2005 Nevada Revised Statutes - Chapter 695B — Nonprofit Corporations for Hospital, Medical and Dental Service
CHAPTER 695B - NONPROFIT CORPORATIONS FORHOSPITAL, MEDICAL AND DENTAL SERVICE
GENERAL PROVISIONS
NRS 695B.010 Shorttitle.
NRS 695B.020 Scope.
NRS 695B.030 Definitions.
NRS 695B.035 Contractbetween corporation and provider of health care: Prohibiting corporation fromcharging provider of health care fee for inclusion on list of providers givento insureds; form for obtaining information on provider of health care; modification;schedule of fees.
ORGANIZATION
NRS 695B.040 Corporationsauthorized to undertake and operate plans.
NRS 695B.050 Mannerof incorporation.
NRS 695B.060 Directors:Qualifications.
NRS 695B.070 Mergerand consolidation: Procedure.
NRS 695B.080 Mergerand consolidation: Continuance of contracts and contribution certificates.
NRS 695B.090 Mergerand consolidation: Withdrawal of prior deposit of securities.
LICENSING; REGULATION
NRS 695B.110 Certificateof authority required; fees.
NRS 695B.120 Certificateof authority: Qualifications.
NRS 695B.130 Certificateof authority: Application; issuance.
NRS 695B.135 Certificateof authority: Expiration; renewal.
NRS 695B.140 Reservefund: Minimum amounts; computation; contracts with hospitals; participation ofphysicians.
NRS 695B.150 Insolvency;determination of financial condition.
NRS 695B.160 Annualstatement of condition and affairs; annual fees; examination by Commissioner.
NRS 695B.170 Acquisitioncosts and administrative expenses; effect of finding of excess costs.
NRS 695B.172 Summaryof coverage: Contents of disclosure; approval by Commissioner.
NRS 695B.174 Summaryof coverage: Copy to be provided before policy issued; policy not to be offeredunless summary approved by Commissioner.
NRS 695B.176 Coveragefor prescription drugs: Provision of notice and information regarding use offormulary.
CONTRACTS
NRS 695B.180 Requiredprovisions.
NRS 695B.181 Provisionin contract requiring binding arbitration authorized; procedures forarbitration; declaratory relief.
NRS 695B.182 Requiredprocedure for arbitration of disputes concerning independent medicalevaluations.
NRS 695B.185 Limitationson deductibles and copayments charged under group contract which offersdifference of payment between preferred providers of health care and providerswho are not preferred.
NRS 695B.187 Groupcontract issued to replace discontinued policy or coverage: Requirements;notice of reduction of benefits; statement of benefits; applicability toself-insured employer.
NRS 695B.189 Continuationof coverage under group contract: Required provision.
NRS 695B.190 Familycontracts.
NRS 695B.1901 Requiredprovision concerning coverage for continued medical treatment.
NRS 695B.1903 Requiredprovision concerning coverage for treatment as part of clinical trial or study.
NRS 695B.1905 Requiredprovision concerning coverage for prescription drug previously approved formedical condition of insured.
NRS 695B.1907 Requiredprovision concerning coverage for screening for colorectal cancer.
NRS 695B.1908 Requiredprovision concerning coverage for certain drugs for treatment of cancer.
NRS 695B.191 Requiredprovision concerning coverage relating to mastectomy.
NRS 695B.1912 Requiredprovision concerning coverage for cytologic screening tests and mammograms forcertain women.
NRS 695B.1914 Requiredprovision concerning coverage of certain gynecological and obstetrical serviceswithout authorization or referral from primary care physician.
NRS 695B.1916 Requiredprovision concerning coverage of drug or device for contraception and ofhormone replacement therapy in certain circumstances; prohibited actions byinsurer; exceptions.
NRS 695B.1918 Requiredprovision concerning coverage of health care services related to contraceptivesand hormone replacement therapy in certain circumstances; prohibited actions byinsurer; exceptions.
NRS 695B.192 Requiredprovision concerning coverage relating to complications of pregnancy.
NRS 695B.1923 Requiredprovision concerning coverage for treatment of certain inherited metabolicdiseases.
NRS 695B.1927 Requiredprovision concerning coverage for management and treatment of diabetes.
NRS 695B.193 Requiredprovision concerning coverage for newly born and adopted children and childrenplaced for adoption.
NRS 695B.1931 Requiredprovision concerning coverage relating to treatment of temporomandibular joint.
NRS 695B.1938 Requiredprovision concerning coverage for treatment of conditions relating to severemental illness.
NRS 695B.194 Requiredprovision concerning benefits for treatment of abuse of alcohol or drugs.
NRS 695B.1944 Requiredprovision concerning coverage for employee or member on leave without pay asresult of total disability.
NRS 695B.196 Reimbursementfor acupuncture.
NRS 695B.197 Reimbursementfor treatment by licensed psychologist.
NRS 695B.1973 Reimbursementfor treatment by licensed marriage and family therapist.
NRS 695B.1975 Reimbursementfor treatment by licensed associate in social work, social worker, independentsocial worker or clinical social worker.
NRS 695B.198 Reimbursementfor treatment by chiropractor.
NRS 695B.199 Reimbursementfor services provided by certain nurses; prohibited limitations; exception.
NRS 695B.1995 Reimbursementto provider of medical transportation.
NRS 695B.200 Groupcontracts written under master contract: Conditions required for issuance.
NRS 695B.210 Groupmaster service contract: Required provisions.
NRS 695B.220 Blanketservice contracts: Issuance to college, school or school personnel; pupils notto be compelled to accept service.
NRS 695B.225 Policiesof group insurance: Order of benefits.
NRS 695B.230 Filingand approval of forms and schedules of premium rates.
NRS 695B.240 Provisionof group service coverage before approval of forms.
NRS 695B.250 Extensionsof time; automatic approval.
NRS 695B.2505 Approvalor denial of claims; payment of claims and interest; requests for additionalinformation; award of costs and attorneys fees; compliance with requirements.
CONVERSION OF GROUP CONTRACTS TO INDIVIDUAL CONTRACTS
NRS 695B.251 Groupsubscriber contracts to contain provision for conversion to individualcontracts; exceptions.
NRS 695B.252 Conversionprivilege available to spouse and children; conditions.
NRS 695B.253 Denialof converted contract because of overinsurance; notice concerning cancellationof other coverage.
NRS 695B.254 Choiceof types of contracts must be offered.
NRS 695B.255 Benefitsexceeding those provided under group contract not required; exclusions andlimitations.
NRS 695B.2555 Benefitspayable under converted contract may be reduced by amount payable under groupcontract.
NRS 695B.256 Issuanceand effective date of converted contract; premiums; persons covered.
NRS 695B.2565 Renewalof converted contract: Request for information on sources of other benefits;grounds for refusal to renew; notice concerning cancellation of other coverage.
NRS 695B.257 Noticeof conversion privilege.
NRS 695B.2575 Convertedcontract delivered outside Nevada: Form.
NRS 695B.258 Extensionof coverage under existing group contract.
NRS 695B.2585 Groupcoverage may be provided in lieu of converted individual contract.
NRS 695B.259 Medicalservice corporation may continue identical coverage in lieu of convertingcontract.
MISCELLANEOUS PROVISIONS
NRS 695B.260 Suspensionor revocation of permission to provide coverage before approval of forms.
NRS 695B.270 Disapprovalof forms; issuance unlawful.
NRS 695B.280 Regulations;limitations.
NRS 695B.285 Useof Uniform Billing and Claims Forms authorized.
NRS 695B.290 Agentslicense required.
NRS 695B.300 Contractswith agencies or political subdivisions of United States or State of Nevada;acceptance of money; subcontracts.
NRS 695B.310 Corporationsubject to same fees, licenses and supervision as domestic mutual insurer.
NRS 695B.315 Insurerto provide certain information regarding renewal of insurance policy uponrequest; fee.
NRS 695B.316 Corporationprohibited from denying coverage solely because person was victim of domesticviolence.
NRS 695B.3165 Corporationprohibited from denying coverage solely because insured was intoxicated orunder the influence of controlled substance; exceptions. [Effective July 1,2006.]
NRS 695B.317 Corporationthat provides health insurance prohibited from requiring or using informationconcerning genetic testing; exceptions.
NRS 695B.318 Corporationsare subject to certain provisions concerning portability and availability ofhealth insurance.
NRS 695B.319 Offeringpolicy of health insurance for purposes of establishing health savings account.
NRS 695B.320 Applicabilityof other provisions.
ELIGIBILITY FOR COVERAGE
NRS 695B.330 Definitions.
NRS 695B.340 Effectof eligibility for medical assistance under Medicaid; assignment of rights tostate agency.
NRS 695B.350 Corporationprohibited from asserting certain grounds to deny enrollment of child ofinsured pursuant to order.
NRS 695B.360 Certainaccommodations to be made when child is covered under policy of noncustodialparent.
NRS 695B.370 Corporationto authorize enrollment of child of parent who is required by order to providemedical coverage under certain circumstances; termination of coverage of child.
SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS
NRS 695B.380 Approval;requirements; examination.
NRS 695B.390 Annualreport; insurer to maintain records of complaints concerning something otherthan health care services.
NRS 695B.400 Writtennotice to insured explaining right to file complaint; notice to insuredrequired when insurer denies coverage of health care service.
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GENERAL PROVISIONS
NRS
(Added to NRS by 1971, 1863)
1. This chapter does not:
(a) Apply to or govern any corporation which is organizedfor profit, which contemplates any pecuniary gain to its shareholders ormembers, or which conducts or is authorized by its articles of incorporation toconduct any business whatsoever on a profit basis.
(b) Authorize and must not be construed to authorize,directly or indirectly, any corporation to operate a hospital or a medical ordental service plan on a profit basis.
2. Except as otherwise provided in subsection 3, acorporation subject to the provisions of this chapter shall not own or operateany hospital or engage in any business other than that of establishing,maintaining and operating a nonprofit hospital, medical or dental service plan.
3. A corporation subject to the provisions of thischapter may, with the approval of the Commissioner, engage in any businessreasonably and necessarily incidental to the business of a nonprofit hospital,medical or dental service plan.
