2005 Nevada Revised Statutes - Chapter 695C — Health Maintenance Organizations

CHAPTER 695C - HEALTH MAINTENANCEORGANIZATIONS

NRS 695C.010 Shorttitle.

NRS 695C.020 Legislativedeclaration.

NRS 695C.030 Definitions.

NRS 695C.050 Applicabilityof certain provisions.

NRS 695C.055 Applicabilityof certain other provisions.

NRS 695C.057 Applicabilityof certain provisions concerning portability and availability of healthinsurance.

NRS 695C.060 Establishmentof organization.

NRS 695C.070 Certificateof authority: Application.

NRS 695C.080 Certificateof authority: Evaluation of application.

NRS 695C.090 Certificateof authority: Issuance.

NRS 695C.100 Certificateof authority: Denial.

NRS 695C.110 Governingbody: Composition; participation by enrollees.

NRS 695C.120 Powersof organization.

NRS 695C.123 Contractswith certain federally qualified health centers.

NRS 695C.125 Contractbetween health maintenance organization and provider of health care: Form toobtain information on provider of health care; modification; provision ofschedule of fees.

NRS 695C.128 Contractsto provide services pursuant to certain state programs: Payment of interest onclaims.

NRS 695C.130 Noticeand approval required for exercise of powers; rules or regulations.

NRS 695C.140 Noticeand approval required for modification of operations; regulations.

NRS 695C.145 Accountingprinciples required for certain reports and transactions; health maintenanceorganization subject to requirements for certain insurers.

NRS 695C.150 Fiduciaryresponsibilities.

NRS 695C.160 Investments.

NRS 695C.161 Eligibilityfor coverage: Definitions.

NRS 695C.163 Eligibilityfor coverage: Effect of eligibility for medical assistance under Medicaid;assignment of rights to state agency.

NRS 695C.165 Eligibilityfor coverage: Organization prohibited from asserting certain grounds to denyenrollment of child pursuant to order if parent is enrolled in health careplan.

NRS 695C.167 Eligibilityfor coverage: Certain accommodations to be made when child is covered underhealth care plan of noncustodial parent.

NRS 695C.169 Eligibilityfor coverage: Organization to authorize enrollment of child of parent who isrequired by order to provide medical coverage under certain circumstances;termination of coverage of child.

NRS 695C.1691 Requiredprovision concerning coverage for continued medical care.

NRS 695C.1693 Requiredprovision concerning coverage for treatment received as part of clinical trialor study.

NRS 695C.1694 Requiredprovision concerning coverage of drug or device for contraception and ofhormone replacement therapy in certain circumstances; prohibited actions byhealth maintenance organization; exceptions.

NRS 695C.1695 Requiredprovision concerning coverage of health care services related to contraceptivesand hormone replacement therapy in certain circumstances; prohibited actions byhealth maintenance organization; exceptions.

NRS 695C.170 Evidenceof coverage: Issuance; form and contents.

NRS 695C.1703 Coveragefor prescription drugs: Provision of notice and information regarding use offormulary.

NRS 695C.1705 Grouphealth care plan issued to replace discontinued policy or coverage: Requirements;notice of reduction of benefits; statement of benefits; applicability toself-insured employer.

NRS 695C.1707 Requiredprovision for continuation of coverage.

NRS 695C.1709 Requiredprovision concerning coverage for enrollee on leave without pay as result oftotal disability.

NRS 695C.171 Requiredprovision concerning coverage relating to mastectomy.

NRS 695C.1713 Requiredprovision concerning coverage of certain gynecological and obstetrical serviceswithout authorization or referral from primary care physician.

NRS 695C.172 Requiredprovision concerning coverage relating to complications of pregnancy.

NRS 695C.1723 Requiredprovision concerning coverage for treatment of certain inherited metabolicdiseases.

NRS 695C.1727 Requiredprovision concerning coverage for management and treatment of diabetes.

NRS 695C.173 Requiredprovision concerning coverage for newly born and adopted children and childrenplaced for adoption.

NRS 695C.1731 Requiredprovision concerning coverage for screening for colorectal cancer.

NRS 695C.1733 Requiredprovision concerning coverage for certain drugs for treatment of cancer.

NRS 695C.1734 Requiredprovision concerning coverage for prescription drug previously approved formedical condition of enrollee.

NRS 695C.1735 Requiredprovision concerning coverage for cytologic screening tests and mammograms forcertain women.

NRS 695C.1738 Requiredprovision concerning coverage for treatment of conditions relating to severemental illness.

NRS 695C.174 Requiredprovision concerning benefits for treatment of abuse of alcohol or drugs.

NRS 695C.1755 Requiredprovision concerning coverage for treatment of temporomandibular joint.

NRS 695C.176 Requiredprovision concerning coverage for hospice care.

NRS 695C.1765 Reimbursementfor acupuncture.

NRS 695C.177 Reimbursementfor treatments by licensed psychologist.

NRS 695C.1773 Reimbursementfor treatment by licensed marriage and family therapist.

NRS 695C.1775 Reimbursementfor treatment by licensed associate in social work, social worker, independentsocial worker or clinical social worker.

NRS 695C.178 Reimbursementfor treatment by chiropractor.

NRS 695C.179 Reimbursementfor services provided by certain nurses; prohibited limitations; exceptions.

NRS 695C.1795 Reimbursementto provider of medical transportation.

NRS 695C.180 Scheduleof charges.

NRS 695C.185 Approvalor denial of claims; payment of claims and interest; requests for additionalinformation; award of costs and attorneys fees; compliance with requirements.

NRS 695C.187 Schedulefor payment of claims: Mandatory inclusion in arrangements for provision ofhealth care.

NRS 695C.190 Commissionermay require submission of information.

NRS 695C.193 Summaryof coverage: Contents of disclosure; approval by Commissioner; regulations.

NRS 695C.195 Summaryof coverage: Copy to be provided before policy issued; policy not to be offeredunless summary approved by Commissioner.

NRS 695C.200 Approvalof forms and schedules.

NRS 695C.201 Offeringpolicy of health insurance for purposes of establishing health savings account.

NRS 695C.203 Denyingcoverage solely because person was victim of domestic violence prohibited.

NRS 695C.205 Denyingcoverage solely because insured was intoxicated or under the influence ofcontrolled substance prohibited; exceptions. [Effective July 1, 2006.]

NRS 695C.207 Requiringor using information concerning genetic testing.

NRS 695C.210 Annualreport and financial statement required; administrative penalty for failure tofile report or statement.

NRS 695C.220 Applications,filings and reports open to public inspection.

NRS 695C.230 Fees.

NRS 695C.240 Informationrequired to be available for inspection.

NRS 695C.250 Openenrollment.

NRS 695C.260 Complaintsystem.

NRS 695C.265 Requiredprocedure for arbitration of disputes concerning independent medicalevaluations.

NRS 695C.267 Provisionrequiring binding arbitration authorized; procedures for arbitration;declaratory relief.

NRS 695C.270 Bondrequired; waiver.

NRS 695C.275 Commissionerto adopt regulations for licensing of provider-sponsored organizations.

NRS 695C.280 Commissionerauthorized to adopt regulations for licensing of agents or brokers.

NRS 695C.290 Insurancecompany may establish or contract with health maintenance organization.

NRS 695C.300 Prohibitedpractices.

NRS 695C.310 Examinations.

NRS 695C.311 Periodicexamination by Commissioner to determine financial condition of healthmaintenance organization.

NRS 695C.313 Financialexamination: Procedure; appointment of examiner; maintenance and use ofrecords; penalty for obstruction or interference.

NRS 695C.315 Financialexamination: Payment of expense.

NRS 695C.317 Statutoryprocedures required for examination and hearing.

NRS 695C.320 Rehabilitation,liquidation or conservation.

NRS 695C.325 Authorizationto offer health care plan to small employer for purpose of establishing medicalsavings accounts.

NRS 695C.330 Disciplinaryproceedings: Grounds; effect of suspension or revocation.

NRS 695C.340 Disciplinaryproceedings: Notice; hearing; judicial review.

NRS 695C.350 Violations:Remedies; penalties.

_________

NRS 695C.010 Shorttitle. This chapter may be cited as the NevadaHealth Maintenance Organization Act.

(Added to NRS by 1973, 1246)

NRS 695C.020 Legislativedeclaration. The Legislature hereby declaresthat the rising cost of health services in recent years has led governmentagencies, private organizations, and legislative bodies to seek alternatives tothe traditional medical delivery system which would provide improved healthcare and would provide such health care at a lower cost. The health maintenanceorganization is a concept which has received much attention as one meansthrough which an improvement in delivery might be achieved. The Legislaturetherefore enacts this chapter to carry out this objective.

(Added to NRS by 1973, 1246)

NRS 695C.030 Definitions. As used in this chapter, unless the context otherwiserequires:

1. Comprehensive health care services means medicalservices, dentistry, drugs, psychiatric and optometric and all other carenecessary for the delivery of services to the consumer.

