, 1751)

NRS 689A.020 Scope. Nothing in this chapter applies to or affects:

1. Any policy of liability or workers compensationinsurance with or without supplementary expense coverage therein.

2. Any group or blanket policy.

3. Life insurance, endowment or annuity contracts, orcontracts supplemental thereto which contain only such provisions relating tohealth insurance as to:

(a) Provide additional benefits in case of death ordismemberment or loss of sight by accident or accidental means; or

(b) Operate to safeguard such contracts against lapse,or to give a special surrender value or special benefit or an annuity if theinsured or annuitant becomes totally and permanently disabled, as defined bythe contract or supplemental contract.

4. Reinsurance, except as otherwise provided in NRS 689A.470 to 689A.740, inclusive, and 689C.610 to 689C.980, inclusive, relating to theprogram of reinsurance.

(Added to NRS by 1971, 1751; A 1997, 2899)

NRS 689A.030 Generalrequirements. A policy of health insurancemust not be delivered or issued for delivery to any person in this state unlessit otherwise complies with this Code, and complies with the following:

1. The entire money and other considerations for thepolicy must be expressed therein.

2. The time when the insurance takes effect andterminates must be expressed therein.

3. It must purport to insure only one person, exceptthat a policy may insure, originally or by subsequent amendment, upon theapplication of an adult member of a family, who shall be deemed thepolicyholder, any two or more eligible members of that family, including thehusband, wife, dependent children, from the time of birth, adoption orplacement for the purpose of adoption as provided in NRS 689A.043, or any children under aspecified age which must not exceed 19 years except as provided in NRS 689A.045, and any other persondependent upon the policyholder.

4. The style, arrangement and overall appearance ofthe policy must not give undue prominence to any portion of the text, and everyprinted portion of the text of the policy and of any endorsements or attachedpapers must be plainly printed in light-faced type of a style in general use,the size of which must be uniform and not less than 10 points with a lower caseunspaced alphabet length not less than 120 points. Text includes all printedmatter except the name and address of the insurer, the name or the title of thepolicy, the brief description, if any, and captions and subcaptions.

5. The exceptions and reductions of indemnity must beset forth in the policy and, other than those contained in NRS 689A.050 to 689A.290, inclusive, must be printed, atthe insurers option, with the benefit provision to which they apply or underan appropriate caption such as Exceptions or Exceptions and Reductions,except that if an exception or reduction specifically applies only to aparticular benefit of the policy, a statement of that exception or reductionmust be included with the benefit provision to which it applies.

6. Each such form, including riders and endorsements,must be identified by a number in the lower left-hand corner of the first pagethereof.

7. The policy must not contain any provisionpurporting to make any portion of the charter, rules, constitution or bylaws ofthe insurer a part of the policy unless that portion is set forth in full inthe policy, except in the case of the incorporation of or reference to astatement of rates or classification of risks, or short-rate table filed withthe Commissioner.

8. The policy must provide benefits for expensearising from care at home or health supportive services if that care or servicewas prescribed by a physician and would have been covered by the policy ifperformed in a medical facility or facility for the dependent as defined in chapter 449 of NRS.

9. The policy must provide, at the option of theapplicant, benefits for expenses incurred for the treatment of abuse of alcoholor drugs, unless the policy provides coverage only for a specified disease orprovides for the payment of a specific amount of money if the insured ishospitalized or receiving health care in his home.

10. The policy must provide benefits for expensearising from hospice care.

(Added to NRS by 1971, 1752; A 1973, 546; 1975, 446,1108, 1848; 1979, 1176; 1983, 1933, 2035; 1985, 1568, 1772; 1989, 738, 1031)

NRS 689A.035 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;providing schedule of fees.

1. An insurer shall not charge a provider of healthcare a fee to include the name of the provider on a list of providers of healthcare given by the insurer to its insureds.

2. An insurer shall not contract with a provider ofhealth care to provide health care to an insured unless the insurer uses theform prescribed by the Commissioner pursuant to NRS 629.095 to obtain any informationrelated to the credentials of the provider of health care.

3. A contract between an insurer and a provider ofhealth 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 the30-day period, the modification must not become effective unless agreed to byboth parties as described in paragraph (a).

4. If an insurer contracts with a provider of healthcare to provide health care to an insured, the insurer 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 chapter 630, 631,632 or 633 ofNRS.

(Added to NRS by 1999, 1647; A 2001, 2729; 2003, 3355)

REQUIRED PROVISIONS

NRS 689A.040 Contentsof policy; substitution of provisions; captions; omission or modification ofprovisions.

1. Except as provided in subsections 2 and 3, eachsuch policy delivered or issued for delivery to any person in this state mustcontain the provisions specified in NRS689A.050 to 689A.170, inclusive,in the words in which the provisions appear, except that the insurer may, atits option, substitute for one or more of the provisions correspondingprovisions of different wording approved by the Commissioner which are in eachinstance not less favorable in any respect to the insured or the beneficiary.Each such provision must be preceded individually by the applicable captionshown, or, at the option of the insurer, by such appropriate individual orgroup captions or subcaptions as the Commissioner may approve.

2. Each policy delivered or issued for delivery inthis state after November 1, 1973, must contain a provision, if applicable,setting forth the provisions of NRS689A.045.

3. If any such provision is in whole or in partinapplicable to or inconsistent with the coverage provided by a particular formof policy, the insurer, with the approval of the Commissioner, may omit fromthe policy any inapplicable provision or part of a provision, and shall modifyany inconsistent provision or part of a provision in such a manner as to makethe provision as contained in the policy consistent with the coverage providedby the policy.

(Added to NRS by 1971, 1753; A 1973, 547; 1985, 1059)

NRS 689A.0403 Procedurefor arbitration of disputes concerning independent medical evaluations.

1. Each policy of health insurance must include aprocedure for binding arbitration to resolve disputes concerning independentmedical evaluations pursuant to the rules of the American ArbitrationAssociation.

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 the contract of insurance, only a physician or chiropractor who is certifiedto practice in the same field of practice as the primary treating physician orchiropractor or who is formally educated in that field may conduct theindependent 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 the procedurefor binding arbitration set forth in the policy of insurance within 30 daysafter he receives the finding of the evaluation. Upon its receipt of an appeal,the insurer shall so notify in writing the primary treating physician or 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 689A.04033 Coveragefor treatment received as part of clinical trial or study.

1. A policy of health insurance must provide coveragefor medical treatment which a policyholder or subscriber receives as part of aclinical 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 policyholder or subscriber has signed, beforehis participation in the clinical trial or study, a statement of consentindicating that he has been informed 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 policyholder or subscriber.

(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 health insurance.

(c) The cost of any routine health care services thatwould otherwise be covered under the policy of health insurance for apolicyholder or subscriber participating in a Phase I clinical trial or study.

(d) The initial consultation to determine whether the policyholderor subscriber is eligible to participate in the clinical trial or study.

(e) Health care services required for the clinicallyappropriate monitoring of the policyholder or subscriber during a Phase II,Phase III or Phase IV clinical trial or study.

(f) Health care services which are required for theclinically appropriate monitoring of the policyholder or subscriber during aPhase I clinical trial or study and which are not directly related to theclinical trial or study.

Except asotherwise provided in NRS 689A.04036,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 policyholder or subscriber is not required to becovered pursuant to this section if that particular medical treatment isprovided by the sponsor of the clinical trial or study free of charge to thepolicyholder or subscriber.

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 policyholders or subscribers policy of healthinsurance, regardless of whether such services are provided under the clinicaltrial 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 policyholder or subscriber 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 policyholder or subscriber.

(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 health insurance specified in subsection 1 may require copies of theapproval or certification issued pursuant to paragraph (b) of subsection 1, thestatement of consent signed by the policyholder or subscriber, protocols forthe clinical trial or study and any other materials related to the scope of theclinical trial or study relevant to the coverage of medical treatment pursuantto this section.

6. An insurer who delivers or issues for delivery apolicy specified in subsection 1 shall:

(a) Include in the disclosure required pursuant to NRS 689A.390 notice to each policyholderand subscriber under the policy of the availability of the benefits required bythis section.

(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 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 specified in subsection 1 is immune from liability for:

(a) Any injury to a policyholder or subscriber causedby:

(1) Any medical treatment provided to thepolicyholder or subscriber in connection with his participation in a clinicaltrial or study described 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 policyholder or subscriber in connection with hisparticipation in a clinical trial or study described in this section.

(b) Any adverse or unanticipated outcome arising out ofa policyholders or subscribers participation in a clinical trial or studydescribed in this section.

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 clinicalinvestigators who have experience working in Phase I clinical trials or studiesconducted at a facility designated as a comprehensive cancer center by theNational Cancer Institute;

(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 auditsinstituted by federal and state agencies.

(c) Provider of health care means:

(1) A hospital; or

(2) A person licensed pursuant to chapter 630, 631or 633 of NRS.

(Added to NRS by 2003, 3519; A 2005, 2009)

NRS 689A.04036 Coveragefor continued medical treatment.

1. The provisions of this section apply to a policy ofhealth insurance offered or issued by an insurer if an insured covered by thepolicy receives health care through a defined set of providers of health carewho 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 2003, 3354)

NRS 689A.0404 Coveragefor use of certain drugs for treatment of cancer. Exceptas otherwise provided in NRS 689A.04033:

1. No 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 anyother use 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 insured.

(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 of health insurance subject to theprovisions of this chapter that is delivered, issued for delivery or renewed onor after October 1, 1999, has the legal effect of including the coveragerequired by this section, and any provision of the policy that conflicts with theprovisions of this section is void.

(Added to NRS by 1999, 759; A 2003, 3522)

NRS 689A.04042 Coveragefor screening for colorectal cancer.

1. A policy of health insurance that provides coveragefor the treatment of colorectal cancer must provide coverage for colorectalcancer 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 professionalorganizations and which include current or prevailing supporting scientificdata.

2. A policy of 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 2003, 1334)

NRS 689A.04045 Coveragefor prescription drug previously approved for medical condition of insured.

1. Except as otherwise provided in this section, apolicy of health insurance which provides coverage for prescription drugs mustnot 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 639.2583 to 639.2597, inclusive; 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 2001, 857; A 2003, 2298)

NRS 689A.0405 Coveragefor cytologic screening test and mammograms for certain women.

1. A policy of health insurance must provide coveragefor 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 health insurance must not require aninsured 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, 1888; A 1997, 1729)

NRS 689A.041 Coveragerelating to mastectomy.

1. A policy of 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 equal theamounts 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. The termincludes augmentation mammoplasty, reduction mammoplasty and mastopexy.

(Added to NRS by 1983, 614; A 1989, 1889; 2001, 2218)

NRS 689A.0413 Coveragefor certain gynecological or obstetrical services without authorization orreferral from primary care physician.

1. A policy of 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 health insurance to designate an obstetrician orgynecologist 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 1999, 1943)

NRS 689A.0415 Coveragefor drug or device for contraception and for hormone replacement therapy incertain circumstances; prohibited actions by insurer; exceptions.

1. Except as otherwise provided in subsection 5, aninsurer that offers or issues a policy of 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 healthinsurance 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 health insurance orcancel a policy of health insurance solely because the person applying for orcovered by the policy uses or may use in the future any of the services listedin 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 ofhealth 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 health insurance and before the renewal of such apolicy, provide to the prospective insured, written notice of the coverage thatthe insurer refuses to provide pursuant to this subsection.

6. As used in this section, provider of health carehas the meaning ascribed to it in NRS629.031.

(Added to NRS by 1999, 1995)

NRS 689A.0417 Coveragefor health care services related to contraceptives and hormone replacementtherapy in certain circumstances; prohibited actions by insurer; exceptions.

1. Except as otherwise provided in subsection 5, aninsurer that offers or issues a policy of 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 healthinsurance 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 health insurance orcancel a policy of health insurance solely because the person applying for orcovered by the policy uses or may use in the future any of the services listedin 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 such a policy ofhealth 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 healthinsurance and before the renewal of such a policy, provide to the prospectiveinsured written notice of the coverage that the insurer refuses to providepursuant to this subsection.