(Added to NRS by 1971, 1863; A 1991, 654)
NRS
1. Dental services means general and special dentalservices ordinarily provided by dentists licensed under the provisions of
2. Hospital services means the furnishing orproviding of any or all of the following:
(a) Maintenance and care in the hospital, including butnot limited to, nursing care, drugs, medicines, supplies, physiotherapy,transportation and use of facilities and appliances.
(b) Reimbursement of the beneficiary or subscriber for,but without requiring that he first pay, expenses incurred for any of the itemsincluded in paragraph (a).
(c) Reimbursement, at a uniform rate, of thebeneficiary or subscriber for, but without requiring that he first pay, thecosts and expenses incurred for medical supplies.
(d) Reimbursement for expenses incurred outside of thehospital for continued care and treatment following the subscribers dischargefrom the hospital, for nursing service, necessary appliances, drugs, medicines,supplies and any other services which would have been available in the hospital(excluding physicians services), whether or not provided through a hospital.
(e) Reimbursement for ambulance service expenses.
3. Medical services means the furnishing orproviding of any or all of the following:
(a) Medical or surgical services, in or out of ahospital, by a physician licensed to practice under the laws of Nevada.
(b) Reimbursement for expenses incurred for nursingservices, necessary appliances, drugs, medicines, supplies and any other healthcare services.
(Added to NRS by 1971, 1863; A 1977, 966)
NRS
1. A corporation subject to the provisions of thischapter shall not charge a provider of health care a fee to include the name ofthe provider on a list of providers of health care given by the corporation toits insureds.
2. A corporation specified in subsection 1 shall notcontract with a provider of health care to provide health care to an insuredunless the corporation uses the form prescribed by the Commissioner pursuant toNRS 629.095 to obtain any informationrelated to the credentials of the provider of health care.
3. A contract between a corporation specified insubsection 1 and a provider of health care may be modified:
(a) At any time pursuant to a written agreementexecuted by both parties.
(b) Except as otherwise provided in this paragraph, bythe corporation 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 a corporation specified in subsection 1contracts with a provider of health care to provide health care to an insured,the corporation shall:
(a) If requested by the provider of health care at thetime the contract is made, submit to the provider of health care the scheduleof payments applicable to the provider of health care; or
(b) If requested by the provider of health care at anyother time, submit to the provider of health care the schedule of paymentsspecified in paragraph (a) within 7 days after receiving the request.
5. As used in this section, provider of health caremeans a provider of health care who is licensed pursuant to
(Added to NRS by
ORGANIZATION
NRS
(Added to NRS by 1971, 1864; A 1991, 654)
NRS
(Added to NRS by 1971, 1864)
NRS
1. A majority of the board of directors of acorporation providing or rendering hospital services shall be persons who arenot duly appointed representatives of hospitals with which the corporation hascontracts for the rendering of hospital services.
2. A majority of the board of directors of acorporation providing medical services shall be persons who are not physiciansor duly appointed representatives of the physicians who have signedparticipating agreements with the corporation for the rendering of medicalservices.
3. A majority of the board of directors of acorporation providing dental services shall be persons who are not dentists orduly appointed representatives of the dentists who have signed participatingagreements with the corporation for the rendering of dental services.
4. This section does not apply to any duly appointedrepresentative of a hospital, physician or dentist who is a member of the boardof directors of a corporation on July 1, 1977. Such a person may continue toserve as a member of the board of directors until his term expires.
(Added to NRS by 1971, 1864; A 1971, 1956; 1977, 624)
NRS
1. The agreement of merger and consolidation shall besubmitted to and approved by a two-thirds vote of the members of the cedingcorporation present in person or by proxy at a meeting called to consider thatagreement. A written or printed notice of such meeting shall be mailed orpersonally delivered to each member at least 30 days before the day fixed forthe meeting.
2. Before the merger and consolidation is effected,the corporation which proposes to assume the liabilities of the cedingcorporation shall submit to its members the question of merger andconsolidation and a similar notice shall be given and a similar vote requiredas in the case of members of the ceding corporation.
3. If the vote in the case of both corporations is inthe affirmative by the required majority, a certified copy of all proceedingsrelating to the proposed merger and consolidation shall be filed with theCommissioner. If the Commissioner finds that the proceedings have been inaccordance with law, he shall approve the agreement.
4. Upon the approval by the Commissioner of suchagreement, the consolidated corporation shall issue certificates of assumptionto each and every subscriber of the ceding corporation. Such certificates shallbe in a form approved by the Commissioner.
5. The approval of the Commissioner of the agreementof merger and consolidation shall operate to dissolve the ceding corporation,and all its liability upon its insurance contracts or benefit certificatesshall thereupon cease, but its officers may thereafter perform any actnecessary to close its affairs. The officers of the ceding corporation shallfile a certified copy of the agreement in the office of the Secretary of State.Such certified copy shall be in lieu of any certificate of dissolution requiredby the provisions of the general corporation law.
6. The consolidated corporation shall be entitled toall the assets of the ceding corporation and shall assume all its liabilities.
(Added to NRS by 1971, 1865)
NRS
(Added to NRS by 1971, 1865)
NRS
(Added to NRS by 1971, 1866)
LICENSING; REGULATION
NRS
1. Procured a certificate of authority from theCommissioner for the establishment, maintenance and operation of the plan.
2. Paid to the Commissioner the fees required ofinsurers by NRS 680B.010 for:
(a) The filing of the initial application;
(b) The issuance of the certificate of authority;
(c) Each annual continuation of the certificate ofauthority; and
(d) The filing of each annual report.
(Added to NRS by 1971, 1866; A 1987, 468)
NRS
1. If a nonprofit hospital service corporation, thatit has entered into contracts with hospitals in the State of Nevada having anaggregate bed capacity sufficient to render the services contemplated to befurnished under the hospital service plan to persons in the State of Nevada.
2. That the hospital, medical or dental servicecontract proposed to be entered into by such corporation with those who maybecome subscribers is not such as will work a fraud or injustice upon suchsubscribers or any person.
3. That a schedule of the rates, dues, fees or otherperiodic charges to be paid by subscribers has been filed with the Commissionerand the same are not such as will, after providing for such legal reserves asare required by NRS 695B.140, resultin profit to, or in the accumulation of excessive reserves or surpluses by,such corporation and are such as will enable such corporation to furnish orprovide the hospital, medical or dental services which it proposes to makeavailable to its beneficiaries and subscribers without impairment of its legalreserves and without a constant depletion of the assets of such corporation. Areserve or surplus over and above all approved and required reserves in anamount in excess of the average annual gross income of such corporation for theimmediately preceding 3 calendar years shall be prima facie an excessiveaccumulation.
(Added to NRS by 1971, 1866)
NRS
1. An application for a certificate of authority mustbe filed with the Commissioner in writing by the corporation for medicalservice which is applying for the certificate on forms furnished or accepted bythe Commissioner. The application must set forth such information concerningthe applicant and its qualifications and in other respects as the Commissionermay reasonably require.
2. The application must be accompanied by:
(a) A copy of the applicants charter or articles ofincorporation, certified by the public officer with whom the original isrequired to be filed in its state of domicile;
(b) A copy of the applicants bylaws, certified by thecorporate secretary;
(c) A copy of each contract the applicant has made orproposed to make with hospitals, or physicians or dentists in this state;
(d) A copy of each service contract proposed to beissued to its subscribers in this state;
(e) The schedule of the rates, dues, fees or otherperiodical charges proposed to be charged for such service contracts; and
(f) The applicable fee for an initial application andthe issuance of a certificate of authority.
3. If upon completion of the application theCommissioner determines that the applicant is fully qualified and entitled to acertificate of authority under this chapter, he shall promptly issue acertificate of authority to the applicant. If the Commissioner refuses to issuethe certificate of authority, he shall give the applicant written notice of therefusal setting forth the grounds therefor.
(Added to NRS by 1971, 1867; A 1971, 1956; 1987, 468)
NRS
1. A certificate of authority issued pursuant to thischapter expires on March 1 of the year following its date of issuance orrenewal.
2. To renew a certificate of authority a corporationfor medical service must:
(a) File a written request for renewal with theCommissioner; and
(b) Pay the applicable fee for renewal for acertificate of authority.
3. The Commissioner may accept a request for renewalreceived by him within 30 days after the expiration of the certificate if therequest is accompanied by a fee for renewal of 150 percent of the fee otherwiserequired.
(Added to NRS by 1987, 467)
NRS
1. No corporation subject to the provisions of thischapter may establish, maintain or operate a hospital, medical or dentalservice plan unless it has and at all times maintains a reserve fund equal tothe following minimum amounts in relation to the number of natural personsentitled to hospital, medical or dental services under contracts issued by thecorporation:
1 to 1,000, inclusive......................................................................................... $100,000
1,001 to 10,000, inclusive.................................................................................. 500,000
10,000 or more.................................................................................................... 750,000
but such a reserve fund is not required of a corporationacting only as a fiscal administrator of programs funded by public agencies,authorized insurers and other authorized health service plans.
2. In computing the amount of a reserve fund, theCommissioner shall include the amounts agreed to be paid by contractinghospitals to the corporation or its equivalent value of hospital service to berendered without charge by the contracting hospital to the hospital servicecorporation.
3. In addition to the reserve fund provided for inthis chapter, the Commissioner shall require every corporation subject to thischapter to make, and to maintain in force, such contracts with enough hospitalsin the State of Nevada to be adequate, in the opinion of the Commissioner, toprovide care for all natural persons entitled to hospital benefits in the Stateof Nevada under contracts issued by such a corporation.
4. In addition, the Commissioner shall require medicalor dental service corporations to give evidence of the participation of asufficient number of physicians or dentists, in his judgment, to render themedical or dental services specified under the contract.
(Added to NRS by 1971, 1868; A 1971, 1957; 1985, 613)
NRS
(Added to NRS by 1971, 1868; A
NRS
1. Every corporation subject to the provisions of thischapter shall annually:
(a) On or before March 1, file in the Office of theCommissioner a statement verified by at least two of the principal officers ofthe corporation, showing its condition and affairs as of December 31 of thepreceding calendar year. The statement must be in the form required by theCommissioner and must contain statements relative to the matters required to beestablished as a condition precedent to maintaining or operating a nonprofithospital, medical or dental service plan and to other matters which theCommissioner may prescribe.