2. Enrollee means a natural person who has beenvoluntarily enrolled in a health care plan.

3. Evidence of coverage means any certificate,agreement or contract issued to an enrollee setting forth the coverage to whichhe is entitled.

4. Health care plan means any arrangement wherebyany person undertakes to provide, arrange for, pay for or reimburse any part ofthe cost of any health care services and at least part of the arrangementconsists of arranging for or the provision of health care services paid for byor on behalf of the enrollee on a periodic prepaid basis.

5. Health care services means any services includedin the furnishing to any natural person of medical or dental care orhospitalization or incident to the furnishing of such care or hospitalization,as well as the furnishing to any person of any other services for the purposeof preventing, alleviating, curing or healing human illness or injury.

6. Health maintenance organization means any personwhich provides or arranges for provision of a health care service or servicesand is responsible for the availability and accessibility of such service orservices to its enrollees, which services are paid for or on behalf of theenrollees on a periodic prepaid basis without regard to the dates healthservices are rendered and without regard to the extent of services actuallyfurnished to the enrollees, except that supplementing the fixed prepayments bynominal additional payments for services in accordance with regulations adoptedby the Commissioner shall not be deemed to render the arrangement not to be ona prepaid basis. A health maintenance organization, in addition to offeringhealth care services, may offer indemnity or service benefits provided throughinsurers or otherwise.

7. Provider means any physician, hospital or otherperson who is licensed or otherwise authorized in this state to furnish healthcare services.

(Added to NRS by 1973, 1246; A 1985, 538; 1997, 1629)

NRS 695C.050 Applicabilityof certain provisions.

1. Except as otherwise provided in this chapter or inspecific provisions of this title, the provisions of this title are notapplicable to any health maintenance organization granted a certificate ofauthority under this chapter. This provision does not apply to an insurerlicensed and regulated pursuant to this title except with respect to itsactivities as a health maintenance organization authorized and regulatedpursuant to this chapter.

2. Solicitation of enrollees by a health maintenanceorganization granted a certificate of authority, or its representatives, mustnot be construed to violate any provision of law relating to solicitation oradvertising by practitioners of a healing art.

3. Any health maintenance organization authorizedunder this chapter shall not be deemed to be practicing medicine and is exemptfrom the provisions of chapter 630 of NRS.

4. The provisions of NRS 695C.110, 695C.125, 695C.1691, 695C.1693, 695C.170 to 695C.200, inclusive, 695C.250 and 695C.265 do not apply to a healthmaintenance organization that provides health care services through managedcare to recipients of Medicaid under the state plan for Medicaid or insurancepursuant to the Childrens Health Insurance Program pursuant to a contract withthe Division of Health Care Financing and Policy of the Department of Healthand Human Services. This subsection does not exempt a health maintenanceorganization from any provision of this chapter for services provided pursuantto any other contract.

5. The provisions of NRS 695C.1694, 695C.1695 and 695C.1731 apply to a health maintenanceorganization that provides health care services through managed care torecipients of Medicaid under the state plan for Medicaid.

(Added to NRS by 1973, 1258; A 1983, 2030; 1995,2720; 1997, 311, 1528; 1999,418, 420, 1945, 2004, 2241; 2001, 141, 144, 864, 2734; 2003, 1335, 3366, 3531)

NRS 695C.055 Applicabilityof certain other provisions.

1. The provisions of NRS449.465, 679A.200, 679B.700, subsections 2, 4, 18, 19 and 32of NRS 680B.010, NRS 680B.020 to 680B.060, inclusive, and chapters 686A and 695Gof NRS apply to a health maintenance organization.

2. For the purposes of subsection 1, unless thecontext requires that a provision apply only to insurers, any reference inthose sections to insurer must be replaced by health maintenanceorganization.

(Added to NRS by 1987, 469; A 1995, 472, 988; 1997,299, 311, 2958, 2962; 2001,2735; 2003, 3333,3367)

NRS 695C.057 Applicabilityof certain provisions concerning portability and availability of healthinsurance.

1. A health maintenance organization is subject to theprovisions of NRS 689B.340 to 689B.590, inclusive, and chapter 689C of NRS relating to the portabilityand availability of health insurance offered by such organizations. If there isa conflict between the provisions of this chapter and the provisions of NRS 689B.340 to 689B.590, inclusive, and chapter 689C of NRS, the provisions of NRS 689B.340 to 689B.590, inclusive, and chapter 689C of NRS control.

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 group health plan or carrier must be replaced by healthmaintenance organization.

(Added to NRS by 1997, 2957)

NRS 695C.060 Establishmentof organization.

1. Any person may apply to the Commissioner for andobtain a certificate of authority to establish and operate a health maintenanceorganization in compliance with this chapter. No person shall operate a healthmaintenance organization without obtaining a certificate of authority underthis chapter. A foreign corporation may qualify under this chapter, subject toits qualification to do business in this state as a foreign corporation.

2. No person shall be certified to establish oroperate a health maintenance organization in this state, nor sell or offer tosell, or solicit offers to purchase or receive advance or periodicconsideration in conjunction with health care plans unless such healthmaintenance organization provides or arranges for the provision of comprehensivehealth care services.

3. Every health maintenance organization or personoperating a health maintenance organization shall submit an application for acertificate of authority under NRS695C.070 within 30 days after July 1, 1973. Each such applicant maycontinue to operate until the Commissioner acts upon the application. In theevent that an application is denied under NRS695C.090 and 695C.100, theapplicant shall thereafter be treated as a health maintenance organizationwhose certificate of authority has been revoked. For purposes of thissubsection, a health maintenance organization shall be deemed to be inoperation only if health care services are being provided to the publicgenerally or to some group or groups thereof.

(Added to NRS by 1973, 1247)

NRS 695C.070 Certificateof authority: Application. Each applicationfor a certificate of authority must be verified by an officer or authorizedrepresentative of the applicant, must be in a form prescribed by theCommissioner, and must set forth or be accompanied by the following:

1. A copy of the basic organizational document, ifany, of the applicant, and all amendments thereto;

2. A copy of the bylaws, rules or regulations, or asimilar document, if any, regulating the conduct of the internal affairs of theapplicant;

3. A list of the names, addresses and officialpositions of the persons who will be responsible for the conduct of the affairsof the applicant, including all members of the board of directors, board oftrustees, executive committee, or other governing board or committee, theofficers in the case of a corporation, and the partners or members in the caseof a partnership or association;

4. A copy of any contract made or to be made betweenany providers or persons listed in subsection 3 and the applicant;

5. A statement generally describing the healthmaintenance organization, its health care plan or plans, the location offacilities at which health care services will be regularly available toenrollees and the type of health care personnel who will provide the healthcare services;

6. A copy of the form of evidence of coverage to beissued to the enrollees;

7. A copy of the form of the group contract, if any,which is to be issued to employers, unions, trustees or other organizations;

8. Certified financial statements showing theapplicants assets, liabilities and sources of financial support;

9. The proposed method of marketing the plan, afinancial plan which includes a 3-year projection of the initial operatingresults anticipated and the sources of working capital and any other sources offunding;

10. A power of attorney, executed by the applicant,appointing the Commissioner and his authorized deputies as the true and lawfulattorney of such applicant in and for this State upon whom all lawful processin any legal action or proceeding against the health maintenance organizationon a cause of action arising in this State may be served;

11. A statement reasonably describing the geographicarea to be served;

12. A description of the procedures for resolvingcomplaints and procedures for external reviews to be used as required under NRS 695C.260;

13. A description of the procedures and programs to beimplemented to meet the quality of health care requirements in NRS 695C.080;

14. A description of the mechanism by which enrolleeswill be afforded an opportunity to participate in matters of program contentunder subsection 2 of NRS 695C.110;and

15. Such other information as the Commissioner mayrequire to make the determinations required in NRS 695C.080.

(Added to NRS by 1973, 1247, A 2003, 777)

NRS 695C.080 Certificateof authority: Evaluation of application.

1. Upon receipt of an application for issuance of acertificate of authority, the Commissioner shall forthwith transmit copies ofsuch application and accompanying documents to the State Board of Health.

2. The State Board of Health shall determine whetherthe applicant for a certificate of authority, with respect to health careservices to be furnished:

(a) Has demonstrated the willingness and ability toassure that such health care services will be provided in a manner to assureboth availability and accessibility of adequate personnel and facilities and ina manner enhancing availability, accessibility and continuity of service;

(b) Has organizational arrangements, established inaccordance with regulations promulgated by the State Board of Health; and

(c) Has a procedure established in accordance withregulations of the State Board of Health to develop, compile, evaluate andreport statistics relating to the cost of its operations, the pattern ofutilization of its services, the availability and accessibility of its servicesand such other matters as may be reasonably required by the State Board ofHealth.

3. Within 90 days of receipt of the application forissuance of a certificate of authority, the State Board of Health shall certifyto the Commissioner whether the proposed health maintenance organization meetsthe requirements of subsection 2. If the State Board of Health certifies thatthe health maintenance organization does not meet such requirements, it shallspecify in what respects it is deficient.