6. As used in this section, provider of health carehas the meaning ascribed to it in NRS629.031.

(Added to NRS by 1999, 1996)

NRS 689A.042 Coveragerelating to complications of pregnancy.

1. No health insurance policy may be delivered orissued for delivery in this state if it contains any exclusion, reduction orother limitation of coverage relating to complications of pregnancy, unless theprovision applies generally to all benefits payable under the 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)

NRS 689A.0423 Coveragefor treatment of certain inherited metabolic diseases.

1. A policy of health insurance must provide coveragefor:

(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 689A.0425 Individualhealth benefit plan that includes coverage for maternity care and pediatriccare: Requirement to allow minimum stay in hospital in connection withchildbirth; prohibited acts.

1. Except asotherwise provided in this subsection, an individual health benefit plan issuedpursuant to this chapter that includes coverage for maternity care andpediatric care for newborn infants may not restrict benefits for any length ofstay in a hospital in connection with childbirth for a mother or newborn infantcovered by the plan 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, theindividual health benefit plan may follow such guidelines in lieu of followingthe length of stay set forth above. The provisions of this subsection do notapply to any individual health benefit plan in any case in which the decisionto discharge the mother or newborn infant before the expiration of the minimumlength of stay set forth in this subsection is made by the attending physicianof 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. An individual health benefit plan that offerscoverage for maternity care and pediatric care of newborn infants 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 an individual health benefit plan 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 anindividual health benefit plan and a provider of health care that usescapitation or other financial incentives, if the arrangement is designed toprovide services efficiently and consistently in the best interest of themother and her newborn infant.

(c) Prevents an individual health benefit plan 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, 2898)

NRS 689A.0427 Coveragefor management and treatment of diabetes.

1. No 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 689A.390 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 of health insurance subject to theprovisions of this chapter that is delivered, issued for delivery or renewed onor after January 1, 1998, has the legal effect of including the coveragerequired by this section, and any provision of the policy that conflicts withthis 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 aninsured person after he is initially diagnosed with diabetes which is medicallynecessary for the care and management of diabetes, including, withoutlimitation, counseling in nutrition and the proper use of equipment andsupplies 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 insured person and which requiresmodification of his program of self-management of diabetes; 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, 742)

NRS 689A.043 Coverageof newly born and adopted children and children placed for adoption.

1. All individual health insurance policies providingfamily coverage on an expense-incurred basis must as to family memberscoverage provide that the health benefits applicable for children are payablewith 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 private agencymaking 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 insurerwithin 31 days after the date of birth, adoption or placement for adoption inorder 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.

(Added to NRS by 1975, 1109; A 1989, 739)

NRS 689A.045 Terminationof coverage on dependent child.

1. Any health insurance policy delivered or issued fordelivery after November 1, 1973, which provides for the termination of coverageon a dependent child of a policyholder when such child attains a contractuallyspecified limiting age shall also provide that such coverage shall notterminate when the dependent child reaches such age if such child is andcontinues to be:

(a) Incapable of self-sustaining employment due to aphysical handicap or mental retardation; and

(b) Dependent on the policyholder for support andmaintenance.

2. Proof of such childs incapacity and dependencyshall be furnished to the insurer by the policyholder within 31 days after suchchild attains the specified limiting age and as often as the insurer maythereafter require, but no more than once a year beginning 2 years after suchchild attains the specified limiting age.

(Added to NRS by 1973, 546)

NRS 689A.0455 Coveragefor treatment of conditions relating to severe mental illness.

1. Notwithstanding any provisions of this Title to thecontrary, a policy of health insurance delivered or issued for delivery in thisstate pursuant to this chapter must provide coverage for the treatment ofconditions 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 health insurance.

4. The provisions of this section do not apply to apolicy of health insurance 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 subsection 4,an insurer must submit to the Commissioner a written request therefor that issigned by an actuary and sets forth the reasons and actuarial assumptions uponwhich the request is based. To determine whether an exemption may be granted,the Commissioner shall subtract from the amount of premiums charged during thepolicy year the amount of premiums charged during the period immediatelypreceding the policy year and the amount of any increase in the premiums chargedthat is attributable to factors that are unrelated to providing the coveragerequired by this section. The Commissioner shall verify the information within30 days after receiving the request. The request shall be deemed approved ifthe Commissioner does not deny the request within that time.

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 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-compulsive disorder.

(Added to NRS by 1999, 3100)

NRS 689A.046 Benefitsfor treatment of abuse of alcohol or drugs.

1. The benefits provided by a policy for healthinsurance for treatment of the abuse of alcohol or drugs must consist of:

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

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

(c) Counseling for a person, group or family who is 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, 1176; A 1983, 2036; 1985,1569, 1773; 1993, 1918; 1997, 1301; 1999, 1888; 2001, 438)

NRS 689A.0465 Coverageof treatment of temporomandibular joint.

1. Except as otherwise provided in this section, nopolicy of health insurance may be delivered or issued for delivery in thisstate if it contains an exclusion of coverage of 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, 2137)

REIMBURSEMENT FOR CERTAIN MEDICALLY RELATED TREATMENT ANDSERVICES

NRS 689A.0475 Acupuncture. If any policy of health insurance provides coverage foracupuncture performed by a physician, the insured is entitled to reimbursementfor acupuncture performed by a person who is licensed pursuant to chapter 634A of NRS.

(Added to NRS by 1991, 1133)

NRS 689A.048 Treatmentby licensed psychologist. If any policy ofhealth insurance provides coverage for treatment of an illness which is withinthe authorized scope of the practice of a qualified psychologist, the insuredis entitled to reimbursement for treatments by a psychologist who is licensedpursuant to chapter 641 of NRS.

(Added to NRS by 1979, 367; A 1989, 1553)

NRS 689A.0483 Treatmentby licensed marriage and family therapist. Ifany policy of health insurance provides coverage for treatment of an illnesswhich is within the authorized scope of the practice of a licensed marriage andfamily therapist, the insured is entitled to reimbursement for treatment by amarriage and family therapist who is licensed pursuant to chapter 641A of NRS.

(Added to NRS by 1987, 2133)

NRS 689A.0485 Treatmentby licensed associate in social work, social worker, independent social workeror clinical social worker. If any policy ofhealth insurance provides coverage for treatment of an illness which is withinthe authorized scope of the practice of a licensed associate in social work,social worker, independent social worker or clinical social worker, the insuredis entitled to reimbursement for treatment by an associate in social work,social worker, independent social worker or clinical social worker who islicensed pursuant to chapter 641B of NRS.

(Added to NRS by 1987, 1123)

NRS 689A.049 Treatmentby licensed chiropractor; restriction on policy limitations.

1. If any policy of health insurance provides coveragefor treatment of an illness which is within the authorized scope of practice ofa qualified chiropractor, the insured is entitled to reimbursement fortreatments by a chiropractor who is licensed pursuant to chapter 634 of NRS.

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 reimbursed for similar treatments by other physicians.

(Added to NRS by 1981, 930; A 1983, 327)

NRS 689A.0495 Servicesprovided by certain registered nurses; restriction on policy limitations;exception.

1. If any policy of health insurance provides coveragefor services which are within the authorized scope of practice of a registerednurse who is authorized pursuant to chapter 632of NRS to perform additional acts in an emergency or under other specialconditions as prescribed by the State Board of Nursing, and which are reimbursedwhen provided by another provider of health care, the insured is entitled toreimbursement 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, 1446)

NRS 689A.0497 Providerof medical transportation.

1. Except as otherwise provided in subsection 3, everypolicy of health insurance amended, delivered or issued for delivery in thisState after October 1, 1989, that provides coverage for medical transportation,must contain a provision for the direct reimbursement of a provider of medicaltransportation for covered services if that provider does not receivereimbursement 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)

MISCELLANEOUS PROVISIONS

NRS 689A.050 Entirecontract; changes. There shall be a provisionas follows:

 

Entire Contract; Changes:This policy, including the endorsements and the attached papers, if any,constitutes the entire contract of insurance. No change in this policy shall bevalid until approved by an executive officer of the insurer and unless suchapproval is endorsed hereon or attached hereto. No agent has authority tochange this policy or to waive any of its provisions.

 

(Added to NRS by 1971, 1753)

NRS 689A.060 Timelimit on certain defenses. There shall be aprovision as follows:

 

Time Limit on Certain Defenses:

1. After 3 years from thedate of issue of this policy no misstatements, except fraudulent misstatements,made by the applicant in the application for such policy shall be used to voidthe policy or to deny a claim for loss incurred or disability (as defined inthe policy) commencing after the expiration of such 3-year period.

 

The foregoing policy provision shall not be so construed asto affect any legal requirement for avoidance of a policy or denial of a claimduring such initial 3-year period, nor to limit the application of NRS 689A.200 to 689A.230, inclusive, in the event ofmisstatement with respect to age or occupation or other insurance. A policywhich the insured has the right to continue in force subject to its terms bythe timely payment of the premium until at least age 50 or, in the case of apolicy issued after age 44, for at least 5 years from its date of issue, maycontain in lieu of the foregoing the following provision (from which the clausein parentheses may be omitted at the insurers option): Incontestable: Afterthis policy has been in force for a period of three years during the lifetimeof the insured (excluding any period during which the insured is disabled), itshall become incontestable as to the statements contained in the application.

 

2. No claim for lossincurred or disability (as defined in the policy) commencing after 3 years fromthe date of issue of this policy shall be reduced or denied on the ground thata disease or physical condition not excluded from coverage by name or specificdescription effective on the date of loss had existed prior to the effectivedate of coverage of this policy.

 

(Added to NRS by 1971, 1753)

NRS 689A.070 Graceperiod. There shall be a provision as follows:

 

Grace Period: A grace periodof ..... (insert a number not less than 7 for weekly premium policies, 10for monthly premium policies and 31 for all other policies) days will begranted for the payment of each premium falling due after the first premium,during which grace period the policy shall continue in force.

 

A policy in which the insurer reserves the right to refuseany renewal shall have, at the beginning of the above provision:

 

Unless not less than 30 daysprior to the premium due date the company has delivered to the insured or hasmailed to his last address as shown by the records of the insurer writtennotice of its intention not to renew this policy beyond the period for whichthe premium has been accepted.

 

(Added to NRS by 1971, 1754)

NRS 689A.080 Reinstatement.

1. There shall be a provision as follows:

 

Reinstatement: If any renewalpremium be not paid within the time granted the insured for payment, asubsequent acceptance of premium by the insurer or by any agent duly authorizedby the insurer to accept such premium, without requiring in connectiontherewith an application for reinstatement, shall reinstate the policy;provided, however, that if the insurer or such agent requires an applicationfor reinstatement and issues a conditional receipt for the premium tendered, thepolicy will be reinstated upon approval of such application by the insurer or,lacking such approval, upon the 45th day following the date of such conditionalreceipt unless the insurer has previously notified the insured in writing ofits disapproval of such application. The reinstated policy shall cover onlyloss resulting from such accidental injury as may be sustained after the dateof reinstatement and loss due to such sickness as may begin more than 10 daysafter such date. In all other respects the insured and insurer shall have thesame rights thereunder as they had under the policy immediately before the duedate of the defaulted premium, subject to any provisions endorsed herein orattached hereto in connection with the reinstatement. Any premium accepted inconnection with a reinstatement shall be applied to a period for which premiumhas not been previously paid, but not to any period more than 60 days prior tothe date of reinstatement.

 

2. The last sentence of subsection 1 may be omittedfrom any policy which the insured has the right to continue in force subject toits terms by the timely payment of premiums:

(a) Until at least age 50; or

(b) In the case of a policy issued after age 44, for atleast 5 years from its date of issue.

3. Pursuant to the last sentence in subsection 1, theinsurer shall apply the premium accepted in such manner as to place the policycurrently in force, exclusive of any applicable grace period, but not in anyevent to any period more than 60 days prior to the date of reinstatement.