(b) Pay the annual fee for the renewal of a certificateof authority and the fee for the filing of an annual statement.
2. The Commissioner may examine, as often as he deemsit desirable, the affairs of every corporation subject to the provisions ofthis chapter. He shall, if practicable, examine each such corporation at leastonce in every 3 years, and in any event, at least once in every 5 years, as toits condition, fulfillment of its contractual obligations and compliance withapplicable laws. For examining the financial condition of every suchcorporation the Commissioner shall collect the actual expenses of theexamination. Such expenses must be paid by the corporation. The Commissionershall refuse to issue a certificate of authority or shall revoke hiscertificate of authority issued to any corporation which neglects or refuses topay such expenses.
(Added to NRS by 1971, 1869; A 1987, 468)
NRS
(Added to NRS by 1971, 1869)
NRS
1. The Commissioner shall adopt regulations whichrequire an insurer to file with the Commissioner, for his approval, adisclosure summarizing the coverage provided by each contract for hospital ormedical service offered by the insurer. The disclosure must include:
(a) Any significant exception, reduction or limitationthat applies to the contract; and
(b) Any other information,
that theCommissioner finds necessary to provide for full and fair disclosure of theprovisions of the contract.
2. The disclosure must be written in language which iseasily understood and must include a statement that the disclosure is a summaryof the contract only, and that the contract itself should be read to determinethe governing 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, 1251)
NRS
(Added to NRS by 1989, 1251)
NRS
1. An insurer that offers or issues a contract forhospital or medical services which provides coverage for prescription drugsshall include with any summary, certificate or evidence of that coverageprovided to an insured, notice of whether a formulary is used and, if so, ofthe opportunity to secure information regarding the formulary from the insurerpursuant 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 contract forhospital or medical services which provides coverage for prescription drugs anda formulary is used, the insurer shall:
(a) Provide to any insured or participating provider ofhealth care, upon request:
(1) Information regarding whether a specificdrug is included in the formulary.
(2) Access to the most current list ofprescription drugs in the formulary, organized by major therapeutic category,with an indication of whether any listed drugs are preferred over other listeddrugs. If more than one formulary is maintained, the insurer shall notify therequester that a choice of formulary lists is available.
(b) Notify each person who requests informationregarding the formulary, that the inclusion of a drug in the formulary does notguarantee that a provider of health care will prescribe that drug for aparticular medical condition.
(Added to NRS by
CONTRACTS
NRS
1. Unless the entire consideration therefor isexpressed in the contract.
2. Unless the times at which the benefits or servicesto the subscriber take effect and terminate are stated in a portion of thecontract above the evidence of its execution.
3. If the contract purports to entitle more than oneperson to benefits or services, except for family contracts issued under
4. Unless every printed portion and any endorsement orattached papers are plainly printed in type of which the face is not smallerthan 10 points.
5. Except for group contracts and blanket contractsissued under NRS 695B.220, unless theexceptions of the contract are printed with greater prominence than thebenefits to which they apply.
6. Except for group contracts and blanket contractsissued under NRS 695B.230, unless, ifany portion of the contract purports, by reason of the circumstances underwhich an illness, injury or disablement is incurred to reduce any service toless than that provided for the same illness, injury or disablement incurredunder ordinary circumstances, that portion is printed in boldface type and withgreater prominence than any other text of the contract.
7. If the contract contains any provisions purportingto make any portion of the charter, constitution or bylaws of a nonprofitcorporation a part of the contract unless that portion is set forth in full inthe contract.
8. Unless the contract, if it is a group contract,contains a provision for benefits payable for expenses incurred for thetreatment of the abuse of alcohol or drugs, as provided in
9. Unless the contract provides benefits for expensesincurred for hospice care.
10. Unless the contract for service in a hospitalcontains in blackface type, not less than 10 points, the following provisions:
This contract does notrestrict or interfere with the right of any person entitled to service and carein a hospital to select the contracting hospital or to make a free choice ofhis attending physician, who must be the holder of a valid and unrevokedphysicians license and a member of, or acceptable to, the attending staff andboard of directors of the hospital in which the services are to be provided.
(Added to NRS by 1971, 1869; A 1975, 1851; 1979,1180; 1983, 1935, 2039; 1985, 1777; 1989, 515, 1033)
NRS
1. Except as otherwise provided in
(a) A person who elects to be covered by the contractmust be given the opportunity to decline to participate in binding arbitrationat the time he elects to be covered by the contract.
(b) It must clearly state that the parties to thecontract who have not declined to participate in binding arbitration agree toforego their right to resolve any such dispute in a court of law or equity.
2. Except as otherwise provided in subsection 3, thearbitration must be conducted pursuant to the rules for commercial arbitrationestablished by the American Arbitration Association. The insurer is responsiblefor any administrative fees and expenses relating to the arbitration, exceptthat the insurer is not responsible for attorneys fees and fees for expertwitnesses unless those fees are awarded by the arbitrator.
3. If a dispute required to be submitted to bindingarbitration requires an immediate resolution to protect the physical health ofa person insured under the contract, any party to the dispute may waivearbitration and seek declaratory relief in a court of competent jurisdiction.
4. If a provision described in subsection 1 isincluded in a contract, the provision shall not be deemed unenforceable as anunreasonable contract of adhesion if the provision is included in compliancewith the provisions of subsection 1.
(Added to NRS by 1995, 2558)
NRS
1. Each contract for hospital or medical services mustinclude a procedure for binding arbitration to resolve disputes concerningindependent medical evaluations pursuant to the rules of the AmericanArbitration Association.
2. If a corporation subject to the provisions of thischapter, for any final determination of benefits or care, requires anindependent evaluation of the medical or chiropractic care of any person forwhom such care is covered under a contract for hospital or medical services,only a physician or chiropractor who is certified to practice in the same fieldof practice as the primary treating physician or chiropractor or who isformally educated in that field may conduct the independent evaluation.
3. The independent evaluation must include a physicalexamination of the patient, unless he is deceased, and a personal review of allX rays and reports prepared by the primary treating physician or chiropractor.A certified copy of all reports of findings must be sent to the primarytreating physician or chiropractor and the insured person within 10 workingdays after the evaluation. If the insured person disagrees with the finding ofthe evaluation, he must submit an appeal to the insurer pursuant to the procedurefor binding arbitration set forth in the contract for services 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, 2116)
NRS
1. May not require a deductible of more than $600difference per admission to a facility for inpatient treatment which is not a preferredprovider of health care.
2. May not require a deductible of more than $500difference per treatment, other than inpatient treatment at a hospital, by aprovider which is not preferred.
3. May not require an insured, another insurer whoissues policies of group health insurance, a nonprofit medical servicecorporation or a health maintenance organization to pay any amount in excess ofthe deductible or coinsurance due from the insured based on the rates agreedupon with a provider.
4. May not provide for a difference in percentagerates of payment for coinsurance of more than 30 percentage points between thecopayment required to be paid by the insured to a preferred provider of healthcare and the copayment required to be paid by the insured to a provider ofhealth care who is not preferred.
5. Must require that the deductible and payment forcoinsurance paid by the insured to a preferred provider of health care beapplied to the negotiated reduced rates of that provider.
6. Must include for providers of health care who arenot preferred a provision establishing the point at which an insureds paymentfor coinsurance is no longer required to be paid if such a provision isincluded for preferred providers of health care. Such provisions must be basedon a calendar year. The point at which an insureds payment for coinsurance isno longer required to be paid for providers of health care who are notpreferred must not be greater than twice the amount for preferred providers ofhealth care, regardless of the method of payment.
7. Must provide that if there is a particular servicewhich a preferred provider of health care does not provide and the provider ofhealth care who is treating the insured determines that the use of the serviceis necessary for the health of the insured, the service shall be deemed to beprovided by the preferred provider of health care.
8. Must require the corporation to process a claim ofa provider of health care who is not preferred not later than 30 working daysafter the date on which proof of the claim is received.
(Added to NRS by 1987, 1782; A 1989, 515; 1991, 1331;1995, 1631)
NRS
1. A group contract for hospital, medical or dentalservices issued by a nonprofit hospital, medical or dental service corporationto replace any discontinued policy or coverage for group health insurance must:
(a) Provide coverage for all persons who were coveredunder the previous policy or coverage on the date it was discontinued; and
(b) Except as otherwise provided in subsection 2,provide benefits which are at least as extensive as the benefits provided bythe previous policy or coverage, except that the benefits may be reduced orexcluded to the extent that such a reduction or exclusion was permissible underthe terms of the previous policy or coverage,
if thatcontract is issued within 60 days after the date on which the previous policyor coverage was discontinued.
2. If an employer obtains a replacement contractpursuant to subsection 1 to cover his employees, any benefits provided by theprevious policy or coverage may be reduced if notice of the reduction is givento his employees pursuant to NRS 608.1577.
3. Any corporation which issues a replacement contractpursuant to subsection 1 may submit a written request to the insurer whichprovided the previous policy or coverage for a statement of benefits which wereprovided under that policy or coverage. Upon receiving such a request, theinsurer shall give a written statement to the corporation which indicates whatbenefits were provided and what exclusions or reductions were in effect underthe previous policy or coverage.
4. The provisions of this section apply to aself-insured employer who provides health benefits to his employees andreplaces those benefits with a group contract for hospital, medical or dentalservices issued by a nonprofit hospital, medical or dental service corporation.
(Added to NRS by 1987, 849; A 1997, 2954)
NRS
(Added to NRS by 1987, 2235; A 1997, 2955)
NRS
(Added to NRS by 1971, 1870)
NRS
1. The provisions of this section apply to a policy ofhealth insurance offered or issued by a hospital or medical service corporationif an insured covered by the policy receives health care through a defined setof providers of health care who are under contract with the hospital or medicalservice corporation.