(Added to NRS by 1973, 1249)

NRS 695C.090 Certificateof authority: Issuance. The Commissioner shallissue or deny a certificate of authority to any person filing an applicationpursuant to NRS 695C.060 within 90days of receipt of the certification from the State Board of Health. Issuanceof a certificate of authority must be granted upon payment of the feesprescribed in NRS 695C.230 if theCommissioner is satisfied that the following conditions are met:

1. The persons responsible for the conduct of theaffairs of the applicant are competent, trustworthy and possess goodreputations.

2. The State Board of Health certifies, in accordancewith NRS 695C.080, that the healthmaintenance organizations proposed plan of operation meets the requirements ofsubsection 2 of NRS 695C.080.

3. The health care plan furnishes comprehensive healthcare services.

4. The health maintenance organization is financiallyresponsible and may reasonably be expected to meet its obligations to enrolleesand prospective enrollees. In making this determination, the Commissioner mayconsider:

(a) The financial soundness of the health care plansarrangements for health care services and the schedule of charges used inconnection therewith;

(b) The adequacy of working capital;

(c) Any agreement with an insurer, a government, or anyother organization for insuring the payment of the cost of health careservices;

(d) Any agreement with providers for the provision ofhealth care services; and

(e) Any surety bond or deposit of cash or securitiessubmitted in accordance with NRS 695C.270as a guarantee that the obligations will be duly performed.

5. The enrollees will be afforded an opportunity toparticipate in matters of program content pursuant to NRS 695C.110.

6. Nothing in the proposed method of operation, asshown by the information submitted pursuant to NRS 695C.060, 695C.070 and 695C.140, or by independent investigationis contrary to the public interest.

(Added to NRS by 1973, 1249; A 1987, 469; 1993, 2400)

NRS 695C.100 Certificateof authority: Denial. A certificate ofauthority shall be denied only after compliance with the requirements of NRS 695C.340.

(Added to NRS by 1973, 1250)

NRS 695C.110 Governingbody: Composition; participation by enrollees.

1. The governing body of any health maintenanceorganization may include providers, other individuals or both.

2. Such governing body shall establish a mechanism toafford the enrollees an opportunity to participate in matters of programcontent through the establishment of advisory panels, by the use of advisoryreferenda on major policy decisions or through the use of other mechanisms. Inaddition there shall be a provider advisory board to advise the health plan inthe matter of quality of care. There shall be a joint board of consumers andproviders to advise on consumer satisfaction.

(Added to NRS by 1973, 1250)

NRS 695C.120 Powersof organization. The powers of a health maintenanceorganization include, but are not limited to, the following:

1. The purchase, lease, construction, renovation,operation or maintenance of hospitals, medical facilities, or both, and theirancillary equipment, and such property as may reasonably be required for itsprincipal office or for such other purposes as may be necessary in thetransaction of the business of the organization;

2. The making of loans to a medical group under contractwith it in furtherance of its program or the making of loans to a corporationunder its control for the purpose of acquiring or constructing medicalfacilities and hospitals or in furtherance of a program providing health careservices to enrollees;

3. The furnishing of health care service throughproviders which are under contract with or employed by the health maintenanceorganization;

4. The contracting with any person for the performanceon its behalf of certain functions such as marketing, enrollment andadministration; and

5. The contracting with an insurance company licensedin this state or authorized to do business in this state for the provision ofsuch insurance, indemnity, or reimbursement against the cost of health careservices provided by the health maintenance organization.

(Added to NRS by 1973, 1250; A 1995, 2166; 1999, 1834)

NRS 695C.123 Contractswith certain federally qualified health centers.

1. Except as otherwise provided in NRS 422.273, a health maintenance organizationthat furnishes health care services through providers which are under contractwith the organization shall use its best efforts to contract with at least onehealth center in each geographic area served by the organization to providesuch services to enrollees if the health center:

(a) Meets all conditions imposed by the organization onsimilarly situated providers of health care that are under contract with theorganization, including, without limitation:

(1) Certification for participation in theMedicaid or Medicare program; and

(2) Requirements relating to the appropriatecredentials for providers of health care; and

(b) Agrees to reasonable reimbursement rates that aregenerally consistent with those offered by the organization to similarlysituated providers of health care that are under contract with theorganization.

2. As used in this section, health center has themeaning ascribed to it in 42 U.S.C. 254b.

(Added to NRS by 2001, 1924)

NRS 695C.125 Contractbetween health maintenance organization and provider of health care: Form toobtain information on provider of health care; modification; provision ofschedule of fees.

1. A health maintenance organization shall notcontract with a provider of health care to provide health care to an insuredunless the health maintenance organization uses the form prescribed by theCommissioner pursuant to NRS 629.095 toobtain any information related to the credentials of the provider of healthcare.

2. A contract between a health maintenanceorganization 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 health maintenance organization upon giving to the provider 30 dayswritten notice of the modification. If the provider fails to object in writingto the modification within the 30-day period, the modification becomeseffective at the end of that period. If the provider objects in writing to themodification within the 30-day period, the modification must not becomeeffective unless agreed to by both parties as described in paragraph (a).

3. If a health maintenance organization contracts witha provider of health care to provide health care to an enrollee, the healthmaintenance organization 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.

4. As used in this section, provider of health caremeans a provider of health care who is licensed pursuant to chapter 630, 631,632 or 633 ofNRS.

(Added to NRS by 1999, 1651; A 2001, 2735; 2003, 3367)

NRS 695C.128 Contractsto provide services pursuant to certain state programs: Payment of interest onclaims. Any contract or other agreement enteredinto or renewed by a health maintenance organization on or after October 1,2001:

1. To provide health care services through managedcare to recipients of Medicaid under the state plan for Medicaid; or

2. With the Division of Health Care Financing andPolicy of the Department of Health and Human Services to provide insurancepursuant to the Childrens Health Insurance Program,

must requirethe health maintenance organization to pay interest to a provider of healthcare services on a claim that is not paid within the time provided in the contractor agreement at a rate of interest equal to the prime rate at the largest bankin Nevada, as ascertained by the Commissioner of Financial Institutions, onJanuary 1 or July 1, as the case may be, immediately preceding the date onwhich the payment was due, plus 6 percent. The interest must be calculated from30 days after the date on which the claim is approved until the date on whichthe claim is paid.

(Added to NRS by 2001, 2734)

NRS 695C.130 Noticeand approval required for exercise of powers; rules or regulations.

1. A health maintenance organization shall filenotice, with adequate supporting information, with the Commissioner prior tothe exercise of any power granted in subsections 1 and 2 of NRS 695C.120. The Commissioner shalldisapprove such exercise of power if in his opinion it would substantially andadversely affect the financial soundness of the health maintenance organizationand endanger its ability to meet its obligations. If the Commissioner does notdisapprove within 60 days of the filing, it is deemed approved.

2. The Commissioner may promulgate rules orregulations.

(Added to NRS by 1973, 1250)

NRS 695C.140 Noticeand approval required for modification of operations; regulations.

1. A health maintenance organization shall, unlessotherwise provided for in this chapter, file notice with the Commissioner andthe State Board of Health before any material modification of the operationsdescribed in the information required by NRS695C.070. If the Commissioner does not disapprove within 90 days afterfiling of the notice, the modification is deemed approved.

2. The Commissioner may adopt regulations to carry outthe provisions of this section.

(Added to NRS by 1973, 1248; A 1995, 1632)

NRS 695C.145 Accountingprinciples required for certain reports and transactions; health maintenanceorganization subject to requirements for certain insurers.

1. A health maintenance organization shall useaccounting principles that are recognized by the laws of this state or approvedby the Commissioner for:

(a) All financial reports;

(b) The accounting of investments and deposits; and

(c) Transactions between affiliates and holdingcompanies.

2. A health maintenance organization is subject to therequirements for insurers for:

(a) Administrators, agents, brokers and solicitors,pursuant to chapter 683A of NRS;

(b) Borrowing, pursuant to NRS 693A.180;

(c) Impairment of capital, surplus or assets, pursuantto NRS 693A.260, 693A.270 and 693A.280;

(d) Management and agency contracts executed on orafter January 1, 1992; and

(e) Officers, pursuant to NRS 693A.120 and 693A.130.

3. A domestic health maintenance organization issubject to the requirements for insurers for corporations pursuant to NRS 693A.040 to 693A.070, inclusive.

(Added to NRS by 1991, 2036)

NRS 695C.150 Fiduciaryresponsibilities. Any director, officer,partner, member or employee of a health maintenance organization who receives,collects, disburses or invests funds in connection with the activities of suchorganization shall be responsible for such funds in a fiduciary relationship tothe enrollees.

(Added to NRS by 1973, 1250)

NRS 695C.160 Investments. With the exception of investments made in accordance withsubsections 1 and 2 of NRS 695C.120and NRS 695C.130, the investable fundsof a health maintenance organization shall be invested only in securities orother investments permitted by the laws of this state for the investment ofassets constituting the legal reserves of life insurance companies or suchother securities or investments as the Commissioner may permit.