(Added to NRS by 1971, 1754)

NRS 689A.090 Noticeof claim.

1. There shall be a provision as follows:

 

Notice of Claim: Writtennotice of claim must be given to the insurer within 20 days after theoccurrence or commencement of any loss covered by the policy, or as soonthereafter as is reasonably possible. Notice given by or on behalf of theinsured or the beneficiary to the insurer at ................ (insert thelocation of such office as the insurer may designate for the purpose), or toany authorized agent of the insurer, with information sufficient to identifythe insured, shall be deemed notice to the insurer.

 

2. In a policy providing a loss-of-time benefit whichmay be payable for at least 2 years, an insurer may at its option insert thefollowing between the first and second sentence of subsection 1:

 

Subject to the qualificationsset forth below, if the insured suffers loss of time on account of disabilityfor which indemnity may be payable for at least 2 years, he shall, at leastonce in every 6 months after having given notice of the claim, give to theinsurer notice of continuance of said disability, except in the event of legalincapacity. The period of 6 months following any filing of proof by the insuredor any payment by the insurer on account of such claim or any denial ofliability in whole or in part by the insurer shall be excluded in applying thisprovision. Delay in the giving of such notice shall not impair the insuredsright to any indemnity which would otherwise have accrued during the period of6 months preceding the date on which such notice is actually given.

 

(Added to NRS by 1971, 1755)

NRS 689A.100 Claimforms: Required provision. There shall be aprovision as follows:

 

Claim Forms: The insurer,upon receipt of a notice of claim, will furnish to the claimant such forms asare usually furnished by it for filing proofs of loss. If such forms are notfurnished within 15 days after the giving of such notice the claimant shall bedeemed to have complied with the requirements of this policy as to proof ofloss upon submitting, within the time fixed in the policy for filing proofs ofloss, written proof covering the occurrence, the character and the extent ofthe loss for which claim is made.

 

(Added to NRS by 1971, 1756)

NRS 689A.105 Claimforms: Uniform billing, claims forms. Everyinsurer under a health insurance contract and every state agency for itsrecords shall accept from:

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)

NRS 689A.110 Claimforms: Acceptance of uniform forms. Thereshall be a provision as follows:

 

Proofs of Loss: Written proofof loss must be furnished to the insurer at its office in case of claim forloss for which this policy provides any periodic payment contingent uponcontinuing loss within 90 days after the termination of the period for whichthe insurer is liable and in case of claim for any other loss within 90 daysafter the date of such loss. Failure to furnish such proof within the timerequired shall not invalidate nor reduce any claim if it was not reasonablypossible to give proof within such time, provided such proof is furnished assoon as reasonably possible and in no event, except in the absence of legalcapacity, later than 1 year from the time proof is otherwise required.

 

(Added to NRS by 1971, 1756)

NRS 689A.120 Timeof payment of claims. There shall be aprovision as follows:

 

Time of Payment of Claims:Indemnities payable under this policy for any loss, other than loss for whichthis policy provides any periodic payment, will be paid immediately uponreceipt of due written proof of such loss. Subject to due written proof ofloss, all accrued indemnities for loss for which this policy provides periodicpayment will be paid ................ (insert period for payment which must notbe less frequently than monthly) and any balance remaining unpaid upon thetermination of liability will be paid immediately upon receipt of due writtenproof.

 

(Added to NRS by 1971, 1756)

NRS 689A.130 Paymentof claims.

1. There shall be a provision as follows:

 

Payment of Claims: Indemnityfor loss of life will be payable in accordance with the beneficiary designationand the provisions respecting such payment which may be prescribed herein andeffective at the time of payment. If no such designation or provision is theneffective, such indemnity shall be payable to the estate of the insured. Anyother accrued indemnities unpaid at the insureds death may, at the option ofthe insurer, be paid either to such beneficiary or to such estate. All otherindemnities will be payable to the insured.

 

2. The following provisions, or either of them, may beincluded with the provision in subsection 1 at the option of the insurer:

 

If any indemnity of thispolicy shall be payable to the estate of the insured, or to an insured orbeneficiary who is a minor or otherwise not competent to give a valid release,the insurer may pay such indemnity, up to an amount not exceeding $.....(insert an amount which shall not exceed $1,000), to any relative by blood orconnection by marriage of the insured or beneficiary who is deemed by theinsurer to be equitably entitled thereto. Any payment made by the insurer ingood faith pursuant to this provision shall fully discharge the insurer to theextent of such payment.

Subject to any writtendirection of the insured in the application or otherwise all or a portion ofany indemnities provided by this policy on account of hospital, nursing,medical or surgical services may, at the insurers option and unless theinsured requests otherwise in writing not later than the time of filing proofsof such loss, be paid directly to the hospital or person rendering suchservices; but it is not required that the service be rendered by a particularhospital or person.

 

(Added to NRS by 1971, 1756)

NRS 689A.135 Assignmentof benefits to provider of health care.

1. A person insured under a policy of health insurancemay assign his right to benefits to the provider of health care who providedthe services covered by the policy. The insurer shall pay all or the part ofthe benefits assigned by the insured to the person designated by him. A paymentmade pursuant to this subsection discharges the insurers obligation to paythose benefits.

2. If the insured makes an assignment under thissection, but the insurer after receiving a copy of the assignment pays thebenefits to the insured, the insurer shall also pay those benefits to theprovider of health care who received the assignment as soon as the insurerreceives notice of the incorrect payment.

3. For the purpose of this section, provider ofhealth care has the meaning ascribed to it in NRS 629.031.

(Added to NRS by 1983, 879)

NRS 689A.140 Physicalexamination and autopsy. There shall be a provisionas follows:

 

Physical Examinations andAutopsy: The insurer at its own expense shall have the right and opportunity toexamine the person of the insured when and as often as it may reasonablyrequire during the pendency of a claim hereunder and to make an autopsy in caseof death where it is not forbidden by law.

 

(Added to NRS by 1971, 1757)

NRS 689A.150 Legalactions. There shall be a provision asfollows:

 

Legal Actions: No action atlaw or in equity shall be brought to recover on this policy prior to theexpiration of 60 days after written proof of loss has been furnished inaccordance with the requirements of this policy. No such action shall bebrought after the expiration of 3 years after the time written proof of loss isrequired to be furnished.

 

(Added to NRS by 1971, 1757)

NRS 689A.160 Changeof beneficiary.

1. There shall be a provision as follows:

 

Change of Beneficiary: Unlessthe insured makes an irrevocable designation of beneficiary, the right tochange of beneficiary is reserved to the insured and the consent of thebeneficiary or beneficiaries shall not be requisite to surrender or assignmentof this policy or to any change of beneficiary or beneficiaries, or to anyother changes in this policy.

 

2. The first clause of the provision set forth insubsection 1, relating to the irrevocable designation of beneficiary, may beomitted at the insurers option.

(Added to NRS by 1971, 1757)

NRS 689A.170 Rightto examine and return policy.

1. Except as to nonrenewable accident policies andindividual credit health insurance policies, every individual health insurancepolicy shall contain a provision therein or in a separate rider attachedthereto when delivered, stating in substance that the person to whom the policyis issued shall be permitted to return the policy within 10 days of itsdelivery to such person and to have a refund of the premium paid if afterexamination of the policy the purchaser is not satisfied with it for anyreason. The provision shall be set forth in the policy under an appropriatecaption, and if not so printed on the face page of the policy adequate noticeof the provision shall be printed or stamped conspicuously on the face page.

2. The policy may be so returned to the insurer at itshome or branch office or to the agent through whom it was applied for, andthereupon shall be void as from the beginning and as if the policy had not beenissued.

(Added to NRS by 1971, 1758)

NRS 689A.180 Optionalprovisions. [Effective through June 30, 2006.] Exceptas provided in NRS 689A.040, no suchpolicy delivered or issued for delivery to any person in this State may containprovisions respecting the matters set forth in NRS 689A.190 to 689A.280, inclusive, unless theprovisions are in the words in which the provisions appear in the applicablesection, except that the insurer may, at its option, use in lieu of any suchprovision a corresponding provision of different wording approved by theCommissioner which is not less favorable in any respect to the insured or thebeneficiary. Any such provision contained in the policy must be precededindividually by the appropriate caption or, at the option of the insurer, bysuch appropriate individual or group captions or subcaptions as theCommissioner may approve.

(Added to NRS by 1971, 1758; A 1985, 1060)

NRS 689A.180 Optional provisions. [Effective July1, 2006.] Except as otherwise provided in NRS 689A.040, no such policy delivered orissued for delivery to any person in this State may contain provisionsrespecting the matters set forth in NRS689A.190 to 689A.270, inclusive,unless the provisions are in the words in which the provisions appear in theapplicable section, except that the insurer may, at its option, use in lieu ofany such provision a corresponding provision of different wording approved bythe Commissioner which is not less favorable in any respect to the insured orthe beneficiary. Any such provision contained in the policy must be precededindividually by the appropriate caption or, at the option of the insurer, bysuch appropriate individual or group captions or subcaptions as the Commissionermay approve.

(Added to NRS by 1971, 1758; A 1985, 1060; 2005, 2343,effective July 1, 2006)

NRS 689A.190 Extendeddisability benefit. Any health insurancepolicy may contain a provision for payment not exceeding $500 as an extendeddisability benefit upon the insureds death from any cause, which benefit shallnot be construed as life insurance.

(Added to NRS by 1971, 1758)

NRS 689A.200 Changeof occupation. There may be a provision as follows:

 

Change of Occupation: If theinsured be injured or contracts sickness after having changed his occupation toone classified by the insurer as more hazardous than that stated in this policyor while doing for compensation anything pertaining to an occupation soclassified, the insurer will pay only such portion of the indemnities providedin this policy as the premium paid would have purchased at the rates and withinthe limits fixed by the insurer for such more hazardous occupation. If theinsured changes his occupation to one classified by the insurer as lesshazardous than that stated in this policy, the insurer, upon receipt of proofof such change of occupation, will reduce the premium rate accordingly, andwill return the excess pro rata unearned premium from the date of change ofoccupation or from the policy anniversary date immediately preceding receipt ofsuch proof, whichever is the more recent. In applying this provision, theclassification of occupational risk and the premium rates shall be such as havebeen last filed by the insurer prior to the occurrence of the loss for whichthe insurer is liable or prior to date of proof of change in occupation withthe state official having supervision of insurance in the state where theinsured resided at the time this policy was issued; but if such filing was notrequired, then the classification of occupational risk and the premium ratesshall be those last made effective by the insurer in such state prior to theoccurrence of the loss or prior to the date of proof of change in occupation.

 

(Added to NRS by 1971, 1758)

NRS 689A.210 Misstatementof age. There may be a provision as follows:

 

Misstatement of Age: If theage of the insured has been misstated, all amounts payable under this policyshall be such as the premium paid would have purchased at the correct age.

 

(Added to NRS by 1971, 1759)

NRS 689A.220 Coordinationof benefits: Same insurer. There may be aprovision as follows:

 

If an accident or sickness oraccident and sickness policy or policies previously issued by the insurer tothe insured be in force concurrently herewith, making the aggregate indemnityfor ................ (insert type of coverage or coverages) in excess of $.....(insert maximum limit of indemnity or indemnities), the excess shall be voidand all premiums paid for such excess shall be returned to the insured or tohis estate.

 

Or, in lieu thereof:

 

Insurance effective at anyone time on the insured under this policy and like policy or policies in thisinsurer is limited to the one policy elected by the insured, his beneficiary orhis estate, as the case may be, and the insurer will return all premiums paidfor all other such policies.

 

(Added to NRS by 1971, 1759)

NRS 689A.230 Coordinationof benefits: All coverages.