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 hospital or medical service corporation is terminated duringthe course of the medical treatment, 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 hospital or medical service corporation for the medicaltreatment he provides to the insured pursuant to this section, if the providerof health care agrees:
(1) To provide medical treatment under the termsof the contract between the provider of health care and the hospital or medicalservice corporation with regard to the insured, including, without limitation,the rates of payment for providing medical service, as those terms existedbefore the termination of the contract between the provider of health care andthe hospital or medical service corporation; 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 hospital or medical servicecorporation.
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 hospital or medical service corporation and the hospital or medical servicecorporation terminated that contract because of the medical incompetence orprofessional misconduct of the provider of health care; and
(b) The hospital or medical service corporation did notenter into another contract with the provider of health care after the contractwas terminated pursuant to paragraph (a).
5. A policy subject to the provisions of this chapterthat is delivered, issued for delivery or renewed on or after October 1, 2003,has the legal effect of including the coverage required by this section, andany provision of the policy or renewal thereof that is in conflict with thissection is void.
6. The Commissioner shall adopt regulations to carryout the provisions of this section.
(Added to NRS by
NRS
1. A policy of health insurance issued by a medicalservices corporation must provide coverage for medical treatment which a personinsured under the policy receives as part of a clinical trial or study if:
(a) The medical treatment is provided in a Phase I,Phase II, Phase III or Phase IV study or clinical trial for the treatment ofcancer or in a Phase II, Phase III or Phase IV study or clinical trial for thetreatment of chronic fatigue syndrome;
(b) The clinical trial or study is approved by:
(1) An agency of the National Institutes ofHealth as set forth in 42 U.S.C. 281(b);
(2) A cooperative group;
(3) The Food and Drug Administration as anapplication for a new investigational drug;
(4) The United States Department of VeteransAffairs; or
(5) The United States Department of Defense;
(c) In the case of:
(1) A Phase I clinical trial or study for thetreatment of cancer, the medical treatment is provided at a facility authorizedto conduct Phase I clinical trials or studies for the treatment of cancer; or
(2) A Phase II, Phase III or Phase IV study orclinical trial for the treatment of cancer or chronic fatigue syndrome, themedical treatment is provided by a provider of health care and the facility andpersonnel for the clinical trial or study have the experience and training toprovide the treatment in a capable manner;
(d) There is no medical treatment available which isconsidered a more appropriate alternative medical treatment than the medicaltreatment provided in the clinical trial or study;
(e) There is a reasonable expectation based on clinicaldata that the medical treatment provided in the clinical trial or study will beat least as effective as any other medical treatment;
(f) The clinical trial or study is conducted in thisState; and
(g) The insured has signed, before his participation inthe clinical trial or study, a statement of consent indicating that he has beeninformed of, without limitation:
(1) The procedure to be undertaken;
(2) Alternative methods of treatment; and
(3) The risks associated with participation inthe clinical trial or study, including, without limitation, the general natureand extent of such risks.
2. Except as otherwise provided in subsection 3, thecoverage for medical treatment required by this section is limited to:
(a) Coverage for any drug or device that is approvedfor sale by the Food and Drug Administration without regard to whether theapproved drug or device has been approved for use in the medical treatment ofthe insured person.
(b) The cost of any reasonably necessary health careservices that are required as a result of the medical treatment provided in aPhase II, Phase III or Phase IV clinical trial or study or as a result of anycomplication arising out of the medical treatment provided in a Phase II, PhaseIII or Phase IV clinical trial or study, to the extent that such health careservices would otherwise be covered under the policy of health insurance.
(c) The cost of any routine health care services thatwould otherwise be covered under the policy of health insurance for an insuredparticipating in a Phase I clinical trial or study.
(d) The initial consultation to determine whether theinsured is eligible to participate in the clinical trial or study.
(e) Health care services required for the clinicallyappropriate monitoring of the insured during a Phase II, Phase III or Phase IVclinical trial or study.
(f) Health care services which are required for theclinically appropriate monitoring of the insured during a Phase I clinicaltrial or study and which are not directly related to the clinical trial orstudy.
Except asotherwise provided in NRS 695B.1901,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 medicalservices corporation has contracted for such services. If the medical servicescorporation has not contracted for the provision of such services, the medicalservices corporation shall pay the provider the rate of reimbursement that ispaid to other providers with whom the medical services corporation hascontracted for similar services and the provider shall accept that rate of reimbursementas payment in full.
3. Particular medical treatment described insubsection 2 and provided to a person insured under the policy is not requiredto be covered pursuant to this section if that particular medical treatment isprovided by the sponsor of the clinical trial or study free of charge to theperson insured under the policy.
4. The coverage for medical treatment required by thissection does not include:
(a) Any portion of the clinical trial or study that iscustomarily paid for by a government or a biotechnical, pharmaceutical ormedical industry.
(b) Coverage for a drug or device described inparagraph (a) of subsection 2 which is paid for by the manufacturer,distributor or provider of the drug or device.
(c) Health care services that are specifically excludedfrom coverage under the insureds policy of health insurance, regardless ofwhether such services are provided under the clinical trial or study.
(d) Health care services that are customarily providedby the sponsors of the clinical trial or study free of charge to theparticipants in the trial or study.
(e) Extraneous expenses related to participation in theclinical trial or study including, without limitation, travel, housing andother expenses that a participant may incur.
(f) Any expenses incurred by a person who accompaniesthe insured during the trial or study.
(g) Any item or service that is provided solely tosatisfy a need or desire for data collection or analysis that is not directlyrelated to the clinical management of the insured.
(h) Any costs for the management of research relatingto the clinical trial or study.
5. A medical services corporation that delivers orissues for delivery a policy of health insurance specified in subsection 1 mayrequire copies of the approval or certification issued pursuant to paragraph(b) of subsection 1, the statement of consent signed by the insured, protocolsfor the clinical trial or study and any other materials related to the scope ofthe clinical trial or study relevant to the coverage of medical treatmentpursuant to this section.
6. A medical services corporation that delivers orissues for delivery a policy of health insurance specified in subsection 1shall:
(a) Include in the disclosure required pursuant to
(b) Provide the coverage required by this sectionsubject to the same deductible, copayment, coinsurance and other suchconditions for coverage that are required under the policy.
7. A policy of 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. A medical services corporation that delivers orissues for delivery a policy of health insurance specified in subsection 1 isimmune from liability for:
(a) Any injury to the insured caused by:
(1) Any medical treatment provided to theinsured in connection with his participation in a clinical trial or studydescribed in this section; or
(2) An act or omission by a provider of healthcare who provides medical treatment or supervises the provision of medicaltreatment to the insured in connection with his participation in a clinicaltrial or study described in this section.
(b) Any adverse or unanticipated outcome arising out ofan insureds participation in a clinical trial or study described in thissection.
9. As used in this section:
(a) Cooperative group means a network of facilitiesthat collaborate on research projects and has established a peer review programapproved by the National Institutes of Health. The term includes:
(1) The Clinical Trials Cooperative GroupProgram; and
(2) The Community Clinical Oncology Program.
(b) Facility authorized to conduct Phase I clinicaltrials or studies for the treatment of cancer means a facility or an affiliateof a facility that:
(1) Has in place a Phase I program which permitsonly selective participation in the program and which uses clear-cut criteriato determine eligibility for participation in the program;
(2) Operates a protocol review and monitoringsystem which conforms to the standards set forth in the Policies andGuidelines Relating to the Cancer-Center Support Grant published by theCancer Centers Branch 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
(Added to NRS by
NRS
1. Except as otherwise provided in this section, acontract for hospital or medical services which provides coverage for prescriptiondrugs must not limit or exclude coverage for a drug if the drug:
(a) Had previously been approved for coverage by theinsurer for a medical condition of an insured and the insureds provider ofhealth care determines, after conducting a reasonable investigation, that noneof the drugs which are otherwise currently approved for coverage are medicallyappropriate for the insured; and
(b) Is appropriately prescribed and considered safe andeffective for treating the medical condition of the insured.
2. The provisions of subsection 1 do not:
(a) Apply to coverage for any drug that is prescribedfor a use that is different from the use for which that drug has been approvedfor marketing by the Food and Drug Administration;
(b) Prohibit:
(1) The insurer from charging a deductible,copayment or coinsurance for the provision of benefits for prescription drugsto the insured or from establishing, by contract, limitations on the maximumcoverage for prescription drugs;
(2) A provider of health care from prescribinganother drug covered by the contract that is medically appropriate for theinsured; or
(3) The substitution of another drug pursuant toNRS 639.23286 or
(c) Require any coverage for a drug after the term ofthe contract.
3. Any provision of a contract for hospital or medicalservices subject to the provisions of this chapter that is delivered, issuedfor delivery or renewed on or after October 1, 2001, which is in conflict withthis section is void.
(Added to NRS by
NRS
1. A policy of health insurance issued by a hospitalor medical service corporation that provides coverage for the treatment ofcolorectal cancer must provide coverage for colorectal cancer screening inaccordance 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
NRS
1. No contract for hospital or medical services thatprovides coverage for a drug approved by the Food and Drug Administration foruse in the treatment of an illness, disease or other medical condition may bedelivered or issued for delivery in this state unless the contract includescoverage for any other use of the drug for the treatment of cancer, if that useis:
(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 a person covered under the contract.
(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 contract for hospital or medical services subjectto the provisions of this chapter that is delivered, issued for delivery orrenewed on or after October 1, 1999, has the legal effect of including thecoverage required by this section, and any provision of the contract thatconflicts with the provisions of this section is void.
(Added to NRS by
NRS
1. A policy of health insurance, issued by a medicalservice corporation, which provides coverage for the surgical procedure knownas a mastectomy must also provide commensurate coverage for:
(a) Reconstruction of the breast on which themastectomy has been performed;
(b) Surgery and reconstruction of the other breast toproduce a symmetrical structure; and
(c) Prostheses and physical complications for allstages of mastectomy, including lymphedemas.
2. The provision of services must be determined by theattending physician and the patient.
3. The plan or issuer may require deductibles andcoinsurance payments if they are consistent with those established for otherbenefits.