(Added to NRS by 1973, 1253)

NRS 695C.161 Eligibilityfor coverage: Definitions. As used in NRS 695C.161 to 695C.169, inclusive, unless the contextotherwise requires:

1. Medicaid means a program established in any statepursuant to Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) toprovide assistance for part or all of the cost of medical care rendered onbehalf of indigent persons.

2. Order for medical coverage means an order of acourt or administrative tribunal to provide coverage under a health care planto a child pursuant to the provisions of 42 U.S.C. 1396g-1.

(Added to NRS by 1995, 2435)

NRS 695C.163 Eligibilityfor coverage: Effect of eligibility for medical assistance under Medicaid;assignment of rights to state agency.

1. A health maintenance organization shall not, whenconsidering eligibility for coverage or making payments under a health careplan, consider the availability of, or eligibility of a person for, medicalassistance under Medicaid.

2. To the extent that payment has been made byMedicaid for health care, a health maintenance organization:

(a) Shall treat Medicaid as having a valid andenforceable assignment of benefits due an enrollee or claimant under himregardless of any exclusion of Medicaid or the absence of a written assignment;and

(b) May, as otherwise allowed by its plan, evidence ofcoverage or contract and applicable law or regulation concerning subrogation,seek to enforce any rights of a recipient of Medicaid to reimbursement againstany other liable party if:

(1) It is so authorized pursuant to a contractwith Medicaid for managed care; or

(2) It has reimbursed Medicaid in full for thehealth care provided by Medicaid to its enrollee.

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 health care plan,

theorganization responsible for the health care plan shall not impose any requirementsupon the state agency except requirements it imposes upon the agents orassignees of other persons covered by the same plan.

(Added to NRS by 1995, 2435)

NRS 695C.165 Eligibilityfor coverage: Organization prohibited from asserting certain grounds to denyenrollment of child pursuant to order if parent is enrolled in health careplan. An organization shall not deny theenrollment of a child pursuant to an order for medical coverage under a healthcare plan in which a parent of the child is enrolled, on the ground that thechild:

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 theorganizations geographic area of service.

(Added to NRS by 1995, 2436)

NRS 695C.167 Eligibilityfor coverage: Certain accommodations to be made when child is covered underhealth care plan of noncustodial parent. If achild has coverage under a health care plan in which a noncustodial parent ofthe child is enrolled, the organization responsible for that plan shall:

1. Provide to the custodial parent such information asnecessary for the child to obtain any benefits under that coverage.

2. Allow the custodial parent or, with the approval ofthe custodial parent, a provider to submit claims for covered services withoutthe approval of the noncustodial parent.

3. Make payments on claims submitted pursuant tosubsection 2 directly to the custodial parent, the provider or an agency ofthis or another state responsible for the administration of Medicaid.

(Added to NRS by 1995, 2436)

NRS 695C.169 Eligibilityfor coverage: Organization to authorize enrollment of child of parent who isrequired by order to provide medical coverage under certain circumstances;termination of coverage of child. If a parentis required by an order for medical coverage to provide coverage for a childand the parent is eligible for coverage of members of his family under a healthcare plan, the organization responsible for that plan:

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 theorganization 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, 2436)

NRS 695C.1691 Requiredprovision concerning coverage for continued medical care.

1. The provisions of this section apply to a healthcare plan offered or issued by a health maintenance organization if an insuredcovered by the health care plan receives health care through a defined set ofproviders of health care who are under contract with the health maintenanceorganization.

2. Except as otherwise provided in this section, if aninsured who is covered by a health care plan described in subsection 1 isreceiving medical treatment for a medical condition from a provider of healthcare whose contract with the health maintenance organization is terminatedduring the course of the medical treatment, the health care plan must providethat:

(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 health maintenance organization 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 health maintenanceorganization with regard to the insured, including, without limitation, therates of payment for providing medical service, as those terms existed beforethe termination of the contract between the provider of health care and thehealth maintenance organization; 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 health maintenance organization.

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 health maintenance organization and the health maintenance organizationterminated that contract because of the medical incompetence or professionalmisconduct of the provider of health care; and

(b) The health maintenance organization did not enterinto another contract with the provider of health care after the contract wasterminated pursuant to paragraph (a).

5. An evidence of coverage for a health care plansubject to the provisions of this chapter that is delivered, issued fordelivery or renewed on or after October 1, 2003, has the legal effect ofincluding the coverage required by this section, and any provision of theevidence of coverage or renewal thereof that is in conflict with this sectionis void.

6. The Commissioner shall adopt regulations to carryout the provisions of this section.

(Added to NRS by 2003, 3365)

NRS 695C.1693 Requiredprovision concerning coverage for treatment received as part of clinical trialor study.

1. Except as otherwise provided in NRS 695C.050, a health care plan issuedby a health maintenance organization must provide coverage for medicaltreatment which an enrollee 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 enrollee has signed, before his participationin the clinical trial or study, a statement of consent indicating that he hasbeen informed of, without limitation:

(1) The procedure to be undertaken;

(2) Alternative methods of treatment; and

(3) The risks associated with participation inthe clinical trial or study, including, without limitation, the general natureand extent of such risks.

2. Except as otherwise provided in subsection 3, thecoverage for medical treatment required by this section is limited to:

(a) Coverage for any drug or device that is approvedfor sale by the Food and Drug Administration without regard to whether theapproved drug or device has been approved for use in the medical treatment ofthe enrollee.

(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 any complicationarising out of the medical treatment provided in a Phase II, Phase III or PhaseIV clinical trial or study, to the extent that such health care services wouldotherwise be covered under the health care plan.

(c) The cost of any routine health care services thatwould otherwise be covered under the health care plan for an enrollee in aPhase I clinical trial or study.

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

(e) Health care services required for the clinicallyappropriate monitoring of the enrollee 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 enrollee during a Phase I clinicaltrial or study and which are not directly related to the clinical trial orstudy.

Except asotherwise provided in NRS 695C.1691,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 healthmaintenance organization has contracted for such services. If the healthmaintenance organization has not contracted for the provision of such services,the health maintenance organization shall pay the provider the rate ofreimbursement that is paid to other providers with whom the health maintenanceorganization has contracted for similar services and the provider shall acceptthat rate of reimbursement as payment in full.

3. Particular medical treatment described insubsection 2 and provided to an enrollee is not required to be covered pursuantto this section if that particular medical treatment is provided by the sponsorof the clinical trial or study free of charge to the enrollee.

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 enrollees health care plan, regardless of whether suchservices 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 enrollee during the clinical trial or study.

(g) Any item or service that is provided solely tosatisfy a need or desire for data collection or analysis that is not directlyrelated to the clinical management of the enrollee.

(h) Any costs for the management of research relating tothe clinical trial or study.

5. A health maintenance organization that delivers orissues for delivery a health care plan specified in subsection 1 may requirecopies of the approval or certification issued pursuant to paragraph (b) ofsubsection 1, the statement of consent signed by the enrollee, protocols forthe clinical trial or study and any other materials related to the scope of theclinical trial or study relevant to the coverage of medical treatment pursuantto this section.

6. A health maintenance organization that delivers orissues for delivery a health care plan specified in subsection 1 shall:

(a) Include in the disclosure required pursuant to NRS 695C.193 notice to each enrollee ofthe availability of the benefits required by this section.

(b) Provide the coverage required by this sectionsubject to the same deductible, copayment, coinsurance and other suchconditions for coverage that are required under the plan.

7. A health care plan subject to the provisions ofthis chapter that is delivered, issued for delivery or renewed on or afterJanuary 1, 2006, has the legal effect of including the coverage required bythis section, and any provision of the plan that conflicts with this section isvoid.

8. A health maintenance organization that delivers orissues for delivery a health care plan specified in subsection 1 is immune fromliability for:

(a) Any injury to an enrollee caused by:

(1) Any medical treatment provided to theenrollee 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 enrollee in connection with his participation in a clinicaltrial or study described in this section.

(b) Any adverse or unanticipated outcome arising out ofan enrollees 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 chapter 630, 631or 633 of NRS.

(Added to NRS by 2003, 3528; A 2005, 2018)

NRS 695C.1694 Requiredprovision concerning coverage of drug or device for contraception and ofhormone replacement therapy in certain circumstances; prohibited actions byhealth maintenance organization; exceptions.

1. Except as otherwise provided in subsection 5, ahealth maintenance organization which offers or issues a health care plan thatprovides coverage for prescription drugs or devices shall include in the plancoverage 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. A health maintenance organization that offers orissues a health care plan that provides coverage for prescription drugs shallnot:

(a) Require an enrollee 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 plan;

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

(c) Offer or pay any type of material inducement orfinancial incentive to an enrollee to discourage the enrollee from accessingany of the services listed in subsection 1;

(d) Penalize a provider of health care who provides anyof the services listed in subsection 1 to an enrollee, 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 anenrollee.

3. Except as otherwise provided in subsection 5,evidence of coverage subject to the provisions of this chapter that isdelivered, issued for delivery or renewed on or after October 1, 1999, has thelegal effect of including the coverage required by subsection 1, and anyprovision of the evidence of coverage or the renewal which is in conflict withthis section is void.