1. There may be a provision as follows:

 

Coordination of Benefits: If,with respect to a person covered under this policy, benefits for allowableexpense incurred during a claim determination period under this policy,together with benefits for allowable expense during such period under all othervalid coverage (without giving effect to this provision or to any coordinationof benefits provision applying to such other valid coverage), exceed the totalof such persons allowable expense during such period, this insurer shall beliable only for such proportionate amount of the benefits for allowable expenseunder this policy during such period as (a) the total allowable expense duringsuch period bears to (b) the total amount of benefits payable during suchperiod for such expense under this policy and all other valid coverage (withoutgiving effect to this provision or to any coordination of benefits provisionapplying to such other valid coverage) less in both (a) and (b) any amount ofbenefits for allowable expense payable under other valid coverage which doesnot contain a coordination of benefits provision. In no event shall thisprovision operate to increase the amount of benefits for allowable expensepayable under this policy with respect to a person covered under this policyabove the amount which would have been paid in the absence of this provision.This insurer may pay benefits to any insurer providing other valid coverage inthe event of overpayment by such insurer. Any such payment shall discharge theliability of this insurer as fully as if the payment had been made directly tothe insured, his assignee or his beneficiary. If this insurer pays benefits tothe insured, his assignee or his beneficiary, in excess of the amount whichwould have been payable if the existence of other valid coverage had been disclosed,this insurer shall have a right of action against the insured, his assignee orhis beneficiary to recover the amount which would not have been paid had therebeen a disclosure of the existence of the other valid coverage. The amount ofother valid coverage which is on a provision of service basis shall be computedas the amount the services rendered would have cost in the absence of suchcoverage.

For the purposes of thisprovision:

(1) Allowable expense means100 percent of any necessary, reasonable and customary item of expense which iscovered, in whole or in part, as a hospital, surgical, medical or major medicalexpense under this policy or under any other valid coverage.

(2) Claim determinationperiod with respect to any covered person means the initial period of .....(insert period of not less than 30 days) and each successive period of a likenumber of days, during which allowable expense covered under this policy isincurred on account of such person. The first such period begins on the datewhen the first such expense is incurred, and successive periods shall beginwhen such expense is incurred after expiration of a prior period.

 

or, in lieu thereof:

 

(2) Claim determinationperiod with respect to any covered person means each ..... (insert calendar orpolicy period of not less than a month) during which allowable expense coveredunder this policy is incurred on account of such person.

(3) Coordination of benefitsprovision means this provision and any other provision which may reduce aninsurers liability because of the existence of benefits under other validcoverage.

 

2. The foregoing policy provisions may be inserted inall policies providing hospital, surgical, medical or major medical benefitsfor which the application includes a question as to other coverages subject tothis provision. If the policy provision stated in subsection 1 is included in apolicy which also contains the policy provision stated in NRS 689A.240, there shall be added to thecaption of the provision stated in subsection 1 of the phrase expense-incurredbenefits. The insurer may make this provision applicable to either or both:

(a) Other valid coverage with other insurers; and

(b) Other valid coverage with the same insurer.

The insurershall include in this provision a definition of other valid coverage approvedas to form by the Commissioner. Such term may include hospital, surgical,medical or major medical benefits provided by individual or family-typecoverage, government programs or workmens compensation. Such term shall notinclude any group insurance, automobile medical payments or third partyliability coverage. The insurer shall not include a subrogation clause in thepolicy. The insurer may require, as part of the proof of claim, the informationnecessary to administer this provision.

3. If by application of any of the foregoingprovisions the insurer effects a material reduction of benefits otherwisepayable under the policy, the insurer shall refund to the insured any premiumunearned on the policy by reason of such reduction of coverage during thepolicy year current and that next preceding at the time the loss commenced,subject to the insurers right to provide in the policy that no such reductionof benefits or refund will be made unless the unearned premium to be so refundedamounts to $5 or such larger sum as the insurer may so specify.

(Added to NRS by 1971, 1760)

NRS 689A.240 Relationof earnings to insurance.

1. There may be a provision as follows:

 

Relation of Earnings toInsurance: After the loss-of-time benefit of this policy has been payable for90 days, such benefit will be adjusted, as provided below, if the total amountof unadjusted loss-of-time benefits provided in all valid loss-of-time coverageupon the insured should exceed ..... percent of the insureds earned income;provided, however, that if the information contained in the applicationdiscloses that the total amount of loss-of-time benefits under this policy andunder all other valid loss-of-time coverage expected to be effective upon theinsured in accordance with the application for this policy exceeded .....percent of the insureds earned income at the time of such application, suchhigher percentage will be used in place of ..... percent. Such adjustedloss-of-time benefit under this policy for any month shall be only suchproportion of the loss-of-time benefit otherwise payable under this policy as(a) the product of the insureds earned income and ..... percent (or, if higherthe alternative percentage described at the end of the first sentence of thisprovision) bears to (b) the total amount of loss-of-time benefits payable forsuch month under this policy and all other valid loss-of-time coverage on theinsured (without giving effect to the overinsurance provision in this or anyother coverage) less in both (a) and (b) any amount of loss-of-time benefitspayable under other valid loss-of-time coverage which does not contain anoverinsurance provision. In making such computation, all benefits andearnings shall be converted to a consistent (insert weekly if the loss-of-timebenefit of this policy is payable weekly, monthly if such benefit is payablemonthly, etc.) basis. If the numerator of the foregoing ratio is zero or is negative,no benefit shall be payable under this policy. In no event shall this provision(1) operate to reduce the total combined amount of loss-of-time benefits forsuch month payable under this policy and all other valid loss-of-time coveragebelow the lesser of $300 and the total combined amount of loss-of-time benefitsdetermined without giving effect to any coordination of benefits provision,nor (2) operate to increase the amount of benefits payable under this policyabove the amount which would have been paid in the absence of this provision,nor (3) take into account or operate to reduce any benefit other than theloss-of-time benefit.

For purposes of thisprovision:

(A) Earned income, exceptwhere otherwise specified, means the greater of the monthly earnings of theinsured at the time disability commences and his average monthly earnings for aperiod of 2 years immediately preceding the commencement of such disability,and shall not include any investment income or any other income not derivedfrom the insureds vocational activities.

(B) Coordination of benefitsprovision includes this provision and any other provision with respect to anyloss-of-time coverage which may have the effect of reducing an insurersliability if the total amount of loss-of-time benefits under all coverageexceeds a stated relationship to the insureds earnings.

 

2. If the policy provision stated in subsection 1 isincluded in a policy which also contains the policy provision stated in NRS 689A.230, there shall be added to thecaption of the provision stated in subsection 1 the phrase loss-of-timebenefits.

3. The foregoing provision may be included only in apolicy which provides a loss-of-time benefit which may be payable for at least52 weeks, which is issued on the basis of selective underwriting of eachindividual application, and for which the application includes a questiondesigned to elicit information necessary either to determine the ratio of thetotal loss-of-time benefits of the insured to the insureds earned income or todetermine that such ratio does not exceed the percentage of earnings, not lessthan 60 percent selected by the insurer and inserted in lieu of the blankfactor above. The insurer may require, as part of the proof of claim, the informationnecessary to administer this provision. If the application indicates that otherloss-of-time coverage is to be discontinued, the amount of such other coverageshall be excluded in computing the alternative percentage in the first sentenceof the overinsurance provision. The policy shall include a definition of validloss-of-time coverage, approved as to form by the Commissioner, whichdefinition shall not include group insurance, benefits provided by unionwelfare plans, employer or employee benefit plans, workmens compensation oremployers liability statute or third party liability. The insurer shall notinclude a subrogation clause in the policy.

4. If by application of any of the foregoingprovisions the insurer effects a material reduction of benefits otherwisepayable under the policy, the insurer shall refund to the insured any premium unearnedon the policy by reason of such reduction of coverage during the policy yearcurrent and that next preceding at the time the loss commenced, subject to theinsurers right to provide in the policy that no such reduction of benefits orrefund will be made unless the unearned premium to be so refunded amounts to $5or such larger sum as the insurer may so specify.

(Added to NRS by 1971, 1761)

NRS 689A.250 Unpaidpremiums. There may be a provision as follows:

 

Unpaid Premium: Upon thepayment of a claim under this policy, any premium then due and unpaid orcovered by any note or written order may be deducted therefrom.

 

(Added to NRS by 1971, 1763)

NRS 689A.260 Conformitywith state statutes. There may be a provisionas follows:

 

Conformity with StateStatutes: Any provision of this policy which, on its effective date is inconflict with the statutes of the state in which the insured resides on suchdate is hereby amended to conform to the minimum requirements of such statutes.

 

(Added to NRS by 1971, 1763)

NRS 689A.270 Illegaloccupation. There may be a provision asfollows:

 

Illegal Occupation: Theinsurer shall not be liable for any loss to which a contributing cause was theinsureds commission of or attempt to commit a felony or to which acontributing cause was the insureds being engaged in an illegal occupation.

 

(Added to NRS by 1971, 1763)

NRS 689A.280 Intoxicantsand narcotics. [Effective through June 30, 2006.]

1. There may be a provision as follows:

 

Intoxicants and Narcotics:The insurer is not liable for any loss sustained or contracted in consequenceof the insureds being intoxicated or under the influence of any narcoticunless administered on the advice of a physician.

 

2. If the insurer includes the provision set forth insubsection 1, he shall also provide that such provision in no way affectsbenefits payable for the treatment of alcohol or drug abuse, as required bysubsection 9 of NRS 689A.030.

(Added to NRS by 1971, 1763; A 1975, 1849; R 2005, 2348,effective July 1, 2006)

NRS 689A.290 Renewability. Health insurance policies, other than accident insuranceonly policies, in which the insurer reserves the right to refuse renewal on anindividual basis, shall provide in substance in a provision thereof or in an endorsementthereon or rider attached thereto that subject to the right to terminate thepolicy upon nonpayment of premium when due, such right to refuse renewal maynot be exercised so as to take effect before the renewal date occurring on, orafter and nearest, each policy anniversary (or in the case of lapse andreinstatement, at the renewal date occurring on, or after and nearest, eachanniversary of the last reinstatement), and that any refusal of renewal shallbe without prejudice to any claim originating while the policy is in force.(The parenthetic reference to lapse and reinstatement may be omitted at theinsurers option.)

(Added to NRS by 1971, 1764)

NRS 689A.300 Orderof certain provisions. The provisions whichare the subject of NRS 689A.050 to 689A.290, inclusive, or any correspondingprovisions which are used in lieu thereof in accordance with such sectionsshall be printed in the consecutive order of the provisions in such sectionsor, at the option of the insurer, any such provision may appear as a unit inany part of the policy, with other provisions to which it may be logicallyrelated, provided that the resulting policy shall not be in whole or in partunintelligible, uncertain, ambiguous, abstruse or likely to mislead a person towhom the policy is offered, delivered or issued.

(Added to NRS by 1971, 1764)

NRS 689A.310 Ownershipof policy by person other than insured. Theword insured, as used in this chapter, shall not be construed as preventing aperson other than the insured with a proper insurable interest from makingapplication for and owning a policy covering the insured or from being entitledunder such a policy to any indemnities, benefits and rights provided therein.

(Added to NRS by 1971, 1764)

NRS 689A.320 Requirementsof other jurisdictions.

1. Any policy of a foreign or alien insurer, whendelivered or issued for delivery to any person in this state, may contain anyprovision which is not less favorable to the insured or the beneficiary thanthe provisions of this chapter and which is prescribed or required by the lawof the state or country under which the insurer is organized.

2. Any policy of a domestic insurer may, when issuedfor delivery in any other state or country, contain any provision permitted orrequired by the laws of such other state or country.

(Added to NRS by 1971, 1764)

NRS 689A.330 Policiesissued for delivery in another state. If anypolicy is issued by a domestic insurer for delivery to a person residing inanother state, and if the insurance commissioner or corresponding publicofficer of that other state has informed the Commissioner that the policy isnot subject to approval or disapproval by that officer, the Commissioner may byruling require that the policy meet the standards set forth in NRS 689A.030 to 689A.320, inclusive.

(Added to NRS by 1971, 1765; A 1985, 1447; 1989,1273; 1997, 743; 1999,760, 1997; 2003, 1334, 3355, 3522)

NRS 689A.340 Limitationon provisions not subject to chapter; effect of violation.