4. Written notice of the availability of the coveragemust be given upon enrollment and annually thereafter. The notice must be sentto all participants:
(a) In the next mailing made by the plan or issuer tothe participant or beneficiary; or
(b) As part of any annual information packet sent tothe participant or beneficiary,
whichever isearlier.
5. A plan or issuer may not:
(a) Deny eligibility, or continued eligibility, toenroll or renew coverage, in order to avoid the requirements of subsections 1to 4, inclusive; or
(b) Penalize, or limit reimbursement to, a provider ofcare, or provide incentives to a provider of care, in order to induce theprovider not to provide the care listed in subsections 1 to 4, inclusive.
6. A plan or issuer may negotiate rates ofreimbursement with providers of care.
7. If reconstructive surgery is begun within 3 yearsafter a mastectomy, the amount of the benefits for that surgery must equalthose amounts provided for in the policy at the time of the mastectomy. If thesurgery is begun more than 3 years after the mastectomy, the benefits providedare subject to all of the terms, conditions and exclusions contained in thepolicy at the time of the reconstructive surgery.
8. A policy subject to the provisions of this chapterwhich is delivered, issued for delivery or renewed on or after October 1, 2001,has the legal effect of including the coverage required by this section, andany provision of the policy or the renewal which is in conflict with thissection is void.
9. For the purposes of this section, reconstructivesurgery means a surgical procedure performed following a mastectomy on onebreast or both breasts to reestablish symmetry between the two breasts. Theterm includes augmentation mammoplasty, reduction mammoplasty and mastopexy.
(Added to NRS by 1983, 615; A 1989, 1890;
NRS
1. A policy of healthinsurance issued by a hospital or medical service corporation must providecoverage for benefits payable for expenses incurred for:
(a) An annual cytologicscreening test for women 18 years of age or older;
(b) A baseline mammogram forwomen between the ages of 35 and 40; and
(c) An annual mammogram forwomen 40 years of age or older.
2. A policy of healthinsurance issued by a hospital or medical service corporation must not requirean insured to obtain prior authorization for any service provided pursuant tosubsection 1.
3. A policy subject to theprovisions of this chapter which is delivered, issued for delivery or renewedon or after October 1, 1989, has the legal effect of including the coverage requiredby subsection 1, and any provision of the policy or the renewal which is inconflict with subsection 1 is void.
(Added to NRS by 1989, 1890; A 1997, 1730)
NRS
1. A contract for hospital or medical service mustinclude a provision authorizing a woman covered by the contract to obtaincovered gynecological or obstetrical services without first receivingauthorization or a referral from her primary care physician.
2. The provisions of this section do not authorize awoman covered by a contract for hospital or medical service to designate anobstetrician or gynecologist as her primary care physician.
3. A contract subject to the provisions of thischapter that is delivered, issued for delivery or renewed on or after October1, 1999, has the legal effect of including the coverage required by thissection, and any provision of the contract or the renewal which is in conflictwith this section is void.
4. As used in this section, primary care physicianhas the meaning ascribed to it in NRS695G.060.
(Added to NRS by
NRS
1. Except as otherwise provided in subsection 5, aninsurer that offers or issues a contract for hospital or medical service whichprovides coverage for prescription drugs or devices shall include in thecontract coverage for:
(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 contract forhospital or medical service that provides coverage for prescription drugs shallnot:
(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 contract;
(b) Refuse to issue a contract for hospital or medicalservice or cancel a contract for hospital or medical service solely because theperson applying for or covered by the contract uses or may use in the futureany of the services listed in subsection 1;
(c) Offer or pay any type of material inducement orfinancial incentive to an insured to discourage the insured from accessing anyof the services listed in subsection 1;
(d) Penalize a provider of health care who provides anyof the services listed in subsection 1 to an insured, including, withoutlimitation, reducing the reimbursement of the provider of health care; or
(e) Offer or pay any type of material inducement, bonusor other financial incentive to a provider of health care to deny, reduce,withhold, limit or delay any of the services listed in subsection 1 to aninsured.
3. Except as otherwise provided in subsection 5, a contractsubject 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 thecontract 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 contract.
5. An insurer which offers or issues a contract forhospital or medical service and which is affiliated with a religiousorganization is not required to provide the coverage required by paragraph (a)of subsection 1 if the insurer objects on religious grounds. Such an insurershall, before the issuance of a contract for hospital or medical service andbefore the renewal of such a contract, provide to the group policyholder orprospective insured, as applicable, written notice of the coverage that theinsurer refuses to provide pursuant to this subsection. The insurer shallprovide notice to each insured, at the time the insured receives hiscertificate of coverage or evidence of coverage, that the insurer refused toprovide coverage pursuant to this subsection.
6. If an insurer refuses, pursuant to subsection 5, toprovide the coverage required by paragraph (a) of subsection 1, an employer mayotherwise provide for the coverage for his employees.
7. As used in this section, provider of health carehas the meaning ascribed to it in NRS629.031.
(Added to NRS by
NRS
1. Except as otherwise provided in subsection 5, aninsurer that offers or issues a contract for hospital or medical service whichprovides coverage for outpatient care shall include in the contract coveragefor any health care service related to contraceptives or hormone replacementtherapy.
2. An insurer that offers or issues a contract forhospital or medical service that provides coverage for outpatient care shallnot:
(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 thecontract;
(b) Refuse to issue a contract for hospital or medicalservice or cancel a contract for hospital or medical service solely because theperson applying for or covered by the contract uses or may use in the futureany of the services listed in subsection 1;
(c) Offer or pay any type of material inducement orfinancial incentive to an insured to discourage the insured from accessing anyof the services listed in subsection 1;
(d) Penalize a provider of health care who provides anyof the services listed in subsection 1 to an insured, including, withoutlimitation, reducing the reimbursement of the provider of health care; or
(e) Offer or pay any type of material inducement, bonusor other financial incentive to a provider of health care to deny, reduce,withhold, limit or delay any of the services listed in subsection 1 to aninsured.
3. Except as otherwise provided in subsection 5, acontract subject to the provisions of this chapter that is delivered, issuedfor delivery or renewed on or after October 1, 1999, has the legal effect ofincluding the coverage required by subsection 1, and any provision of thecontract 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 contract.
5. An insurer which offers or issues a contract forhospital or medical service and which is affiliated with a religiousorganization is not required to provide the coverage for health care servicerelated to contraceptives required by this section if the insurer objects onreligious grounds. Such an insurer shall, before the issuance of a contract forhospital or medical service and before the renewal of such a contract, provideto the group policyholder or prospective insured, as applicable, written noticeof the coverage that the insurer refuses to provide pursuant to thissubsection. The insurer shall provide notice to each insured, at the time theinsured receives his certificate of coverage or evidence of coverage, that theinsurer refused to provide coverage pursuant to this subsection.
6. If an insurer refuses, pursuant to subsection 5, toprovide the coverage required by paragraph (a) of subsection 1, an employer mayotherwise provide for the coverage for his employees.
7. As used in this section, provider of health carehas the meaning ascribed to it in NRS629.031.
(Added to NRS by
NRS
1. No hospital, medical or dental service contractissued by a corporation pursuant to the provisions of this chapter may containany exclusion, reduction or other limitation of coverage relating tocomplications of pregnancy, unless the provision applies generally to allbenefits payable under the contract and complies with the provisions of
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 contract subject to the provisions of thischapter which is issued or delivered on or after July 1, 1977, has the legaleffect of including the coverage required by this section, and any provision ofthe contract which is in conflict with this section is void.
(Added to NRS by 1977, 416; A 1997, 2955)
NRS
1. A contract for hospital or medical service mustprovide coverage for:
(a) Enteral formulas for use at home that areprescribed or ordered by a physician as medically necessary for the treatmentof inherited metabolic diseases characterized by deficient metabolism, ormalabsorption originating from congenital defects or defects arising shortlyafter birth, of amino acid, organic acid, carbohydrate or fat; and
(b) At least $2,500 per year for special food productswhich are prescribed or ordered by a physician as medically necessary for thetreatment of a person described in paragraph (a).
2. The coverage required by subsection 1 must beprovided whether or not the condition existed when the contract was purchased.
3. A contract subject to the provisions of thischapter that is delivered, issued for delivery or renewed on or after January1, 1998, has the legal effect of including the coverage required by this section,and any provision of the contract 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, 1527)
NRS
1. No contract for hospital or medical service thatprovides coverage for hospital, medical or surgical expenses may be deliveredor issued for delivery in this state unless the contract includes coverage forthe management and treatment of diabetes, including, without limitation,coverage for the self-management of diabetes.
2. An insurer who delivers or issues for delivery acontract specified in subsection 1:
(a) Shall include in the disclosure required pursuantto NRS 695B.172 notice to eachpolicyholder or subscriber covered under the contract of the availability ofthe benefits 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 contract.
3. A contract for hospital or medical service subjectto the provisions of this chapter that is delivered, issued for delivery orrenewed on or after January 1, 1998, has the legal effect of including thecoverage required by this section, and any provision of the contract thatconflicts with this section is void.
4. As used in this section:
(a) Coverage for the management and treatment ofdiabetes includes coverage for medication, equipment, supplies and appliances thatare medically necessary for the treatment of diabetes.
(b) Coverage for the self-management of diabetesincludes:
(1) The training and education provided to aperson covered under the contract after he is initially diagnosed with diabeteswhich is medically necessary for the care and management of diabetes,including, without limitation, counseling in nutrition and the proper use ofequipment and supplies for the treatment of diabetes;
(2) Training and education which is medicallynecessary as a result of a subsequent diagnosis that indicates a significantchange in the symptoms or condition of the person covered under the contractand which requires modification 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, 744)
NRS
1. All individual and group service or indemnity-typecontracts issued by a nonprofit corporation which provide coverage for a familymember of the subscriber must as to such coverage provide that the healthbenefits applicable for children are payable with respect to:
(a) A newly born child of the subscriber from themoment of 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 subscriber for the purposeof adoption from the moment of placement as certified by the public or privateagency making the placement. The coverage of such a child ceases if theadoption proceedings are terminated as certified by the public or privateagency making the placement.