4. The provisions of this section do not:

(a) Require a health maintenance organization toprovide coverage for fertility drugs.

(b) Prohibit a health maintenance organization fromrequiring an enrollee to pay a deductible, copayment or coinsurance for thecoverage required by paragraphs (a) and (b) of subsection 1 that is the same asthe enrollee is required to pay for other prescription drugs covered by theplan.

5. A health maintenance organization which offers orissues a health care plan and which is affiliated with a religious organizationis not required to provide the coverage required by paragraph (a) of subsection1 if the health maintenance organization objects on religious grounds. Thehealth maintenance organization shall, before the issuance of a health careplan and before renewal of enrollment in such a plan, provide to the grouppolicyholder or prospective enrollee, as applicable, written notice of thecoverage that the health maintenance organization refuses to provide pursuantto this subsection. The health maintenance organization shall provide notice toeach enrollee, at the time the enrollee receives his evidence of coverage, thatthe health maintenance organization refused to provide coverage pursuant tothis subsection.

6. If a health maintenance organization refuses,pursuant to subsection 5, to provide the coverage required by paragraph (a) ofsubsection 1, an employer may otherwise provide for the coverage for hisemployees.

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

(Added to NRS by 1999, 2001)

NRS 695C.1695 Requiredprovision concerning coverage of health care services related to contraceptivesand hormone replacement therapy in certain circumstances; prohibited actions byhealth maintenance organization; exceptions.

1. Except as otherwise provided in subsection 5, ahealth maintenance organization that offers or issues a health care plan whichprovides coverage for outpatient care shall include in the plan coverage forany health care service related to contraceptives or hormone replacementtherapy.

2. A health maintenance organization that offers orissues a health care plan that provides coverage for outpatient care shall not:

(a) Require an enrollee 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 hormone replacementtherapy than is required for other outpatient care covered by the plan;

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

(c) Offer or pay any type of material inducement orfinancial incentive to an enrollee to discourage the enrollee from accessingany of the services listed in subsection 1;

(d) Penalize a provider of health care who provides anyof the services listed in subsection 1 to an enrollee, 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 anenrollee.

3. Except as otherwise provided in subsection 5,evidence of coverage subject to the provisions of this chapter that isdelivered, issued for delivery or renewed on or after October 1, 1999, has thelegal effect of including the coverage required by subsection 1, and anyprovision of the evidence of coverage or the renewal which is in conflict withthis section is void.

4. The provisions of this section do not prohibit ahealth maintenance organization from requiring an enrollee to pay a deductible,copayment or coinsurance for the coverage required by subsection 1 that is thesame as the enrollee is required to pay for other outpatient care covered bythe plan.

5. A health maintenance organization which offers orissues a health care plan and which is affiliated with a religious organizationis not required to provide the coverage for health care service related tocontraceptives required by this section if the health maintenance organizationobjects on religious grounds. The health maintenance organization shall, beforethe issuance of a health care plan and before renewal of enrollment in such aplan, provide to the group policyholder or prospective enrollee, as applicable,written notice of the coverage that the health maintenance organization refusesto provide pursuant to this subsection. The health maintenance organizationshall provide notice to each enrollee, at the time the enrollee receives hisevidence of coverage, that the health maintenance organization refused toprovide coverage pursuant to this subsection.

6. If a health maintenance organization refuses,pursuant to subsection 5, to provide the coverage required by paragraph (a) ofsubsection 1, an employer may otherwise provide for the coverage for hisemployees.

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

(Added to NRS by 1999, 2002)

NRS 695C.170 Evidenceof coverage: Issuance; form and contents.

1. Every enrollee residing in this state is entitledto evidence of coverage under a health care plan. If the enrollee obtainscoverage under a health care plan through an insurance policy, whether byoption or otherwise, the insurer shall issue the evidence of coverage.Otherwise, the health maintenance organization shall issue the evidence ofcoverage.

2. Evidence of coverage or amendment thereto must notbe issued or delivered to any person in this state until a copy of the form ofthe evidence of coverage or amendment thereto has been filed with and approvedby the Commissioner.

3. An evidence of coverage:

(a) Must not contain any provisions or statements whichare unjust, unfair, inequitable, misleading, deceptive, which encouragemisrepresentation or which are untrue, misleading or deceptive as defined insubsection 1 of NRS 695C.300; and

(b) Must contain a clear and complete statement, if acontract, or a reasonably complete summary if a certificate, of:

(1) The health care services and the insuranceor other benefits, if any, to which the enrollee is entitled under the healthcare plan;

(2) Any limitations on the services, kind ofservices, benefits, or kind of benefits, to be provided, including anydeductible or copayment feature;

(3) Where and in what manner the services may beobtained;

(4) The total amount of payment for health careservices and the indemnity or service benefits, if any, which the enrollee isobligated to pay; and

(5) A provision for benefits payable forexpenses incurred for the treatment of the abuse of alcohol or drugs, asprovided in NRS 695C.174.

Anysubsequent change may be evidenced in a separate document issued to theenrollee.

4. A copy of the form of the evidence of coverage tobe used in this state and any amendment thereto is subject to the requirementsfor filing and approval of subsection 2 unless it is subject to thejurisdiction of the Commissioner under the laws governing health insurance, inwhich event the provisions for filing and approval of those laws apply. To theextent that such provisions do not apply to the requirements in subsection 3,such provisions are amended to incorporate the requirements of subsection 3 inapproving or disapproving an evidence of coverage required by subsection 2.

(Added to NRS by 1973, 1251; A 1975, 1852; 1979,1182; 1983, 2041)

NRS 695C.1703 Coveragefor prescription drugs: Provision of notice and information regarding use offormulary.

1. A health maintenance organization or insurer thatoffers or issues evidence of coverage which provides coverage for prescriptiondrugs shall include with any evidence of that coverage provided to an enrollee,notice of whether a formulary is used and, if so, of the opportunity to secureinformation regarding the formulary from the organization or insurer pursuantto 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 organization orinsurer for making a request for information regarding the formulary pursuantto subsection 2.

2. If a health maintenance organization or insureroffers or issues evidence of coverage which provides coverage for prescriptiondrugs and a formulary is used, the organization or insurer shall:

(a) Provide to any enrollee or participating providerof health 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 organization or insurershall notify the requester that a choice of formulary lists is available.

(b) Notify each person who requests informationregarding the formulary, that the inclusion of a drug in the formulary does notguarantee that a provider of health care will prescribe that drug for aparticular medical condition.

(Added to NRS by 2001, 863)

NRS 695C.1705 Grouphealth care plan issued to replace discontinued policy or coverage:Requirements; notice of reduction of benefits; statement of benefits;applicability to self-insured employer. Exceptas otherwise provided in the provisions of NRS689B.340 to 689B.590, inclusive,and chapter 689C of NRS relating to theportability and accountability of health insurance:

1. A group health care plan issued by a healthmaintenance organization to replace any discontinued policy or coverage forgroup health insurance must:

(a) Provide coverage for all persons who were coveredunder the previous policy or coverage on the date it was discontinued; and

(b) Except as otherwise provided in subsection 2,provide benefits which are at least as extensive as the benefits provided bythe previous policy or coverage, except that benefits may be reduced orexcluded to the extent that such a reduction or exclusion was permissible underthe terms of the previous policy or coverage,

if that planis issued within 60 days after the date on which the previous policy orcoverage was discontinued.

2. If an employer obtains a replacement plan pursuantto subsection 1 to cover his employees, any benefits provided by the previouspolicy or coverage may be reduced if notice of the reduction is given to hisemployees pursuant to NRS 608.1577.

3. Any health maintenance organization which issues areplacement plan pursuant to subsection 1 may submit a written request to theinsurer which provided the previous policy or coverage for a statement ofbenefits which were provided under that policy or coverage. Upon receiving sucha request, the insurer shall give a written statement to the organizationindicating what benefits were provided and what exclusions or reductions werein effect under the previous policy or coverage.

4. If an employee or enrollee was a recipient ofbenefits under the coverage provided pursuant to NRS 695C.1709, he is not entitled tohave issued to him by a health maintenance organization a replacement plan unlesshe has reported for his normal employment for a period of 90 consecutive daysafter last being eligible to receive any benefits under the coverage providedpursuant to NRS 695C.1709.

5. The provisions of this section apply to aself-insured employer who provides health benefits to his employees andreplaces those benefits with a group health care plan issued by a healthmaintenance organization.

(Added to NRS by 1987, 850; A 1989, 1253; 1997, 2958)

NRS 695C.1707 Requiredprovision for continuation of coverage. Anypolicy of group insurance to which an enrollee is entitled under a health careplan provided by a health maintenance organization must contain a provisionwhich permits the continuation of coverage pursuant to the provisions of NRS 689B.245 to 689B.249, inclusive, 689B.340 to 689B.590, inclusive, and chapter 689C of NRS relating to the portabilityand accountability of health insurance.

(Added to NRS by 1987, 2235; A 1997, 2959)

NRS 695C.1709 Requiredprovision concerning coverage for enrollee on leave without pay as result oftotal disability.