1. No policy provision which is not subject to thischapter shall make a policy, or any portion thereof, less favorable in anyrespect to the insured or the beneficiary than the provisions thereof which aresubject to this chapter.

2. A policy delivered or issued for delivery to anyperson in this state in violation of this chapter shall be held valid but shallbe construed as provided in this chapter. When any provision in a policysubject to this chapter is in conflict with any provision of this chapter, therights, duties and obligations of the insurer, the insured and the beneficiaryshall be governed by the provisions of this chapter.

(Added to NRS by 1971, 1765)

NRS 689A.350 Agelimit. If any such policy contains a provisionestablishing, as an age limit or otherwise, a date after which the coverageprovided by the policy will not be effective, and if such date falls within aperiod for which a premium is accepted by the insurer or if the insurer acceptsa premium after such date, the coverage provided by the policy will continue inforce subject to any right of termination until the end of the period for whichthe premium has been accepted. If the age of the insured has been misstated andif, according to the correct age of the insured, the coverage provided by thepolicy would not have become effective, or would have ceased prior to theacceptance of such premium or premiums, then the liability of the insurer shallbe limited to the refund of all premiums paid for the period not covered by thepolicy.

(Added to NRS by 1971, 1765)

NRS 689A.360 Filingof rates. Each insurer issuing individualhealth insurance policies for delivery in this state shall, before use thereof,file with the Commissioner its premium rates and classification of riskspertaining to such policies. The insurer shall adhere to its rates andclassifications as filed with the Commissioner. The insurer may change suchfilings from time to time as it deems proper.

(Added to NRS by 1971, 1765)

NRS 689A.370 Healthinsurance on franchise plan.

1. Health insurance on a franchise plan is herebydeclared to be that form of health insurance issued to:

(a) Three or more employees of any corporation,copartnership or individual employer or any governmental corporation, agency ordepartment thereof; or

(b) Ten or more members, employees or employees ofmembers of any trade or professional association or of a labor union or of anyother association having had an active existence for at least 2 years wheresuch association or union has a constitution or bylaws and is formed in goodfaith for purposes other than that of obtaining insurance,

where suchpersons with or without their dependents, are issued the same form of anindividual policy varying only as to amounts and kinds of coverage applied forby such persons under an arrangement whereby the premiums on such policies maybe paid to the insurer periodically by the employer, with or without payrolldeductions, or by the insured, or the association or union for its members, orby some designated person acting on behalf of such employer or association orunion. The term employees as used in this section shall be deemed to includethe officers, managers and employees and retired employees of the employer andthe individual proprietor or partners if the employer is an individualproprietor or partnership.

2. Each policy issued under this section shall providethat the coverage shall terminate when the insured individual no longerqualifies for such policy under this section; but the policy may provide thatit may be continued in force or be replaced with another policy if the premium,benefits and other relevant factors of the continued or replacement policy arethe same as those of a similar individual policy not issued under or pursuantto this section.

(Added to NRS by 1971, 1765)

NRS 689A.380 Definitionsof terms used in policies. As used in anypolicy of health insurance delivered, issued for delivery or used in thisstate, unless otherwise provided in the policy or in an endorsement thereon orin a rider attached thereto:

1. Accidental death means death by accidentexclusively and independently of all other causes.

2. Confinement to house or house confinementincludes the activities of a convalescent not able to be gainfully employed.

3. Medical or surgical services includes alsoservices within the scope of his license rendered by any person while dulylicensed by the State of Nevada under any of the following chapters of NRS: 631(dentistry); 633 (osteopathic medicine); 634 (chiropractic); 634A (Orientalmedicine); 635 (podiatry); or 636 (optometry). No policy of health insurancemay provide that the insured does not have the option of selecting any licenseeprovided for in this subsection to perform any medical or surgical servicescovered by a policy of insurance if the service is within the scope of hislicense.

4. Total disability means inability to perform theduties of any gainful occupation for which the insured is reasonably fitted bytraining, experience and accomplishment.

(Added to NRS by 1971, 1766; A 1971, 1953; 1975, 240;1977, 966)

NRS 689A.390 Summaryof coverage: Contents of disclosure; approval by Commissioner.

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 health insuranceoffered by the insurer. The disclosure must include:

(a) Any significant exception, reduction or limitationthat applies to the policy; and

(b) 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 must include a statement that the disclosure is a summaryof the policy only, and that the policy itself should be read to determine thegoverning contractual 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.

(Added to NRS by 1989, 1248)

NRS 689A.400 Summaryof coverage: Copy to be provided before policy issued; policy may not beoffered unless summary approved by Commissioner. Aninsurer shall provide each person to whom it offers a policy of healthinsurance with a copy of the disclosure approved for that policy pursuant to NRS 689A.390 before the policy is issued.An insurer shall not offer a policy of health insurance unless the disclosurefor that policy has been approved by the Commissioner.

(Added to NRS by 1989, 1249)

NRS 689A.405 Coveragefor prescription drugs: Provision of notice and information regarding use offormulary.

1. An insurer that offers or issues a policy of healthinsurance which provides coverage for prescription drugs shall include with anysummary, certificate or evidence of that coverage provided to an insured,notice of whether a formulary is used and, if so, of the opportunity to secureinformation regarding the formulary from the insurer pursuant to subsection 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 healthinsurance which provides coverage for prescription drugs and a formulary isused, 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 2001, 856)

NRS 689A.410 Approvalor denial of claims; payment of claims and interest; requests for additionalinformation; award of costs and attorneys fees; compliance with requirements.

1. Except as otherwise provided in subsection 2, aninsurer shall approve or deny a claim relating to a policy of health insurancewithin 30 days after the insurer receives the claim. If the claim is approved,the insurer shall pay the claim within 30 days after it is approved. Except asotherwise provided in this section, if the approved claim is not paid withinthat period, the insurer shall pay interest on the claim at a rate of interestequal to the prime rate at the largest bank in Nevada, as ascertained by theCommissioner of Financial Institutions, on January 1 or July 1, as the case maybe, immediately preceding the date on which the payment was due, plus 6percent. The interest must be calculated from 30 days after the date on whichthe claim is approved until the date on which the 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 this sectionfor the late payment of an approved claim may be waived only if the payment wasdelayed because of an act of God or another cause beyond the control of theinsurer.

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 1999, 1647; 2001, 2729; 2003, 3355)

NRS 689A.413 Insurerprohibited from denying coverage solely because person was victim of domesticviolence. An insurer shall not deny a claim,refuse to issue a policy of health insurance or cancel a policy of healthinsurance solely because the claim involves an act that constitutes domesticviolence pursuant to NRS 33.018, orbecause the person applying for or covered by the health insurance policy wasthe victim of such an act of domestic violence, regardless of whether theinsured or applicant contributed to any loss or injury.

(Added to NRS by 1997, 1095)

NRS 689A.415 Insurerprohibited from denying coverage solely because insured was intoxicated orunder influence of controlled substance; exceptions. [Effective July 1, 2006.]

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

(a) Deny a claim under a policy of health insurancesolely because the claim involves an injury sustained by an insured as aconsequence of being intoxicated or under the influence of a controlledsubstance.

(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. Theprovisions of this section do not prohibit an insurer from enforcing aprovision included in a policy of health insurance pursuant to NRS 689A.270 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 health insurance solely becauseof such a claim; or

(c) Refuse to issue a policy of health insurance to aneligible applicant solely because of such a claim.

(Added to NRS by 2005, 2343,effective July 1, 2006)

NRS 689A.417 Insurerprohibited from requiring or using information concerning genetic testing;exceptions.

1. Except as otherwise provided in subsection 2, aninsurer who provides 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 the coverageor 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 health insurance that provides coverage forlong-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, 1459)

NRS 689A.419 Offeringpolicy of health insurance for purposes of establishing health savings account. An insurer may, subject to regulation by the Commissioner,offer a policy of health insurance that has a high deductible and is incompliance with 26 U.S.C. 223 for the purposes of establishing a healthsavings account.

(Added to NRS by 2005, 2136)

ELIGIBILITY FOR COVERAGE

NRS 689A.420 Definitions. As used in NRS689A.420 to 689A.460, inclusive,unless the context otherwise requires:

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 policy of healthinsurance to a child pursuant to the provisions of 42 U.S.C. 1396g-1.

(Added to NRS by 1995, 2427)

NRS 689A.430 Effectof eligibility for medical assistance under Medicaid; assignment of rights tostate agency.

1. An insurer shall not, when considering eligibilityfor coverage or making payments under a policy of health insurance, considerthe availability 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)), service benefit plan, health maintenance organization or otherorganization that has issued a policy of health insurance:

(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 right 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 policy of health insurance,

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, 2427)

NRS 689A.440 Insurerprohibited from asserting certain grounds to deny enrollment of child ofinsured pursuant to order. An insurer shallnot deny the enrollment of a child pursuant to an order for medical coverage,under a policy of health insurance pursuant to which a parent of the child isinsured, on the ground that the child:

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 the insurersgeographic area of service.

(Added to NRS by 1995, 2427)

NRS 689A.450 Certainaccommodations to be made when child is covered under policy of noncustodialparent. If a child has coverage under a policyof health insurance pursuant to which a noncustodial parent of the child isinsured, the insurer issuing that policy shall:

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, 2428)

NRS 689A.460 Insurerto authorize enrollment of child of parent who is required by order to providemedical coverage under certain circumstances; termination of coverage of child. If a parent is required by an order for medical coverageto provide coverage under a policy of health insurance for a child and theparent is eligible for coverage of members of his family under a policy ofhealth insurance, the insurer that issued the policy:

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, 2428)

PORTABILITY AND ACCOUNTABILITY

General Provisions

NRS 689A.470 Definitions. As used in NRS689A.470 to 689A.740, inclusive,unless the context otherwise requires, the words and terms defined in NRS 689A.475 to 689A.605, inclusive, have the meaningsascribed to them in those sections.

(Added to NRS by 1997, 2883; A 2001, 1922; 2005, 2136)

NRS 689A.475 Affiliateddefined. Affiliated means any entity or personwho directly, or indirectly through one or more intermediaries, controls or iscontrolled by or is under common control with a specified entity or person.

(Added to NRS by 1997, 2883)

NRS 689A.480 Basichealth benefit plan defined. Basic healthbenefit plan means the basic health benefit plan developed pursuant to NRS 689C.610 to 689C.980, inclusive.

(Added to NRS by 1997, 2883)

NRS 689A.485 Bonafide association defined. Bona fideassociation means, with respect to health insurance coverage offered in thisstate, an association that:

1. Has been actively in existence for at least 5years;

2. Has been formed and maintained in good faith forpurposes other than obtaining insurance;

3. Does not condition membership in the association onany health status-related factor relating to an individual, including anemployee of an employer or a dependent of an employee;

4. Makes health insurance coverage offered through theassociation available to all of its members regardless of any healthstatus-related factors of the members or other individuals who are eligible forsuch health insurance coverage through a member of the association;

5. Does not make health insurance coverage offeredthrough the association available other than in connection with a member of theassociation; and

6. Meets such additional requirements as may beimposed by specific statute.

(Added to NRS by 1997, 2883)

NRS 689A.490 Churchplan defined. Church plan has the meaningascribed to it in section 3(33) of the Employee Retirement Income Security Actof 1974, as that section existed on July 16, 1997.

(Added to NRS by 1997, 2884)

NRS 689A.495 Controldefined. Control has the meaning ascribed toit in NRS 692C.050.

(Added to NRS by 1997, 2884)

NRS 689A.500 Convertedpolicy defined. Converted policy means abasic or standard health benefit plan issued in accordance with NRS 689B.120 to 689B.210, inclusive, and 689B.590.

(Added to NRS by 1997, 2884; A 2001, 2219)

NRS 689A.505 Creditablecoverage defined. Creditable coveragemeans, with respect to a person, health benefits or coverage provided pursuantto:

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 of UniformedServices, 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 student accident and health insurancepolicy.