Thecontracts must provide the coverage specified in subsection 3, and must notexclude premature births.
2. The contract may require that notification of:
(a) The birth of a newly born child;
(b) The effective date of adoption of a child; or
(c) The date of placement of a child for adoption,
and paymentsof the required fees, if any, must be furnished to the nonprofit servicecorporation within 31 days after the date of birth, adoption or placement foradoption in order to have the coverage continue beyond the 31-day period.
3. The coverage for newly born and adopted childrenand children placed for adoption consists of coverage of injury or sickness,including the necessary care and treatment of medically diagnosed congenitaldefects and birth abnormalities and, within the limits of the policy, necessarytransportation costs from place of birth to the nearest specialized treatmentcenter under major medical policies, and with respect to basic policies to theextent such costs are charged by the treatment center.
4. A corporation shall not restrict the coverage of adependent child adopted or placed for adoption solely because of a preexistingcondition the child has at the time he would otherwise become eligible forcoverage pursuant to that contract. Any provision relating to an exclusion fora preexisting condition must comply with NRS689C.190.
5. For covered services provided to the child, thecorporation shall reimburse noncontracted providers of health care to an amountequal to the average amount of payment for which the organization hasagreements, contracts or arrangements for those covered services.
(Added to NRS by 1975, 1110; A 1989, 741; 1995, 2434;1997, 2956)
NRS
1. Except as otherwise provided in this section, nocontract for hospital or medical service may be delivered or issued fordelivery in this state if it contains an exclusion of coverage of the treatmentof the temporomandibular joint whether by specific language in the contract orby a claims settlement practice. A contract for hospital or medical service mayexclude coverage of those methods of treatment which are recognized as dentalprocedures, including, but not limited to, the extraction of teeth and theapplication of orthodontic devices and splints.
2. Pursuant to a contract for hospital or medicalservice, a corporation may limit its liability on the treatment of thetemporomandibular joint to:
(a) No more than 50 percent of the usual and customarycharges for such treatment actually received by a subscriber, but in no casemore than 50 percent of the maximum benefits provided by the contract for suchtreatment; and
(b) Treatment which is medically necessary.
3. Any provision of a contract subject to theprovisions of this chapter and issued or delivered on or after January 1, 1990,which is in conflict with this section is void.
(Added to NRS by 1989, 2138)
NRS
1. Notwithstanding any provisions of this title to thecontrary, a contract for hospital or medical service delivered or issued fordelivery in this state pursuant to this chapter must provide coverage for thetreatment of conditions relating to severe mental illness.
2. The coverage required by this section:
(a) Must provide:
(1) Benefits for at least 40 days ofhospitalization as an inpatient per contract year and 40 visits for treatmentas an outpatient per contract 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 contract required to providecoverage for more than 40 days of hospitalization as an inpatient per contractyear.
(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 contract for hospital or medical services.
4. The provisions of this section do not apply to acontract for hospital or medical service:
(a) Delivered or issued for delivery to an employer toprovide coverage for his employees if the employer has no more than 25employees.
(b) If, at the end of the contract year, the premiumscharged for that contract, or a standard grouping of contracts, increase bymore than 2 percent as a result of providing the coverage required by thissection and the insurer obtains an exemption from the Commissioner pursuant tosubsection 5.
5. To obtain the exemption required by paragraph (b)of subsection 4, an insurer must submit to the Commissioner a written requesttherefor that is signed by an actuary and sets forth the reasons and actuarialassumptions upon which the request is based. To determine whether an exemptionmay be granted, the Commissioner shall subtract from the amount of premiumscharged during the contract year the amount of premiums charged during theperiod immediately preceding the contract year and the amount of any increasein the premiums charged that is attributable to factors that are unrelated toproviding the coverage required by this section. The Commissioner shall verifythe information within 30 days after receiving the request. The request shallbe deemed approved if the Commissioner does not deny the request within thattime.
6. The provisions of this section do not:
(a) Limit the provision of specialized services coveredby Medicaid for persons with conditions relating to mental health or substanceabuse.
(b) Supersede any provision of federal law, any federalor state policy relating to Medicaid, or the terms and conditions imposed onany Medicaid waiver granted to this state with respect to the provisions ofservices to persons with conditions relating to mental health or substanceabuse.
7. A contract for hospital or medical service subjectto the provisions of this chapter which is delivered, issued for delivery orrenewed on or after January 1, 2000, has the legal effect of including thecoverage required by this section, and any provision of the contract or therenewal which is in conflict with this section is void, unless the contract isotherwise exempt from 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
NRS
1. The annual benefitsprovided by a policy for group health insurance issued by a medical servicecorporation, as required by subsection 8 of NRS695B.180, for treatment of the abuse of alcohol or drugs must consist of:
(a) Treatment for withdrawalfrom the physiological effects of alcohol or drugs, with a minimum benefit of$1,500 per calendar year.
(b) Treatment for a patientadmitted to a facility, with a minimum benefit of $9,000 per calendar year.
(c) Counseling for a person,group or family who is not admitted to a facility, with a minimum benefit of$2,500 per calendar year.
2. These benefits must bepaid in the same manner as benefits for any other illness covered by a similarpolicy are paid.
3. The insured person isentitled to these benefits if treatment is received in any:
(a) Facility for thetreatment of abuse of alcohol or drugs which is certified by the HealthDivision of the Department of Health and Human Services.
(b) Hospital or other medicalfacility or facility for the dependent which is licensed by the Health Divisionof the Department of Health and Human Services, accredited by the JointCommission on Accreditation of Healthcare Organizations and provides a programfor the treatment of abuse of alcohol or drugs as part of its accreditedactivities.
(Added to NRS by 1979, 1179; A 1983, 2040; 1985,1570, 1778; 1989, 516; 1993, 1922; 1997, 1302;
NRS
1. As used in this section, total disability andtotally disabled mean the continuing inability of the employee or member,because of an injury or illness, to perform substantially the duties related tohis employment for which he is otherwise qualified.
2. No group subscriber contract for hospital, medicalor dental service may be delivered or issued for delivery in this state unlessit provides continuing coverage for an employee or member and his dependentswho are otherwise covered by the policy while the employee or member is onleave without pay as a result of a total disability. The coverage must be forany injury or illness suffered by the employee or member which is not relatedto the total disability or for any injury or illness suffered by his dependent.The coverage for such injury or illness must be equal to or greater than thecoverage otherwise provided by the policy.
3. The coverage required pursuant to subsection 2 mustcontinue until:
(a) The date on which the employment of the employee ormember is terminated;
(b) The date on which the employee or member obtainsanother policy of health insurance;
(c) The date on which the group subscriber contract isterminated; or
(d) After a period of 12 months in which benefits undersuch coverage are provided to the employee or member,
whicheveroccurs first.
(Added to NRS by 1989, 1251)
NRS
(Added to NRS by 1991, 1134)
NRS
(Added to NRS by 1981, 576; A 1989, 1553)
NRS
(Added to NRS by 1987, 2133)
NRS
(Added to NRS by 1987, 1123)
NRS
1. If any contract for hospital or medical serviceprovides coverage for treatment of an illness which is within the authorizedscope of practice of a qualified chiropractor, the insured is entitled toreimbursement for treatments by a chiropractor who is licensed pursuant to
2. The terms of the policy must not limit:
(a) Coverage for treatments by a chiropractor to anumber less than for treatments by other physicians.
(b) Reimbursement for treatments by a chiropractor toan amount less than that charged for similar treatments by other physicians.
(Added to NRS by 1981, 930; A 1983, 328)
NRS
1. If any contract for medical service providescoverage for services which are within the authorized scope of practice of aregistered nurse who is authorized pursuant to chapter632 of NRS to perform additional acts in an emergency or under otherspecial conditions as prescribed by the State Board of Nursing, and which arereimbursed when provided by another provider of health care, the insured isentitled to reimbursement for services provided by such a registered nurse.
2. The terms of the contract must not limit:
(a) Coverage for services provided by such a registerednurse to a number of occasions less than for services provided by anotherprovider of health care.
(b) Reimbursement for services provided by such aregistered nurse to an amount less than that reimbursed for similar servicesprovided by another provider of health care.
3. An insurer is not required to pay for servicesprovided by such a registered nurse which duplicate services provided byanother provider of health care.
(Added to NRS by 1985, 1447)
NRS
1. Except as otherwise provided in subsection 3, everycontract for medical service 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 receive reimbursementfrom any other source.
2. The subscriber or the provider may submit the claimfor reimbursement. The provider shall not demand payment from the subscriberuntil after that reimbursement has been granted or denied.
3. Subsection 1 does not apply to any agreementbetween a corporation for medical service and a provider of medicaltransportation for the direct payment by the corporation for the providersservices.
(Added to NRS by 1989, 1274)
NRS
(Added to NRS by 1971, 1871)
NRS
1. A provision that the contract, the application ofthe employer, or executive officer or trustee of any association or trustees,and the individual applications, if any, of the employees or members coveredshall constitute the entire contract between the parties, and that allstatements made by the employer, or the executive officer, or trustee ortrustees, or by the individual employee or member shall, in the absence offraud, be deemed representations and not warranties, and that no such statementshall be used in defense to a claim under the contract, unless it is containedin a written application.
2. A provision that the corporation will issue to theemployer or to the executive officer or trustee of the association or to thetrustees, for delivery to each of the employees or members who are coveredunder such contract, an individual certificate setting forth a statement as tothe hospital or medical or dental service to which he is entitled.
3. A provision that to the group or class thereoforiginally covered shall be added from time to time all new employees of theemployer or members of the association eligible to and applying for coverage insuch group or class.
4. A statement that such contract is not in lieu ofworkmens compensation insurance.
5. Such provisions as may be promulgated by theCommissioner from time to time.
(Added to NRS by 1971, 1871)
NRS
(Added to NRS by 1971, 1871)
NRS
1. A policy that does not coordinate with otherpolicies is always the primary policy.
2. The benefits of the policy which covers a person asan employee, member or subscriber, other than a dependent, is the primarypolicy. The policy which covers the person as a dependent is the secondarypolicy.