1. As used in this section, total disability andtotally disabled mean the continuing inability of the enrollee, because of aninjury or illness, to perform substantially the duties related to hisemployment for which he is otherwise qualified.

2. No policy of group insurance to which an enrolleeis entitled under a health care plan provided by a health maintenanceorganization may be delivered or issued for delivery in this state unless itprovides continuing coverage for an enrollee and his dependents who areotherwise covered by the policy while the enrollee is on leave without pay as aresult of a total disability. The coverage must be for any injury or illnesssuffered by the enrollee which is not related to the total disability or forany injury or illness suffered by his dependent. The coverage must be equal toor greater than the coverage otherwise provided by the policy.

3. The coverage required pursuant to subsection 2 mustcontinue until:

(a) The date on which the employment of the enrollee isterminated;

(b) The date on which the enrollee obtains anotherpolicy of health insurance;

(c) The date on which the policy of group insurance isterminated; or

(d) After a period of 12 months in which benefits undersuch coverage are provided to the enrollee,

whicheveroccurs first.

(Added to NRS by 1989, 1253)

NRS 695C.171 Requiredprovision concerning coverage relating to mastectomy.

1. A health maintenance plan which provides coveragefor the surgical procedure known as a mastectomy must also provide commensuratecoverage 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 of reimbursementwith 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, but is not limited to, augmentation mammoplasty, reductionmammoplasty and mastopexy.

(Added to NRS by 1983, 615; A 1989, 1891; 2001, 2250)

NRS 695C.1713 Requiredprovision concerning coverage of certain gynecological and obstetrical serviceswithout authorization or referral from primary care physician.

1. A health care plan must include a provisionauthorizing a woman covered by the plan to obtain covered gynecological orobstetrical services without first receiving authorization or a referral fromher primary care physician.

2. The provisions of this section do not authorize awoman covered by a health care plan to designate an obstetrician orgynecologist as her primary care physician.

3. An evidence of coverage subject to the provisionsof this chapter that is delivered, issued for delivery or renewed on or afterOctober 1, 1999, has the legal effect of including the coverage required bythis section, and any provision of the evidence of coverage or the renewalwhich is in conflict with 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 1999, 1944)

NRS 695C.172 Requiredprovision concerning coverage relating to complications of pregnancy.

1. No health maintenance organization may issueevidence of coverage under a health care plan to any enrollee in this state ifit contains any exclusion, reduction or other limitation of coverage relatingto complications of pregnancy unless the provision applies generally to allbenefits payable under the policy and complies with the provisions of NRS 689B.340 to 689B.590, inclusive, and chapter 689C of NRS relating to the portabilityand accountability of health insurance.

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. Evidence of coverage under a health care plansubject to the provisions of this chapter which is issued on or after July 1,1977, has the legal effect of including the coverage required by this section,and any provision which is in conflict with this section is void.

(Added to NRS by 1977, 416; A 1997, 2959)

NRS 695C.1723 Requiredprovision concerning coverage for treatment of certain inherited metabolicdiseases.

1. A health maintenance plan must provide 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 health maintenance planwas purchased.

3. Any evidence of coverage subject to the provisionsof this chapter that is delivered, issued for delivery or renewed on or afterJanuary 1, 1998, has the legal effect of including the coverage required bythis section, and any provision of the evidence of coverage or the renewalwhich is in conflict with this section 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 695C.1727 Requiredprovision concerning coverage for management and treatment of diabetes.

1. No evidence of coverage that provides coverage forhospital, medical or surgical expenses may be delivered or issued for deliveryin this state unless the evidence of coverage includes coverage for themanagement and treatment of diabetes, including, without limitation, coveragefor the self-management of diabetes.

2. An insurer who delivers or issues for delivery anevidence of coverage specified in subsection 1:

(a) Shall include in the disclosure required pursuantto NRS 695C.193 notice to eachenrollee under the evidence of coverage of the availability of the benefits requiredby this section.

(b) Shall provide the coverage required by this sectionsubject to the same deductible, copayment, coinsurance and other suchconditions for the evidence of coverage that are required under the evidence ofcoverage.

3. Evidence of coverage subject to the provisions ofthis chapter that is delivered, issued for delivery or renewed on or afterJanuary 1, 1998, has the legal effect of including the coverage required bythis section, and any provision of the evidence of coverage that conflicts withthis section is void.

4. As used in this section:

(a) Coverage for the management and treatment ofdiabetes includes coverage for medication, equipment, supplies and appliancesthat are medically necessary for the treatment of diabetes.

(b) Coverage for the self-management of diabetesincludes:

(1) The training and education provided to theenrollee after he is initially diagnosed with diabetes which is medicallynecessary for the care and management of diabetes, including, withoutlimitation, counseling in nutrition and the proper use of equipment andsupplies for the treatment of diabetes;

(2) Training and education which is medicallynecessary as a result of a subsequent diagnosis that indicates a significantchange in the symptoms or condition of the enrollee and which requiresmodification of his program of self-management of diabetes; and

(3) Training and education which is medicallynecessary because of the development of new techniques and treatment fordiabetes.

(c) Diabetes includes type I, type II and gestationaldiabetes.

(Added to NRS by 1997, 745)

NRS 695C.173 Requiredprovision concerning coverage for newly born and adopted children and childrenplaced for adoption.

1. All individual and group health care plans whichprovide coverage for a family member of the enrollee must as to such coverageprovide that the health care services applicable for children are payable withrespect to:

(a) A newly born child of the enrollee from the momentof birth;

(b) An adopted child from the date the adoption becomeseffective, if the child was not placed in the home before adoption; and

(c) A child placed with the enrollee for the purpose ofadoption from the moment of placement as certified by the public or privateagency making the placement. The coverage of such a child ceases if theadoption proceedings are terminated as certified by the public or privateagency making the placement.

The plansmust provide the coverage specified in subsection 3, and must not excludepremature births.

2. The evidence of coverage may require thatnotification of:

(a) The birth of a newly born child;

(b) The effective date of adoption of a child; or

(c) The date of placement of a child for adoption,

and paymentsof the required charge, if any, must be furnished to the health maintenanceorganization 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 preventive health care services aswell as coverage of injury or sickness, including the necessary care andtreatment of medically diagnosed congenital defects and birth abnormalitiesand, within the limits of the policy, necessary transportation costs from placeof birth to the nearest specialized treatment center under major medicalpolicies, and with respect to basic policies to the extent such costs arecharged by the treatment center.

4. A health maintenance organization shall notrestrict the coverage of a dependent child adopted or placed for adoptionsolely because of a preexisting condition the child has at the time he wouldotherwise become eligible for coverage pursuant to that plan. Any provisionrelating to an exclusion for a preexisting condition must comply with NRS 689B.500 or 689C.190, as appropriate.

5. For covered services provided to the child, thehealth maintenance organization shall reimburse noncontracted providers ofhealth care to an amount equal to the average amount of payment for which theorganization has agreements, contracts or arrangements for those coveredservices.

(Added to NRS by 1975, 1110; A 1989, 741; 1995, 2436;1997, 2959)

NRS 695C.1731 Requiredprovision concerning coverage for screening for colorectal cancer.

1. A health care plan issued by a health maintenanceorganization that provides coverage for the treatment of colorectal cancer mustprovide coverage for colorectal cancer screening in accordance with:

(a) The guidelines concerning colorectal cancerscreening which are published by the American Cancer Society; or

(b) Other guidelines or reports concerning colorectalcancer screening which are published by nationally recognized professionalorganizations and which include current or prevailing supporting scientificdata.

2. An evidence of coverage for a health care plansubject to the provisions of this chapter that is delivered, issued fordelivery or renewed on or after October 1, 2003, has the legal effect ofincluding the coverage required by this section, and any provision of theevidence of coverage that conflicts with the provisions of this section isvoid.

(Added to NRS by 2003, 1335)

NRS 695C.1733 Requiredprovision concerning coverage for certain drugs for treatment of cancer.Except as otherwise provided in NRS695C.1693:

1. No evidence of coverage that provides coverage fora drug approved by the Food and Drug Administration for use in the treatment ofan illness, disease or other medical condition may be delivered or issued fordelivery in this state unless the evidence of coverage includes coverage forany other use of the drug for the treatment of cancer, if that use is:

(a) Specified in the most recent edition of orsupplement to:

(1) The United States Pharmacopoeia DrugInformation; or

(2) The American Hospital Formulary ServiceDrug Information; or

(b) Supported by at least two articles reporting theresults of scientific studies that are published in scientific or medicaljournals, as defined in 21 C.F.R. 99.3.

2. The coverage required pursuant to this section:

(a) Includes coverage for any medical servicesnecessary to administer the drug to the enrollee.

(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. Any evidence of coverage subject to the provisionsof this chapter that is delivered, issued for delivery or renewed on or afterOctober 1, 1999, has the legal effect of including the coverage required bythis section, and any provision of the evidence of coverage that conflicts withthe provisions of this section is void.

(Added to NRS by 1999, 761; A 2003, 3531)

NRS 695C.1734 Requiredprovision concerning coverage for prescription drug previously approved formedical condition of enrollee.