(Added to NRS by 1997, 2884; A 1999, 2239, 2802)

NRS 689A.510 Dependentdefined. Dependent has the meaning ascribedto it in NRS 689C.055.

(Added to NRS by 1997, 2884)

NRS 689A.515 Eligibleperson defined. Eligible person means:

1. A person:

(a) Who, as of the date on which he seeks coveragepursuant to this chapter, has an aggregate period of creditable coverage thatis 18 months or more;

(b) Whose most recent prior creditable coverage, otherthan coverage under a short-term health insurance policy, was under a grouphealth plan, governmental plan, church plan or health insurance coverageoffered in connection with any such plan;

(c) Who is not eligible for coverage under a grouphealth plan, Part A or Part B of Title XVIII of the Social Security Act, 42U.S.C. 1395c et seq., also known as Medicare, a state plan pursuant to TitleXIX of the Social Security Act, 42 U.S.C. 1396 et seq., also known asMedicaid, or any successor program, and who does not have any other healthinsurance coverage;

(d) Whose most recent health insurance coverage withinthe period of aggregate creditable coverage was not terminated because of afailure to pay premiums or fraud;

(e) Who has exhausted his continuation of coverageunder the Consolidation Omnibus Budget Reconciliation Act of 1985, Public Law99-272, or under a similar state program, if any; and

(f) Who has not had a break of more than 63 consecutivedays in his creditable coverage.

2. A person whose most recent prior creditablecoverage was under a basic or standard health benefit plan and was not renewedby a carrier who discontinued offering and renewing individual health benefitplans in this state pursuant to NRS689A.630.

3. Notwithstanding the provisions of paragraph (a) ofsubsection 1, a newborn child or a child placed for adoption, if the child wasenrolled timely and would have otherwise met the requirements of an eligibleperson as set forth in subsection 1.

(Added to NRS by 1997, 2884; A 1999, 2803)

NRS 689A.520 Establishedgeographic service area defined. Establishedgeographic service area means a geographic area, as approved by the Commissionerand based on the certificate of authority of the carrier to transact insurancein this state, within which the carrier is authorized to provide coverage.

(Added to NRS by 1997, 2885)

NRS 689A.523 Exclusionfor a preexisting condition defined. Exclusionfor a preexisting condition means:

1. Any limitation or exclusion of benefits relating toa condition that was present before the date coverage was first provided,regardless of whether any medical advice, diagnosis, care or treatment wasrecommended or received before that date; or

2. Any exclusion applicable to an individual based onany information relating to the status of an individuals health that wasobtained before the date coverage was first provided, including, withoutlimitation, any identification of a condition resulting from:

(a) A preenrollment questionnaire or physicalexamination provided to the individual; or

(b) A review of any medical records relating to theperiod of preenrollment.

(Added to NRS by 2005, 2136)

NRS 689A.525 Geographicarea defined. Geographic area means an areaestablished by the Commissioner for use in adjusting the rates for a health benefitplan.

(Added to NRS by 1997, 2885)

NRS 689A.530 Governmentalplan defined. Governmental plan has themeaning ascribed to it in section 3(32) of the Employee Retirement Income SecurityAct of 1974, as that section existed on July 16, 1997, and any health plan ofthe Federal Government.

(Added to NRS by 1997, 2885)

NRS 689A.535 Grouphealth plan defined.

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 infederal 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, 2885)

NRS 689A.540 Healthbenefit plan defined.

1. Health benefit plan means a policy, contract,certificate or agreement offered by a carrier to provide for, deliver paymentfor, arrange for the payment of, pay for or reimburse any of the costs ofhealth care services. Except as otherwise provided in this section, the termincludes catastrophic health insurance policies and a policy that pays on acost-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 Public Law 104-191 under which benefitsfor medical 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. 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 the Health Insurance Portability andAccountability Act of 1996, 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 the 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, 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, 2886; A 1999, 2803)

NRS 689A.545 Healthstatus-related factor defined. Healthstatus-related factor means, with regard to a person who is or seeks to beinsured:

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, 2887)

NRS 689A.550 Individualcarrier defined. Individual carrier meansany entity subject to the provisions of this title and the regulations adoptedpursuant thereto, that contracts or offers to contract to provide for, deliverpayment for, arrange for payment of, pay for, or reimburse any cost of healthcare services, including a sickness and accident health service corporation,and any other entity providing a plan of health insurance, health benefits orhealth services to individuals and their dependents in this state.

(Added to NRS by 1997, 2887)

NRS 689A.555 Individualhealth benefit plan defined. Individualhealth benefit plan means:

1. A health benefit plan for individuals and theirdependents, other than a converted policy or a plan for coverage of a bona fideassociation; and

2. A certificate issued to an individual thatevidences coverage under a policy or contract issued to a trust or anassociation or to any other similar group of persons, other than a plan forcoverage of a bona fide association, regardless of the situs of delivery of thepolicy or contract, if the individual pays the premium and is not being coveredunder the policy or contract pursuant to any provision for the continuation ofbenefits applicable under federal or state law.

(Added to NRS by 1997, 2887)

NRS 689A.560 Individualreinsuring carrier defined. Individual reinsuringcarrier means an individual carrier that is eligible to reinsure eligiblepersons in the Program of Reinsurance established pursuant to NRS 689C.610 to 689C.980, inclusive.

(Added to NRS by 1997, 2887)

NRS 689A.565 Individualrisk-assuming carrier defined. Individualrisk-assuming carrier means an individual carrier that has elected to act as arisk-assuming carrier.

(Added to NRS by 1997, 2888)

NRS 689A.570 Planfor coverage of a bona fide association defined. Planfor coverage of a bona fide association means a health benefit plan for themembers, and their dependents, of a bona fide association in this stateregardless of the situs of delivery of the policy or contract, if the healthbenefit plan conforms with NRS 689A.725.

(Added to NRS by 1997, 2888)

NRS 689A.575 Planof operation defined. Plan of operationmeans the plan of operation of the Program of Reinsurance established pursuantto NRS 689C.610 to 689C.980, inclusive.

(Added to NRS by 1997, 2888)

NRS 689A.580 Plansponsor defined. Plan sponsor has themeaning ascribed to it in section 3(16)(B) of the Employee Retirement SecurityAct of 1974, as that section existed on July 16, 1997.

(Added to NRS by 1997, 2888)

NRS 689A.585 Preexistingcondition defined. Preexisting conditionmeans a condition, regardless of the cause of the condition, for which medicaladvice, diagnosis, care or treatment was recommended or received during the 6months preceding the effective date of the new coverage. The term does notinclude genetic information in the absence of a diagnosis of the conditionrelated to such information.

(Added to NRS by 1997, 2888)

NRS 689A.590 Producerdefined. Producer means an agent or brokerlicensed pursuant to this Title.

(Added to NRS by 1997, 2888)

NRS 689A.595 Programof Reinsurance defined. Program of Reinsurancemeans the Program of Reinsurance for Small Employers and Eligible Personsestablished pursuant to NRS 689C.740.

(Added to NRS by 1997, 2888)

NRS 689A.600 Provisionfor a restricted network defined. Provisionfor a restricted network means any provision of a health benefit plan thatconditions the payment of benefits, in whole or in part, on the use of aprovider of health care that has entered into a contractual arrangement with anindividual carrier to provide health care services to individuals covered bythe plan.

(Added to NRS by 1997, 2888)

NRS 689A.605 Standardhealth benefit plan defined. Standard healthbenefit plan means a standard health benefit plan developed pursuant to NRS 689C.610 to 689C.980, inclusive.

(Added to NRS by 1997, 2888)

NRS 689A.610 Applicability;ceding arrangement prohibited in certain circumstances.

1. NRS 689A.470 to 689A.740, inclusive, apply to:

(a) Any health benefit plan that must be made availableto eligible persons; and

(b) Any certificate issued to a trust or an associationor other similar groupings of persons for coverage of eligible persons,

regardlessof the location of delivery of the policy or certificate, if the eligibleperson pays the premium and is not otherwise covered under the policy orcontract pursuant to any federal or state law relating to the continuation ofbenefits.

2. For the purposes of NRS 689A.470 to 689A.740, inclusive, and except asotherwise provided in subsection 3, two or more individual carriers which areaffiliated companies or which are eligible to file a consolidated tax returnshall be deemed to be one individual carrier, and any restriction or limitationimposed by NRS 689A.470 to 689A.740, inclusive, applies as if allhealth benefit plans delivered or issued for delivery to eligible persons inthis State by the affiliated individual carriers were issued by one individualcarrier.

3. An affiliated individual carrier that is a healthmaintenance organization having a certificate of authority issued pursuant tothe provisions of chapter 695C of NRS may beconsidered a separate individual carrier for the purposes of NRS 689A.470 to 689A.740, inclusive.

4. Unless otherwise authorized by the Commissioner, anindividual carrier shall not enter into any ceding arrangement with respect toa health benefit plan delivered or issued for delivery to any eligible personin this State if the ceding arrangement would result in the ceding individualcarrier retaining less than 30 percent of the insurance obligations or risks forthat health benefit plan.

(Added to NRS by 1997, 2888)

NRS 689A.615 Certainplan, fund or program to be treated as employee welfare benefit plan which isgroup health plan; partnership deemed employer of each partner. For the purposes of NRS689A.470 to 689A.740, inclusive:

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 to current or former partnersin the partnership or to their dependents, as defined under the terms of theplan, fund or program, directly or through insurance, reimbursement orotherwise, must be treated, subject to subsection 2, as an employee welfarebenefit plan which 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, 2889)

NRS 689A.620 Certainperson with break in coverage deemed eligible person. Aperson who meets the requirements to be an eligible person as set forth in NRS 689A.515, except that the person hada break in creditable coverage of more than 63 days, shall be deemed to be an eligibleperson and is eligible to obtain health insurance coverage pursuant to thischapter as an eligible person if the person seeks that coverage between January1, 1998, and January 31, 1998, inclusive.

(Added to NRS by 1997, 2889)

NRS 689A.625 Supplementalcoverage not health benefit plan if individual carrier files annualcertification with Commissioner. Supplementalcoverage is not a health benefit plan if:

1. On or before March 1 of each year, the individualcarrier files a certification with the Commissioner which contains:

(a) A statement from the individual carrier certifyingthat the policies or certificates described are being offered and marketed assupplemental health insurance and not as a substitute for hospital or medicalexpense insurance or major medical expense insurance; and

(b) A summary description of each policy or certificatedescribed, including the average annual premium rates, or range of premiumrates for cases in which premiums vary by age, sex or other factors, charged forthe policies and certificates in this state.

2. In the case of a policy or certificate that isoffered for the first time in this state on or after January 1, 1998, theindividual carrier files with the Commissioner the statement and summarydescription required by subsection 1 at least 30 days before the date on whichthe policy or certificate is issued or delivered in this state.

(Added to NRS by 1997, 2890)

Individual Carriers

NRS 689A.630 Requirementto renew coverage at option of individual; exceptions; discontinuation of formof product of health benefit plan; discontinuation of health benefit planavailable through bona fide association.

1. Except asotherwise provided in this section, coverage under an individual health benefitplan must be renewed by the individual carrier that issued the plan, at theoption of the individual, unless:

(a) The individual has failed to pay premiums orcontributions in accordance with the terms of the health benefit plan or theindividual carrier has not received timely premium payments.

(b) The individual 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 individual carrier decides to discontinue offeringand renewing all health benefit plans delivered or issued for delivery in thisstate. If the individual carrier decides to discontinue offering and renewingsuch plans, the individual carrier shall:

(1) Provide notice of its intention to the Commissionerand the chief regulatory officer for insurance in each state in which theindividual carrier is licensed to transact insurance at least 60 days beforethe date on which notice of cancellation or nonrenewal is delivered or mailedto the persons covered by the insurance to be discontinued pursuant tosubparagraph (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 thenonrenewal of any health benefit plan by the individual carrier.

(3) Discontinue all health insurance issued ordelivered for issuance for individuals in this state and not renew coverageunder any health benefit plan issued to such individuals.