3. When more than one policy covers the same child asa dependent of different parents who are not divorced or separated, the primarypolicy is the policy of the parent whose birthday falls earlier in the year.The secondary policy is the policy of the parent whose birthday falls later inthe year. If both parents have the same birthday, the benefits of the policywhich covered the parent the longer is the primary policy. The policy whichcovered the parent the shorter time is the secondary policy.
4. If more than one policy covers a person as adependent child of divorced or separated parents, benefits for the child aredetermined in the following order:
(a) First, the policy of the parent with custody of thechild;
(b) Second, the policy of the spouse of the parent withcustody; and
(c) Third, the policy of the parent without custody ofthe child,
unless thespecific terms of a court decree state that one parent is responsible for thehealth care expenses of the child, in which case, the policy of that parent isthe primary policy. a parent responsible for the health care pursuant to acourt decree shall notify the insurer of the terms of the decree.
5. The primary policy is the policy which covers aperson as an employee who is neither laid off nor retired, or that employeesdependent. The secondary policy is the policy which covers that person as alaid off or retired employee, or that employees dependent.
6. If none of the rules in subsections 1 to 5,inclusive, determines the order of benefits, the primary policy is the policywhich covered an employee, member or subscriber longer. The secondary policy isthe policy which covered that person the shorter time.
When apolicy is determined to be a secondary policy it acts to provide benefits inexcess of those provided by the primary policy. The secondary policy may not reducebenefits based upon payments by the primary policy, except that this provisiondoes not require duplication of benefits.
(Added to NRS by 1989, 514)
NRS
1. A hospital or medical or dental service contract orevidence of coverage under a group or nongroup contract must not be issued ordelivered in this state until a copy of the form of the contract is filed withthe Commissioner and either:
(a) Thirty days expires without notice from theCommissioner after the copy is filed; or
(b) The Commissioner gives his written approval beforethat time.
2. A schedule of premium rates to be paid by subscribersunder either a group or nongroup contract must not be issued, delivered or usedby any nonprofit hospital, medical or dental service corporation until thatcorporation files with the Commissioner a copy of the schedule together withany supplementary information required by the Commissioner and either:
(a) Thirty days expires without notice from theCommissioner after the copy is filed; or
(b) The Commissioner gives his written approval beforethat time.
(Added to NRS by 1971, 1872; A 1989, 517)
NRS
1. A corporation subject to the provisions of thischapter is permitted to provide group hospital or group medical or dentalservice coverage prior to the approval of the form of the contract orcertificate if all the conditions of subsection 2 of this section are met priorthereto and if thereafter it acts as required by subsection 3.
2. The conditions referred to in subsection 1 arethat:
(a) The group is one eligible for coverage pursuant tothe provisions of this chapter.
(b) An executed memorandum has been or is concurrentlydelivered to the subscriber containing a provision that unless a group hospitalor group medical or dental service certificate, the form of which has beenapproved by the Commissioner, which is issued under a group hospital or groupmedical or dental service contract the form of which has been approved by theCommissioner, and which embodies the coverage, has been issued and delivered tothe subscriber within 90 days after the date on which the coverage is providedor agreed to be provided, the coverage provided pursuant to such memorandumterminates 120 days after such date. The memorandum shall contain aspecification in either complete or summary form of:
(1) The class or classes of employees eligiblefor coverage.
(2) The benefits to be provided.
(3) The exceptions and reductions to suchbenefits, if any.
3. A corporation subject to the provisions of thischapter providing coverage pursuant to this section shall:
(a) Within 60 days after the date on which the coverageis provided or agreed to be provided, submit to the Commissioner for approval aform of a group hospital or group medical or dental service contract, and aform of a certificate of individual coverage, drafted to provide the coverageprovided by such memorandum and to meet all requirements of law.
(b) Make such revisions in the contract and certificatesubmitted as the Commissioner may lawfully require.
(c) Terminate such coverage in accordance with theprovisions of paragraph (b) of subsection 2 of this section if approval of suchcontract and certificate is not secured within the time specified therein.
(Added to NRS by 1971, 1872)
NRS
1. Upon written request from the corporation subjectto the provisions of this chapter filed within 50 days after the date on whichthe coverage is provided or agreed to be provided and upon proof satisfactoryto him that the corporation is acting with due diligence and that hardship willresult unless an extension is granted, the Commissioner may extend the time setforth in paragraph (a) of subsection 3 of NRS695B.240 for a period of not to exceed 30 days. Upon such extension, the corporationwith the consent of the subscriber may amend the memorandum referred to inparagraph (b) of subsection 2 of NRS 695B.240to extend the time within which the certificate must be issued and delivered tothe subscriber to 30 days after the date to which the Commissioner has extendedthe time within which a form of contract and certificate must be submitted tohim for approval and to extend the date for termination of coverage to 30 daysthereafter.
2. A contract and certificate submitted to theCommissioner with a letter from the corporation stating that coverage has beenprovided in accordance with this section shall be automatically approved unlessthe Commissioner disapproves the same within 30 days of the date of itssubmission to him.
(Added to NRS by 1971, 1873)
NRS
1. Except as otherwise provided in subsection 2, acorporation subject to the provisions of this chapter shall approve or deny aclaim relating to a contract for dental, hospital or medical services within 30days after the corporation receives the claim. If the claim is approved, thecorporation 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 corporation shall pay interest on the claim at a rate ofinterest equal to the prime rate at the largest bank in Nevada, as ascertainedby the Commissioner of Financial Institutions, on January 1 or July 1, as thecase may be, immediately preceding the date on which the payment was due, plus6 percent. 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 corporation requires additional informationto determine whether to approve or deny the claim, it shall notify the claimantof its request for the additional information within 20 days after it receivesthe claim. The corporation shall notify the provider of dental, hospital ormedical services of all the specific reasons for the delay in approving ordenying the claim. The corporation shall approve or deny the claim within 30days after receiving the additional information. If the claim is approved, thecorporation shall pay the claim within 30 days after it receives the additionalinformation. If the approved claim is not paid within that period, thecorporation shall pay interest on the claim in the manner prescribed insubsection 1.
3. A corporation shall not request a claimant to resubmitinformation that the claimant has already provided to the corporation, unlessthe corporation provides a legitimate reason for the request and the purpose ofthe request is not to delay the payment of the claim, harass the claimant ordiscourage the filing of claims.
4. A corporation shall not pay only part of a claimthat has been approved and is fully payable.
5. A court shall award costs and reasonable attorneysfees to the prevailing party in an action brought pursuant to this section.
6. The payment of interest provided for in thissection for the late payment of an approved claim may be waived only if thepayment was delayed because of an act of God or another cause beyond thecontrol of the corporation.
7. The Commissioner may require a corporation toprovide evidence which demonstrates that the corporation has substantiallycomplied with the requirements set forth in this section, including, withoutlimitation, payment within 30 days of at least 95 percent of approved claims orat least 90 percent of the total dollar amount for approved claims.
8. If the Commissioner determines that a corporationis not in substantial compliance with the requirements set forth in thissection, the Commissioner may require the corporation to pay an administrativefine in an amount to be determined by the Commissioner. Upon a second orsubsequent determination that a corporation is not in substantial compliancewith the requirements set forth in this section, the Commissioner may suspendor revoke the certificate of authority of the corporation.
(Added to NRS by 1991, 1330; A
CONVERSION OF GROUP CONTRACTS TO INDIVIDUAL CONTRACTS
NRS
1. Except as otherwiseprovided in the provisions of this section, NRS689B.340 to 689B.590, inclusive,and chapter 689C of NRS relating to theportability and availability of health insurance, all group subscribercontracts delivered or issued for delivery in this state providing forhospital, surgical or major medical coverage, or any combination of thesecoverages, on a service basis or an expense-incurred basis, or both, mustcontain a provision that the employee or member is entitled to have issued tohim a subscriber contract of health coverage when the employee or member is nolonger covered by the group subscriber contract.
2. The requirement insubsection 1 does not apply to contracts providing benefits only for specificdiseases or accidental injuries.
3. If an employee or memberwas a recipient of benefits under the coverage provided pursuant to
(Added to NRS by 1979, 1087; A 1989, 1252; 1997,2956)
NRS
1. To the surviving spouse, if any, upon the death ofthe employee or member, with respect to the spouse and any child whose coverageunder the group contract is terminated by reason of such death, or if there isno surviving spouse, to each surviving child whose coverage under the groupcontract terminates by reason of such death, or, if the group contract providesfor continuation of dependents coverage following the employees or membersdeath, at the end of the continued coverage;
2. To the spouse of the employee or member upontermination of coverage of the spouse while the employee or member remains coveredunder the group contract, if the spouse ceases to be a dependent as defined bythe group contract, and to any child whose coverage under the group contractterminates at the same time; or
3. To a child solely with respect to himself upontermination of his coverage because he ceases to be a dependent as defined bythe group contract, if a conversion privilege is not otherwise provided withrespect to the termination.
(Added to NRS by 1979, 1089)
NRS
1. The medical service corporation is not required toissue a converted contract to any person who:
(a) Is covered for similar benefits by anotherhospital, surgical, medical or major medical expense insurance policy, ahospital or medical service subscriber contract, a medical practice or otherprepayment plan, or by any other kind of plan or program;
(b) Is eligible to be covered for similar benefitsunder any arrangement of coverage for individuals in a group, whether on aninsured or uninsured basis; or
(c) Has similar benefits provided for or availableunder the requirements of any state or federal law,
if anybenefits provided under the sources listed in this subsection, together withthe benefits to be provided by the converted contract, would result inoverinsurance according to the medical service corporations standards.
2. Before denying a converted contract to an applicantbecause he has coverage as described in paragraph (a) of subsection 1, themedical service corporation shall notify him that the converted contract willbe issued only if the other coverage is cancelled.
(Added to NRS by 1979, 1087)
NRS
1. A person who is entitled to a converted contractmust be given his choice of at least three types of contracts offering benefitson a service basis or an expense-incurred basis, or both.
2. The converted contract may include major medical orcatastrophic benefits if they were provided under the group contract.