1. Except as otherwise provided in this section,evidence of coverage which provides coverage for prescription drugs must notlimit or exclude coverage for a drug if the drug:

(a) Had previously been approved for coverage by thehealth maintenance organization or insurer for a medical condition of anenrollee and the enrollees provider of health care determines, afterconducting a reasonable investigation, that none of the drugs which areotherwise currently approved for coverage are medically appropriate for theenrollee; and

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

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 health maintenance organization orinsurer from charging a deductible, copayment or coinsurance for the provisionof benefits for prescription drugs to the enrollee or from establishing, bycontract, limitations on the maximum coverage for prescription drugs;

(2) A provider of health care from prescribinganother drug covered by the evidence of coverage that is medically appropriatefor the enrollee; or

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

(c) Require any coverage for a drug after the term ofthe evidence of coverage.

3. Any provision of an evidence of coverage subject tothe provisions of this chapter that is delivered, issued for delivery orrenewed on or after October 1, 2001, which is in conflict with this section isvoid.

(Added to NRS by 2001, 863; A 2003, 2300)

NRS 695C.1735 Requiredprovision concerning coverage for cytologic screening tests and mammograms forcertain women.

1. A health maintenance planmust provide coverage 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 health maintenance planmust not require an insured to obtain prior authorization for any serviceprovided pursuant to subsection 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 coveragerequired by subsection 1, and any provision of the policy or the renewal whichis in conflict with subsection 1 is void.

(Added to NRS by 1989, 1891; A 1997, 1730)

NRS 695C.1738 Requiredprovision concerning coverage for treatment of conditions relating to severemental illness.

1. Notwithstanding any provisions of this title to thecontrary, any evidence of coverage delivered or issued for delivery in thisstate pursuant to this chapter must provide coverage for the treatment ofconditions relating to severe mental illness.

2. The coverage required by this section:

(a) Must provide:

(1) Benefits for at least 40 days ofhospitalization as an inpatient per year of coverage and 40 visits fortreatment as an outpatient per year of coverage, excluding visits for themanagement of medication; 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 evidence of coverage required toprovide coverage for more than 40 days of hospitalization as an inpatient per yearof coverage.

(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 evidence of coverage.

4. The provisions of this section do not apply to anyevidence of coverage:

(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 year for which coverage wasprovided, the premiums charged for the evidence of coverage, or a standardgrouping of evidence of coverage, increase by more than 2 percent as a resultof providing the coverage required by this section and the health maintenanceorganization obtains an exemption from the Commissioner pursuant to subsection5.

5. To obtain the exemption required by paragraph (b)of subsection 4, a health maintenance organization must submit to theCommissioner a written request therefor that is signed by an actuary and setsforth the reasons and actuarial assumptions upon which the request is based. Todetermine whether an exemption may be granted, the Commissioner shall subtractfrom the amount of premiums charged during the year for which coverage wasprovided the amount of premiums charged during the period immediately precedingthat year and the amount of any increase in the premiums charged that isattributable to factors that are unrelated to providing the coverage requiredby this section. The Commissioner shall verify the information within 30 daysafter receiving the request. The request shall be deemed approved if theCommissioner does not deny the request within that time.

6. The provisions of this section do not:

(a) Limit the provision of specialized services coveredby Medicaid for persons with conditions relating to mental health or substanceabuse.

(b) Supersede any provision of federal law, any federalor state policy relating to Medicaid, or the terms and conditions imposed onany Medicaid waiver granted to this state with respect to the provisions ofservices to persons with conditions relating to mental health or substanceabuse.

7. Any evidence of coverage subject to the provisionsof this chapter which is delivered, issued for delivery or renewed on or afterJanuary 1, 2000, has the legal effect of including the coverage required bythis section, and any provision of the evidence of coverage or the renewalwhich is in conflict with this section is void, unless the evidence of coverageis otherwise exempt from the provisions of this section pursuant to subsection4.

8. As used in this section, severe mental illnessmeans any of the following mental illnesses that are biologically based and forwhich diagnostic criteria are prescribed in the Diagnostic and StatisticalManual of Mental Disorders, Fourth Edition, published by the AmericanPsychiatric Association:

(a) Schizophrenia.

(b) Schizoaffective disorder.

(c) Bipolar disorder.

(d) Major depressive disorders.

(e) Panic disorder.

(f ) Obsessive-compulsivedisorder.

(Added to NRS by 1999, 3104)

NRS 695C.174 Requiredprovision concerning benefits for treatment of abuse of alcohol or drugs.

1. The benefits provided byhealth maintenance plans for treatment of the abuse of alcohol or drugs asrequired by subparagraph (5) of paragraph (b) of subsection 3 of NRS 695C.170, 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, 1181; A 1983, 2042; 1985,1571, 1778; 1993, 1922; 1997, 1302; 1999, 1890; 2001, 440)

NRS 695C.1755 Requiredprovision concerning coverage for treatment of temporomandibular joint.

1. Except as otherwise provided in this section, noevidence of coverage may be delivered or issued for delivery in this state ifit contains an exclusion of coverage of the treatment of the temporomandibularjoint whether by specific language in the evidence of coverage or by a claimssettlement practice. An evidence of coverage may exclude coverage of thosemethods of treatment which are recognized as dental procedures, including, butnot limited to, the extraction of teeth and the application of orthodonticdevices and splints.

2. The health maintenance organization may limit itsliability on the treatment of the temporomandibular joint to:

(a) No more than 50 percent of the usual and customarycharges for such treatment actually received by an enrollee, but in no casemore than 50 percent of the maximum benefits provided by the evidence ofcoverage for such treatment; and

(b) Treatment which is medically necessary.

3. Any provision of an evidence of coverage subject tothe provisions 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, 2139)

NRS 695C.176 Requiredprovision concerning coverage for hospice care. Eachhealth care plan must provide benefits for hospice care.

(Added to NRS by 1983, 1936; A 1985, 1779; 1989,1033)

NRS 695C.1765 Reimbursementfor acupuncture. If any evidence of coverageprovides coverage for acupuncture performed by a physician, the insured isentitled to reimbursement for acupuncture performed by a person who is licensedpursuant to chapter 634A of NRS.

(Added to NRS by 1991, 1134)

NRS 695C.177 Reimbursementfor treatments by licensed psychologist. Ifany evidence of coverage provides coverage for treatment of an illness which iswithin the authorized scope of the practice of a qualified psychologist, theinsured is entitled to reimbursement for treatments by a psychologist who islicensed pursuant to chapter 641 of NRS.

(Added to NRS by 1981, 576; A 1989, 1553)

NRS 695C.1773 Reimbursementfor treatment by licensed marriage and family therapist. If any evidence of coverage provides coverage fortreatment of an illness which is within the authorized scope of the practice ofa licensed marriage and family therapist, the insured is entitled toreimbursement for treatment by a marriage and family therapist who is licensedpursuant to chapter 641A of NRS.

(Added to NRS by 1987, 2134)

NRS 695C.1775 Reimbursementfor treatment by licensed associate in social work, social worker, independentsocial worker or clinical social worker. Ifany evidence of coverage provides coverage for treatment of an illness which iswithin the authorized scope of the practice of a licensed associate in socialwork, social worker, independent social worker or clinical social worker, theinsured is entitled to reimbursement for treatment by an associate in socialwork, social worker, independent social worker or clinical social worker who islicensed pursuant to chapter 641B of NRS.

(Added to NRS by 1987, 1123)

NRS 695C.178 Reimbursementfor treatment by chiropractor.

1. If any evidence of coverage provides coverage fortreatment of an illness which is within the authorized scope of practice of aqualified chiropractor, the insured is entitled to reimbursement for treatmentsby a chiropractor who is licensed pursuant to chapter634 of NRS.

2. The terms of the policy must not limit:

(a) Coverage for treatments by a chiropractor to anumber less than for treatments by other physicians.

(b) Reimbursement for treatments by a chiropractor toan amount less than that charged for similar treatments by other physicians.

(Added to NRS by 1981, 930; A 1983, 328)

NRS 695C.179 Reimbursementfor services provided by certain nurses; prohibited limitations; exceptions.

1. If any evidence of coverage provides coverage forservices which are within the authorized scope of practice of a registered nursewho is authorized pursuant to chapter 632 ofNRS to perform additional acts in an emergency or under other specialconditions as prescribed by the State Board of Nursing, and which are reimbursedwhen provided by another provider of health care, the insured is entitled toreimbursement for services provided by such a registered nurse.

2. The terms of the evidence of coverage must notlimit:

(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, 1448)

NRS 695C.1795 Reimbursementto provider of medical transportation.

1. Except as otherwise provided in subsection 3, everyevidence of coverage amended, delivered or issued for delivery in this Stateafter October 1, 1989, that provides coverage for medical transportation, mustcontain a provision for the direct reimbursement of a provider of medicaltransportation for covered services if that provider does not receivereimbursement from any other source.