(d) The Commissioner finds that the continuation of thecoverage in this state by the individual carrier would not be in the bestinterests of the policyholders or certificate holders of the individual carrieror would impair the ability of the individual carrier to meet its contractualobligations. If the Commissioner makes such a finding, the Commissioner shallassist the persons covered by the discontinued insurance in this state infinding replacement coverage.

2. An individual carrier may discontinue the issuanceand renewal of a form of a product of a health benefit plan if the Commissionerfinds that the form of the product offered by the individual carrier isobsolete and is being replaced with comparable coverage. A form of a product ofa health benefit plan may be discontinued by the individual carrier pursuant tothis subsection only if:

(a) The individual carrier notifies the Commissionerand the chief regulatory officer for insurance in each state in which it islicensed of its decision pursuant to this subsection to discontinue theissuance and renewal of the form of the product at least 60 days before theindividual carrier notifies the persons covered by the discontinued insurancepursuant to paragraph (b).

(b) The individual carrier notifies each person coveredby the discontinued insurance, the Commissioner and the chief regulatoryofficer for insurance in each state in which a person covered by thediscontinued insurance is known to reside of the decision of the individualcarrier to discontinue offering the form of the product. The notice must bemade to persons covered by the discontinued insurance at least 180 days beforethe date on which the individual carrier will discontinue offering the form ofthe product.

(c) The individual carrier offers to each personcovered by the discontinued insurance the option to purchase any other healthbenefit plan currently offered by the individual carrier to individuals in thisstate.

(d) In exercising the option to discontinue the form ofthe product and in offering the option to purchase other coverage pursuant toparagraph (c), the individual carrier acts uniformly without regard to theclaim experience of the persons covered by the discontinued insurance or anyhealth status-related factor relating to those persons or beneficiaries coveredby the discontinued form of the product or any persons or beneficiaries who maybecome eligible for such coverage.

3. An individual carrier may discontinue the issuanceand renewal of a health benefit plan that is made available to individualspursuant to this chapter only through a bona fide association if:

(a) The membership of the individual in the associationwas the basis for the provision of coverage;

(b) The membership of the individual in the associationceases; and

(c) The coverage is terminated pursuant to thissubsection uniformly without regard to any health status-related factorrelating to the covered individual.

4. An individual carrier that elects not to renew ahealth benefit plan pursuant to paragraph (c) of subsection 1 shall not writenew business for individuals pursuant to this chapter for 5 years after thedate on which notice is provided to the Commissioner pursuant to subparagraph(2) of paragraph (c) of subsection 1.

5. If an individual carrier does business in only oneestablished geographic service area of this state, the provisions of thissection apply only to the operations of the individual carrier in that servicearea.

(Added to NRS by 1997, 2890)

NRS 689A.635 Coverageoffered through network plan not required to be offered to eligible person whodoes not reside or work in established geographic service area.

1. An individualcarrier that offers coverage through a network plan is not required pursuant toNRS 689A.630 to offer coverage to oraccept an application from an eligible person if the eligible person does notreside or work in the established geographic service area or in a geographicarea for which the individual carrier is authorized to transact insurance,provided that the coverage is refused or terminated uniformly without regard toany health status-related factor of any eligible person.

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 is provided, in whole or in part, through a definedset of providers under contract with the carrier. The term does not include anarrangement for the financing of premiums.

(Added to NRS by 1997, 2892)

NRS 689A.637 Coverageoffered through plan that provides for restricted network: Contracts withcertain federally qualified health centers.

1. An individual carrier that offers a health benefitplan that includes a provision for a restricted network shall use its bestefforts to contract with at least one health center in each establishedgeographic service area to provide health care services to persons covered bythe plan 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, health center has themeaning ascribed to it in 42 U.S.C. 254b.

(Added to NRS by 2001, 1922)

NRS 689A.640 Eachhealth benefit plan marketed in this State required to be offered to eligiblepersons.

1. As a conditionof transacting insurance in this State with individuals, an individual carriermust actively market to eligible persons each health benefit plan that isactively marketed in this State by the individual carrier to any individual inthis State. The health insurance plans marketed pursuant to this section by anindividual carrier must include, without limitation, a basic health benefitplan and a standard health benefit plan.

2. An individual carrier shall issue to an eligibleperson any basic or standard individual health benefit plan that it markets inaccordance with subsection 1 if the eligible person applies for the plan andagrees to make the required premium payments and satisfy the other reasonableprovisions of the health benefit plan that are not inconsistent with NRS 689A.470 to 689A.740, inclusive.

(Added to NRS by 1997, 2892)

NRS 689A.645 Coverageto eligible person who does not reside in established geographic service areanot required; coverage within certain areas not required. An individual carrier is not required pursuant to NRS 689A.640 to offer coverage to oraccept an application for coverage:

1. From an eligible person if he does not reside inthe established geographic service area of the individual carrier.

2. Within an area where the individual carrierreasonably anticipates, and demonstrates to the satisfaction of theCommissioner, that the individual carrier does not have the capacity within itsestablished geographic service area to deliver adequate service to additionaleligible persons because of its obligations to existing policyholders. If anindividual carrier is authorized by the Commissioner not to offer coveragepursuant to this subsection, the individual carrier shall not thereafter offercoverage in the applicable area to additional eligible persons until theindividual carrier demonstrates to the satisfaction of the Commissioner that ithas regained the capacity to deliver adequate service to additional eligiblepersons in that service area.

(Added to NRS by 1997, 2893)

NRS 689A.650 Coverageto eligible persons not required under certain circumstances; notice toCommissioner of and prohibition on writing new business after election not tooffer new coverage required.

1. An individualcarrier is not required to provide coverage to eligible persons pursuant to NRS 689A.640:

(a) During any period in which the Commissionerdetermines that requiring the individual carrier to provide such coverage wouldplace the individual carrier in a financially impaired condition.

(b) If the individual carrier elects not to offer anynew coverage to any persons in this State. An individual carrier that electsnot to offer new coverage in accordance with this paragraph may maintain itsexisting policies issued to persons in this State, subject to the requirementsof NRS 689A.630.

2. An individual carrier that elects not to offer newcoverage pursuant to paragraph (b) of subsection 1 shall notify theCommissioner forthwith of that election and shall not thereafter write any newbusiness to individuals in this State for 5 years after the date of thenotification.

(Added to NRS by 1997, 2893; A 1999, 2805)

NRS 689A.655 Requirementto file basic and standard health benefit plans with Commissioner; disapprovalof plan.

1. Eachindividual carrier shall file with the Commissioner within 90 days after thedate on which a basic health benefit plan and a standard health benefit planare approved pursuant to NRS 689C.770,or for a new individual carrier within 90 days after the date it enters theindividual market in this State, in a format and manner prescribed by theCommissioner, the basic health benefit plans and the standard health benefitplans to be offered by the individual carrier. A health benefit plan filedpursuant to this section may not be offered by an individual carrier until theearlier of:

(a) The date of approval by the Commissioner; or

(b) Thirty days after the date on which the plans arefiled, unless the Commissioner disapproves the use of the plans before the30-day period expires.

2. The Commissioner may, at any time, after providingnotice and an opportunity for a hearing, disapprove the continued use of abasic or standard health benefit plan by the individual carrier on the groundthat the plan does not meet the requirements of NRS 689A.470 to 689A.740, inclusive, and 689C.610 to 689C.980, inclusive.

(Added to NRS by 1997, 2892)

NRS 689A.660 Prohibitedacts concerning preexisting conditions and modification of health benefit plan. An individual carrier shall not:

1. Impose on an eligible person who is covered under abasic or standard health benefit plan any exclusion because of a preexistingcondition.

2. Modify a health benefit plan, with respect to aneligible person, through riders, endorsements or otherwise, to restrict orexclude services otherwise covered by the plan.

(Added to NRS by 1997, 2893; A 1999, 2805)

NRS 689A.665 Certainhealth carriers not required to offer health benefit insurance coverage toindividuals. Nothing in NRS 689A.640 to 689A.660, inclusive, requires a healthcarrier that offers a health benefit plan only in connection with a grouphealth plan or through a bona fide association, or both, to offer such healthbenefit insurance coverage to individuals.

(Added to NRS by 1997, 2893)

NRS 689A.670 Electionto operate as individual risk-assuming carrier or individual reinsuringcarrier: Notice to Commissioner; effective date; change in status.

1. Within 30 daysafter the date on which a plan of operation is approved by the Commissionerpursuant to NRS 689C.770, or for a newcarrier within 30 days after the date on which it enters the individual marketin this state, an individual carrier shall elect to operate as either anindividual risk-assuming carrier or an individual reinsuring carrier and shallnotify the Commissioner of its election.

2. The initial election of an individual carrier toact as an individual risk-assuming or reinsuring carrier is effective on theindividual carrier for 2 years after the date on which it notifies theCommissioner pursuant to subsection 1. After the initial 2-year period, such anelection is effective for 5 years. The Commissioner may allow an individualcarrier to modify its election at any time for good cause shown. TheCommissioner may waive or modify the period during which the election of acarrier to operate as an individual risk-assuming or reinsuring carrier iseffective.

3. An individual carrier may apply to theCommissioner, in a manner prescribed by the Commissioner by regulation, tochange its status as an individual risk-assuming or reinsuring carrier.

4. An individual reinsuring carrier that elects or issubsequently authorized by the Commissioner to operate as a risk-assumingcarrier:

(a) Shall not continue to reinsure any individualhealth benefit plan with the Program of Reinsurance.

(b) Shall pay a prorated assessment based upon businessissued as an individual reinsuring carrier for any portion of the year that thebusiness was reinsured.

(Added to NRS by 1997, 2893)

NRS 689A.675 Electionto act as individual risk-assuming carrier: Suspension by Commissioner;applicable statutes.

1. TheCommissioner may suspend the election of an individual carrier to act as anindividual risk-assuming carrier, if the Commissioner finds that:

(a) The financial condition of the individual carrierno longer supports the assumption of risk from issuing coverage to eligiblepersons in compliance with NRS 689A.640to 689A.660, inclusive, without theprotection afforded by the Program of Reinsurance;

(b) The individual carrier has failed to market itshealth benefit plans fairly to all eligible persons in this state or in itsestablished geographic service area, as applicable; or

(c) The individual carrier has failed to providecoverage to eligible persons as required pursuant to NRS 689A.640 to 689A.660, inclusive.

2. An individual carrier that elects to become anindividual risk-assuming carrier is subject to:

(a) The provisions of NRS 689A.640 to 689A.660, inclusive, relating to theavailability of coverage; and

(b) The provisions of NRS 689A.680 to 689A.700, inclusive, relating to premiumrates.

(Added to NRS by 1997, 2894)

NRS 689A.680 Ratesfor individual health benefit plans to be developed based on ratingcharacteristics: Prohibited characteristics; health status as rating factor.

1. An individualcarrier shall develop its rates for its individual health benefit planspursuant to NRS 689A.470 to 689A.740, inclusive, based on ratingcharacteristics. After any adjustments for rating characteristics and design ofbenefits, the rate for any block of business for an individual health benefitplan written on or after January 1, 2000, must not exceed the rate for anyother block of business for an individual health benefit plan offered by theindividual carrier by more than 50 percent. The rate for a block of business isequal to the average rate charged to all the insureds in the block of business.In determining whether the rate of a block of business complies with theprovisions of this subsection, any differences in rating factors between blocksof business must be considered.

2. In determining the rating factors to establishpremium rates for a health benefit plan, an individual carrier shall not usecharacteristics other than age, sex, occupation, geographic area, compositionof the family of the individual and health status.

3. If an individual carrier uses health status as a ratingfactor in establishing premium rates, the highest factor associated with anyclassification for health status may not exceed the lowest factor by more than75 percent.

4. For the purposes of this section, ratingcharacteristics must not include durational or tier rating, or adverse changesin health status or claim experience after the policy is issued.