3. For those subscribers eligible for Medicare, themedical service corporation may provide for a supplement to Medicare as part ofthe conversion privilege.
(Added to NRS by 1979, 1088)
NRS
(Added to NRS by 1979, 1088)
NRS
(Added to NRS by 1979, 1088)
NRS
1. Issue the converted contract without evidence ofinsurability;
2. Base the premium on the converted policies for thefirst 12 months, and subsequent renewals, upon the medical servicecorporations table of premium rates applicable to the age and class of risk ofeach person to be covered under the contract and to the type and amount ofcoverage provided. The frequency of premium payments must be the same as iscustomarily required by the medical service corporation for the contract formand plan selected except that premium payments must not be required more oftenthan quarterly;
3. Provide that the effective date of the convertedcontract is 12:01 a.m. on the day after the termination of coverage under thegroup contract; and
4. Provide that the converted contract covers theemployee or member and his dependents who were covered by the group contract onthe date of his termination. At the option of the insurer, a separate convertedcontract may be issued to cover any dependent.
(Added to NRS by 1979, 1087)
NRS
1. A converted contract issued under
2. The medical service corporation may not refuse torenew the contract or the coverage of any person unless:
(a) Benefits provided under the sources listed insubsection 1 of NRS 695B.253, togetherwith the benefits provided by the converted contract would result in overinsuranceaccording to the medical service corporations standards;
(b) The holder of the converted contract has refused toprovide requested information as to such sources; or
(c) Fraud was committed in applying for any benefitsunder the converted contract.
3. Before refusing to renew a converted contractbecause of overinsurance, the medical service corporation shall notify thesubscriber that the converted contract will be renewed only if the othercoverage is cancelled.
(Added to NRS by 1979, 1088)
NRS
(Added to NRS by 1979, 1089)
NRS
(Added to NRS by 1979, 1089)
NRS
(Added to NRS by 1979, 1089)
NRS
(Added to NRS by 1979, 1089)
NRS
(Added to NRS by 1979, 1089; A 1987, 2235)
MISCELLANEOUS PROVISIONS
NRS
1. Misrepresented the conditional nature of thecoverage.
2. Neglected or refused either to cancel or otherwiseterminate such coverage within the time required by such section.
3. Delivered any such memorandum which did not complywith such section.
4. Shown a lack of diligence in making revisions inthe contract or certificate necessary to obtain its approval by theCommissioner.
5. Failed so often in so many important respects indrafting any such contract or certificate to conform to the applicablerequirements of the insurance laws that a conclusion of lack of good faith orcompetency in drafting is reasonably justified.
6. Circulated announcements of coverage to individualsubscribers which failed to advise them of the conditional nature of thecoverage.
7. In any other manner so negligently or carelesslyhandled the effecting of group hospital or group medical or dental servicecoverage under NRS 695B.240 or theadministration thereof that the subscriber or the persons covered by thecontract or certificate have been misled or exposed to the danger of loss.
(Added to NRS by 1971, 1873)
NRS
(Added to NRS by 1971, 1874)
NRS
1. The word subscriber as a designation of theobligee.
2. The phrase a family member as a designation forthe members of the family of the obligee.
3. The word contract or agreement as a designationfor the undertakings of the hospital or medical or dental service corporation.
4. The phrases furnishing of service or payment ofbenefits as a designation for the commitments of the hospital or medical ordental service corporation.
5. The phrase the service as a designation for thecorporate obligor in any such contract or agreement.
(Added to NRS by 1971, 1874; A 1981, 107)
NRS
(Added to NRS by 1975, 897)
NRS
(Added to NRS by 1971, 1874)
NRS
(Added to NRS by 1971, 1874)
NRS
(Added to NRS by 1971, 1875)
NRS
1. If a policyholder requests information for therenewal of his policy, an insurer shall provide to the policyholder informationregarding claims paid on behalf of the policyholder. The information must beprovided within 30 working days after the insurer receives a written requestfrom the policyholder. The insurer may charge the policyholder a reasonable feefor the information.
2. The Commissioner may adopt regulations to carry outthe provisions of subsection 1.
(Added to NRS by 1993, 2400)
NRS
(Added to NRS by 1997, 1096)
NRS
1. Except as otherwise provided in subsection 2, a medicalservices corporation that issues contracts for hospital, medical or dentalservices shall not:
(a) Deny a claim under such a contract solely because theclaim involves an injury sustained by an insured as a consequence of beingintoxicated or under the influence of a controlled substance.
(b) Cancel such a contract solely because an insuredhas made a claim involving an injury sustained by the insured as a consequenceof being intoxicated or under the influence of a controlled substance.
(c) Refuse to issue such a contract to an eligibleapplicant 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 a medical services corporation fromenforcing a provision included in a contract for hospital, medical or dental servicesto:
(a) Deny a claim which involves an injury to which acontributing cause was the insureds commission of or attempt to commit afelony;
(b) Cancel such a contract solely because of such aclaim; or
(c) Refuse to issue such a contract to an eligibleapplicant solely because of such a claim.
(Added to NRS by
NRS
1. Except as otherwise provided in subsection 2, acorporation that 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 thecoverage or benefits for health care provided to an insured person based on:
(1) Whether the insured person or any member ofhis family has taken a genetic test; or
(2) Any genetic information of the insuredperson or any member of his family.
2. The provisions of this section do not apply to acorporation that 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, 1461)
NRS
1. Nonprofit hospital, medical or dental servicecorporations are subject to the provisions of
2. For the purposes of subsection 1, unless thecontext requires that a provision apply only to a group health plan or acarrier that provides coverage under a group health plan, any reference inthose sections to:
(a) Carrier must be replaced by corporation.
(b) Group health plan must be replaced by groupcontract for hospital, medical or dental services.
(Added to NRS by 1997, 2954; A
NRS
(Added to NRS by
NRS
(Added to NRS by 1971, 1875; A 1995, 988, 1631, 1636;1997, 2957, 3036; 1999,631)
ELIGIBILITY FOR COVERAGE
NRS
1. Contract means a contract for hospital, medicalor dental services issued pursuant to this chapter.
2. Corporation means a corporation organizedpursuant to this chapter.
3. 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.
4. Order for medical coverage means an order of acourt or administrative tribunal to provide coverage under a contract to achild pursuant to the provisions of 42 U.S.C. 1396g-1.
(Added to NRS by 1995, 2433)
NRS
1. A corporation shall not, when consideringeligibility for coverage or making payments under a contract, consider theavailability of, or any eligibility of a person for, medical assistance underMedicaid.
2. To the extent that payment has been made byMedicaid for health care, a corporation:
(a) Shall treat Medicaid as having a valid andenforceable assignment of benefits of a subscriber or policyholder or claimantunder him regardless of any exclusion of Medicaid or the absence of a writtenassignment; and
(b) May, as otherwise allowed by the policy, evidenceof coverage or contract and applicable law or regulation concerningsubrogation, seek to enforce any rights of a recipient of Medicaid against anyother 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 subscriber or policyholder.
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 contract,
thecorporation that issued the contract shall not impose any requirements upon thestate agency except requirements it imposes upon the agents or assignees ofother persons covered by the same contract.
(Added to NRS by 1995, 2433)
NRS
1. Was born out of wedlock;
2. Has not been claimed as a dependent on the parentsfederal income tax return; or
3. Does not reside with the parent or within thecorporations geographic area of service.
(Added to NRS by 1995, 2433)
NRS
1. Provide to the custodial parent such information asnecessary for the child to obtain any benefits under that coverage.
2. Allow the custodial parent or, with the approval ofthe custodial parent, a provider of health care to submit claims for coveredservices without the approval of the noncustodial parent.
3. Make payments on claims submitted pursuant tosubsection 2 directly to the custodial parent, the provider of health care oran agency of this or another state responsible for the administration ofMedicaid.
(Added to NRS by 1995, 2433)
NRS
1. Shall, if the child is otherwise eligible for thatcoverage, allow the parent to enroll the child in that coverage without regardto any restrictions upon periods for enrollment.
2. Shall, if:
(a) The child is otherwise eligible for that coverage;and
(b) The parent is enrolled in that coverage but failsto apply for enrollment of the child,
enroll thechild in that coverage upon application by the other parent of the child, or byan agency of this or another state responsible for the administration of Medicaidor a state program for the enforcement of child support established pursuant to42 U.S.C. 651 et seq., without regard to any restrictions upon periods forenrollment.
3. Shall not terminate the enrollment of the child inthat coverage or otherwise eliminate that coverage of the child unless thecorporation 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, 2434)
SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS
NRS
1. Except as otherwise provided in subsection4, each insurer that issues a contract for hospital or medical services in thisState shall establish a system for resolving any complaints of an insuredconcerning health care services covered under the policy. The system must beapproved by the Commissioner 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 contract for hospitalor medical services 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 contract specified insubsection 1 shall, if the contract provides, delivers, arranges for, pays foror reimburses any cost of health care services through managed care, provide asystem for resolving any complaints of an insured concerning those health careservices that complies with the provisions of
(Added to NRS by 1997, 310; A
NRS
1. Each insurer that issues a contract for hospital ormedical services in this State shall submit to the Commissioner and the StateBoard of Health an annual report regarding its system for resolving complaintsestablished pursuant to subsection 1 of NRS695B.380 on a form prescribed by the Commissioner in consultation with theState 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, 310; A
NRS
1. Following approval by the Commissioner, each insurerthat issues a contract for hospital or medical services in this State shallprovide written notice to an insured, in clear and comprehensible language thatis understandable to an ordinary layperson, explaining the right of the insuredto file a written complaint. Such notice must be provided to an insured:
(a) At the time he receives his certificate of coverageor evidence of coverage;
(b) Any time that the insurer denies coverage of ahealth care service or limits coverage of a health care service to an insured;and
(c) Any other time deemed necessary by theCommissioner.
2. Any time that an insurer denies coverage of ahealth care service to a beneficiary or subscriber, including, withoutlimitation, denying a claim relating to a contract for dental, hospital ormedical services pursuant to NRS695B.2505, it shall notify the beneficiary or subscriber in writing within10 working days after it denies coverage of the health care service 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, 310; A
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