5. As used in this section, characteristics meansdemographic or other information concerning individuals that is considered by acarrier in the determination of premium rates for individuals.

(Added to NRS by 1997, 2894; A 1999, 2805)

NRS 689A.685 Amountof change in rate of single block of business; plan with provision forrestricted network; involuntary transfer of individual or dependent prohibited;premiums adjusted for block of business.

1. The amount ofchange in the rate of a single block of business of an individual carrier inany 12-month period because of claims experience or health status-relatedfactors of that block of business, after adjustment for allowed rating characteristicsand design of benefits, must not exceed the amount of any similar change in therate of any other block of business of that individual carrier during the sameperiod by more than 15 percent.

2. For the purposes of NRS 689A.470 to 689A.740, inclusive, a health benefitplan that contains a provision for a restricted network must not be consideredto be a similar design of benefits when compared to a health benefit plan thatdoes not contain such a provision if the restriction of benefits to the networkproviders results in substantial differences in the cost of claims.

3. An individual carrier shall not transfer anindividual or his dependent covered by an individual health benefit plan issuedby the individual carrier involuntarily into or out of a block of business.

4. If an individual carrier adjusts its premiums for ablock of business to a level that is higher than permitted by requirementsrelating to the ratio of losses, as set forth in this Title and the regulationsadopted pursuant thereto, to comply with this section and NRS 689A.680, the individual carriershall make such adjustments on its entire individual health benefit planbusiness as needed to meet those requirements.

(Added to NRS by 1997, 2895)

NRS 689A.690 Informationrequired to be disclosed as part of solicitation and sales materials;information required to be maintained at place of business; actuarialcertification required to be filed with Commissioner.

1. As part of itssolicitation and sales materials for an individual health benefit plan, anindividual carrier shall disclose, to the extent reasonable:

(a) The extent to which premium rates for an individualand his dependent are established or adjusted based upon ratingcharacteristics;

(b) The right of the individual carrier to changepremium rates and the factors, other than claims experience, that may affectchanges in premium rates;

(c) Any provisions in the individual health benefitplan relating to the renewability of the plan; and

(d) Any provisions in the individual health benefitplan relating to an exclusion for a preexisting condition.

2. For the purposes of this section, an individualcarrier shall maintain at its principal place of business a complete anddetailed description of its rating practices and underwriting practices,including information and documentation that demonstrate that its ratingmethods and practices are based upon commonly accepted actuarial assumptionsand are in accordance with sound actuarial principles.

3. On or before March 1 of each year, an individualcarrier shall file with the Commissioner an actuarial certification that theindividual carrier is in compliance with NRS689A.680 to 689A.700, inclusive,and that the rating methods of the individual carrier are actuarially sound.The certification must be in such a form and must contain such information asspecified by the Commissioner. A copy of the certification must be retained bythe individual carrier at its principal place of business.

4. As used in this section, actuarial certificationmeans a written statement signed by a member of the American Academy ofActuaries or any other person acceptable to the Commissioner that an individualcarrier is in compliance with the provisions of NRS 689A.680 to 689A.700, inclusive, based upon anexamination conducted by the person which included a review of the appropriaterecords and the actuarial assumptions and methods used by the individualcarrier in establishing premium rates for applicable health benefit plans.

(Added to NRS by 1997, 2895)

NRS 689A.695 Informationand documents to be made available to Commissioner; proprietary information. An individual carrier shall make the information anddocuments described in NRS 689A.680 to689A.700, inclusive, available to theCommissioner upon request. Except in cases of violations of the provisions ofthis chapter, the information, other than the premium rates charged by theindividual carrier, is proprietary, constitutes a trade secret and is notsubject to disclosure by the Commissioner to persons outside of the Divisionexcept as agreed to by the individual carrier or as ordered by a court ofcompetent jurisdiction.

(Added to NRS by 1997, 2896)

NRS 689A.700 Regulationsregarding rates. The Commissioner may adoptregulations to carry out the provisions of NRS689A.680 to 689A.700, inclusive,and to ensure that the practices used by individual carriers relating to theestablishment of rates are consistent with the purposes of NRS 689A.470 to 689A.740, inclusive, including, but notlimited to, determining the manner in which geographic areas are designated byall individual carriers.

(Added to NRS by 1997, 2895)

NRS 689A.705 Regulationsconcerning reissuance of health benefit plan. TheCommissioner may adopt regulations to require an individual carrier, as a conditionof transacting business with individuals in this state after July 16, 1997, toreissue a health benefit plan to any individual whose health benefit plan hasbeen terminated or not renewed by the individual carrier after July 1, 1997.The Commissioner may prescribe such terms for the reissue of coverage as hefinds are reasonable and necessary to provide continuity of coverage toindividuals.

(Added to NRS by 1997, 2897)

NRS 689A.710 Prohibitedacts; denial of application for coverage; regulations; violation may constituteunfair trade practice; applicability of section.

1. Except asotherwise provided in this section, an individual carrier or a producer shallnot, directly or indirectly:

(a) Encourage or direct an eligible person to refrainfrom filing an application for coverage with an individual carrier because ofthe health status, claims experience, industry, occupation or geographiclocation of the eligible person.

(b) Encourage or direct an eligible person to seek coveragefrom another carrier because of the health status, claims experience, industry,occupation or geographic location of the eligible person.

2. The provisions of subsection 1 do not apply toinformation provided to an eligible person by an individual carrier or aproducer relating to the established geographic service area or a provision fora restricted network of the individual carrier.

3. Except as otherwise provided in this subsection, anindividual carrier shall not, directly or indirectly, enter into any contract,agreement or arrangement with a producer if the contract, agreement orarrangement provides for or results in a variation to the compensation paid toa producer for the sale of a health benefit plan because of the health status,claims experience, industry, occupation or geographic location of theindividual at the time that the health benefit plan is issued to or renewed bythe individual. The provisions of this subsection do not apply to any arrangementfor compensation that provides payment to a producer on the basis of apercentage of premiums, except that the percentage may not vary because of thehealth status, claims experience, industry, occupation or geographic area ofthe individual.

4. An individual carrier shall not terminate, fail torenew, or limit its contract or agreement of representation with a producer forany reason related to the health status, claims experience, industry,occupation or geographic location of an individual at the time that the healthbenefit plan is issued to or renewed by the individual placed by the producerwith the individual carrier.

5. A denial by an individual carrier of an applicationfor coverage from an eligible person must be in writing and must state thereason for the denial.

6. The Commissioner may adopt regulations that setforth additional standards to provide for the fair marketing and broadavailability of health benefit plans to eligible persons in this state.

7. A violation of any provision of this section by anindividual carrier may constitute an unfair trade practice for the purposes of chapter 686A of NRS.

8. The provisions of this section apply to athird-party administrator if the third-party administrator enters into acontract, agreement or other arrangement with an individual carrier to provideadministrative, marketing or other services related to the offering of a healthbenefit plan to eligible persons in this state.

9. Nothing in this section interferes with the rightand responsibility of a broker to advise and represent the best interests of aneligible person who is seeking health insurance coverage from an individualcarrier.

(Added to NRS by 1997, 2896)

Individual Health Insurance Coverage

NRS 689A.715 Requirementsfor employee welfare benefit plan for providing benefits for employees of morethan one employer.

1. An employeewelfare benefit plan for providing benefits for employees of more than oneemployer under which individual health insurance coverage is provided mustcomply with the provisions of NRS 679B.139and 689A.470 to 689A.740, inclusive, and the regulationsadopted by the Commissioner pursuant thereto.

2. As used in this section, the term employee welfarebenefit plan for providing benefits for employees of more than one employer isintended to be equivalent to the term employee welfare benefit plan which is amultiple employer welfare arrangement as used in federal statutes andregulations.

(Added to NRS by 1997, 2890)

NRS 689A.720 Writtencertification of coverage required for determining period of creditablecoverage accumulated by person; provision of certificate to insured.

1. To determinethe period of creditable coverage of a person, a health insurance issueroffering individual health insurance coverage shall provide written certificationof coverage on a form prescribed by the Commissioner to the person thatcertifies:

(a) The period of creditable coverage of the personunder the individual health insurance coverage; and

(b) The date that a substantially completed applicationwas received by the health insurance issuer from the person for individualhealth insurance coverage.

2. The certification of coverage must be provided tothe insured:

(a) At the time that the insured ceases to be coveredunder the individual health insurance coverage or otherwise becomes coveredunder any provision of the Consolidated Omnibus Budget Reconciliation Act of1985, as that act existed on July 16, 1997, relating to the continuation ofcoverage;

(b) If the insured becomes covered under such aprovision, at the time that the insured ceases to be covered by that provision;and

(c) Upon the request of the insured, if the request ismade not later than 24 months after the date on which the insured ceased to becovered as described in paragraphs (a) and (b).

(Added to NRS by 1997, 2897)

Bona Fide Associations

NRS 689A.725 Requirementsfor plan for coverage. For the purposes of NRS 689A.470 to 689A.740, inclusive, a plan for coverageof a bona fide association must:

1. Conform with NRS689A.680 to 689A.700, inclusive,concerning rates.

2. Provide for the renewability of coverage formembers of the bona fide association, and their dependents, if such coveragemeets the criteria set forth in NRS689A.630.

3. Provide for the availability of coverage formembers of the bona fide association, and their dependents, if such coverageconforms with NRS 689A.640, exceptthat the bona fide association is not required to offer basic and standardhealth benefit plan coverage to its members or their dependents.

4. Conform with subsection 1 of NRS 689A.660, relating to preexistingconditions.

(Added to NRS by 1997, 2889)

NRS 689A.730 Producermay only sign up eligible persons if eligible persons are actively engaged inor related to association. For the purposes ofproviding coverage under a health benefit plan pursuant to the provisions of NRS 689A.470 to 689A.740, inclusive, a producer may onlymarket association memberships to eligible persons, accept applications forsuch membership, or sign up such members in a bona fide association if theeligible persons being marketed are actively engaged in, or directly relatedto, the bona fide association.

(Added to NRS by 1997, 2889)

Miscellaneous Provisions

NRS 689A.735 Reportto Commissioner by trustee of medical savings account.On or before July 1 of each year, a trustee of a medical savingsaccount established and maintained in accordance with 26 U.S.C. 220 shallreport to the Commissioner the number of medical savings accounts administeredby the trustee during the previous calendar year.

(Added to NRS by 1997, 2899)

NRS 689A.740 Regulations. The Commissioner shall adopt regulations as necessary tocarry out the provisions of NRS 689A.470to 689A.740, inclusive.

(Added to NRS by 1997, 2896)

SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS

NRS 689A.745 Approval;requirements; examination.

1. Except as otherwise provided in subsection 4, eachinsurer that issues a policy of health insurance in this State shall establisha system for resolving any complaints of an insured concerning health careservices 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 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 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 those healthcare services that complies with the provisions of NRS 695G.200 to 695G.310, inclusive.

(Added to NRS by 1997, 307; A 2003, 774)

NRS 689A.750 Annualreport; insurer to maintain records of complaints concerning something otherthan health care services.

1. Each insurerthat issues a policy of health insurance in this State shall submit to theCommissioner and the State Board of Health an annual report regarding itssystem for resolving complaints established pursuant to subsection 1 of NRS 689A.745 on a form prescribed by theCommissioner in consultation with the State Board of Health which includes,without limitation:

(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, 308; A 2003, 774)

NRS 689A.755 Writtennotice to insured explaining right to file complaint; notice to insuredrequired when insurer denies coverage of health care service.

1. Followingapproval by the Commissioner, each insurer that issues a policy of healthinsurance in this State shall provide written notice to an insured, in clearand comprehensible language that is understandable to an ordinary layperson,explaining the right of the insured to file a written complaint. Such noticemust be provided to an insured:

(a) At the time he receives his 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 a healthcare service to an insured, including, without limitation, denying a claimrelating to a policy of health insurance pursuant to NRS 689A.410, it shall notify the insuredin writing within 10 working days after it denies coverage of the health careservice of:

(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, 308; A 1999, 3082)

 

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