2. The enrollee or the provider may submit the claimfor reimbursement. The provider shall not demand payment from the enrolleeuntil after that reimbursement has been granted or denied.

3. Subsection 1 does not apply to any agreementbetween a health maintenance organization and a provider of medicaltransportation for the direct payment by the organization for the providersservices.

(Added to NRS by 1989, 1274)

NRS 695C.180 Scheduleof charges.

1. No schedule of charges for enrollee coverage forhealth care services or amendment thereto may be used in conjunction with anyhealth care plan until a copy of such schedule or amendment thereto has beenfiled with and approved by the Commissioner.

2. Such charges may be established in accordance withactuarial principles for various categories of enrollees. However the chargesshall not be excessive, inadequate nor unfairly discriminatory. A certificationby a qualified actuary to the adequacy of the charges shall accompany thefiling along with adequate supporting information.

(Added to NRS by 1973, 1251)

NRS 695C.185 Approvalor denial of claims; payment of claims and interest; requests for additionalinformation; award of costs and attorneys fees; compliance with requirements.

1. Except as otherwise provided in subsection 2, ahealth maintenance organization shall approve or deny a claim relating to ahealth care plan within 30 days after the health maintenance organizationreceives the claim. If the claim is approved, the health maintenanceorganization 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 health maintenance organization shall pay interest on theclaim at a rate of interest equal to the prime rate at the largest bank inNevada, as ascertained by the Commissioner of Financial Institutions, onJanuary 1 or July 1, as the case may be, immediately preceding the date onwhich the payment was due, plus 6 percent. The interest must be calculated from30 days after the date on which the claim is approved until the date on whichthe claim is paid.

2. If the health maintenance organization requiresadditional information to determine whether to approve or deny the claim, itshall notify the claimant of its request for the additional information within20 days after it receives the claim. The health maintenance organization shallnotify the provider of health care services of all the specific reasons for thedelay in approving or denying the claim. The health maintenance organizationshall approve or deny the claim within 30 days after receiving the additionalinformation. If the claim is approved, the health maintenance organizationshall pay the claim within 30 days after it receives the additional information.If the approved claim is not paid within that period, the health maintenanceorganization shall pay interest on the claim in the manner prescribed insubsection 1.

3. A health maintenance organization shall not requesta claimant to resubmit information that the claimant has already provided tothe health maintenance organization, unless the health maintenance organizationprovides a legitimate reason for the request and the purpose of the request isnot to delay the payment of the claim, harass the claimant or discourage thefiling of claims.

4. A health maintenance organization shall not payonly part of a claim that 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 health maintenance organization.

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

8. If the Commissioner determines that a healthmaintenance organization is not in substantial compliance with the requirementsset forth in this section, the Commissioner may require the health maintenanceorganization to pay an administrative fine in an amount to be determined by theCommissioner. Upon a second or subsequent determination that a healthmaintenance organization is not in substantial compliance with the requirementsset forth in this section, the Commissioner may suspend or revoke thecertificate of authority of the health maintenance organization.

(Added to NRS by 1991, 1331; A 1999, 1651; 2001, 2735; 2003, 3368)

NRS 695C.187 Schedulefor payment of claims: Mandatory inclusion in arrangements for provision ofhealth care.

1. A health maintenance organization shall not:

(a) Enter into any contract or agreement, or make anyother arrangements, with a provider for the provision of health care; or

(b) Employ a provider pursuant to a contract, anagreement or any other arrangement to provide health care,

unless thecontract, agreement or other arrangement specifically provides that the healthmaintenance organization and provider agree to the schedule for the payment ofclaims set forth in NRS 695C.185.

2. Any contract, agreement or other arrangementbetween a health maintenance organization and a provider that is entered intoor renewed on or after October 1, 2001, that does not specifically include aprovision concerning the schedule for the payment of claims as required bysubsection 1 shall be deemed to conform with the requirements of subsection 1by operation of law.

(Added to NRS by 2001, 2734)

NRS 695C.190 Commissionermay require submission of information. TheCommissioner may require the submission of whatever relevant information hedeems necessary in determining whether to approve or disapprove a filing madepursuant to NRS 695C.170 to 695C.200, inclusive.

(Added to NRS by 1973, 1252; A 1985, 1448; 1989,1274)

NRS 695C.193 Summaryof coverage: Contents of disclosure; approval by Commissioner; regulations.

1. The Commissioner shall adopt regulations whichrequire a health maintenance organization to file with the Commissioner, forhis approval, a disclosure summarizing the coverage provided by each healthcare plan offered by the health maintenance organization. The disclosure mustinclude:

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

(b) Any other information,

that theCommissioner finds necessary to provide for full and fair disclosure of theprovisions of the plan.

2. The disclosure must be written in language which iseasily understood and must include a statement that the disclosure is a summaryof the plan only, and that the evidence of coverage itself should be read todetermine the 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, 1253)

NRS 695C.195 Summaryof coverage: Copy to be provided before policy issued; policy not to be offeredunless summary approved by Commissioner. Ahealth maintenance organization shall provide to the group policyholder to whomit offers a health care plan a copy of the disclosure approved for that planpursuant to NRS 695C.193 before theplan is issued. A health maintenance organization shall not offer a health careplan unless the disclosure for that plan has been approved by the Commissioner.

(Added to NRS by 1989, 1253)

NRS 695C.200 Approvalof forms and schedules. The Commissioner shallwithin a reasonable period approve any form if the requirements of NRS 695C.170 are met and any schedule ofcharges if the requirements of NRS695C.180 are met. It is unlawful to issue such form or to use such scheduleof charges until approved. If the Commissioner disapproves such filing, heshall notify the filer. In the notice, the Commissioner shall specify thereasons for his disapproval. A hearing will be granted within 90 days after arequest in writing by the person filing.

(Added to NRS by 1973, 1251)

NRS 695C.201 Offeringpolicy of health insurance for purposes of establishing health savings account. A health maintenance organization may, subject toregulation by the Commissioner, offer a policy of health insurance that has ahigh deductible and is in compliance with 26 U.S.C. 223 for the purposes ofestablishing a health savings account.

(Added to NRS by 2005, 2158)

NRS 695C.203 Denyingcoverage solely because person was victim of domestic violence prohibited. A health maintenance organization shall not deny a claim,refuse to issue a policy or cancel a policy solely because the claim involvesan act that constitutes domestic violence pursuant to NRS 33.018, or because the person applyingfor or covered by the policy was the victim of such an act of domestic violence,regardless of whether the insured or applicant contributed to any loss orinjury.

(Added to NRS by 1997, 1096)

NRS 695C.205 Denyingcoverage solely because insured was intoxicated or under the influence ofcontrolled substance prohibited; exceptions. [Effective July 1, 2006.]

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

(a) Deny a claim under a health care plan solelybecause the claim involves an injury sustained by an enrollee as a consequenceof being intoxicated or under the influence of a controlled substance.

(b) Cancel participation under a health care plansolely because an enrollee has made a claim involving an injury sustained bythe enrollee as a consequence of being intoxicated or under the influence of acontrolled substance.

(c) Refuse participation under a health care plan to aneligible applicant solely because the applicant has made a claim involving an injurysustained by the applicant as a consequence of being intoxicated or under theinfluence of a controlled substance.

2. Theprovisions of this section do not prohibit a health maintenance organizationfrom enforcing a provision included in a health care plan to:

(a) Deny a claim which involves an injury to which acontributing cause was the insureds commission of or attempt to commit afelony;

(b) Cancel participation under a health care plansolely because of such a claim; or

(c) Refuse participation under a health care plan to aneligible applicant solely because of such a claim.

(Added to NRS by 2005, 2345,effective July 1, 2006)

NRS 695C.207 Requiringor using information concerning genetic testing.

1. A health maintenance organization shall not:

(a) Require an enrollee or any member of his family totake a genetic test;

(b) Require an enrollee to disclose whether he or anymember of his family has taken a genetic test or the genetic information of theenrollee 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 enrollee based on:

(1) Whether the enrollee or any member of hisfamily has taken a genetic test; or

(2) Any genetic information of the enrollee orany member of his family.

2. 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 which 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 695C.210 Annualreport and financial statement required; administrative penalty for failure tofile report or statement.

1. Every health maintenance organization shall filewith the Commissioner on or before March 1 of each year a report showing itsfinancial condition on the last day of the preceding calendar year. The reportmust be verified by at least two principal officers of the organization. Theorganization shall file a copy of the report with the State Board of Health.

2. The report must be on forms prescribed by theCommissioner and must include:

(a) A financial statement of the organization,including its balance sheet and receipts and disbursements for the precedingcalendar year;

(b) Any material changes in the information submittedpursuant to NRS 695C.070;

(c) The number of persons enrolled during the year, thenumber of enrollees as of the end of the year, the number of enrollmentsterminated during the year and, if requested by the Commissioner, a compilationof the reasons for such terminations;

(d) The number and amount of malpractice claimsinitiated against the health maintenance organization and any of the providersused by it during the year broken down into claims with and without form oflegal process, and the disposition, if any, of each such claim, if requested bythe Commissioner;

(e) A summary of information compiled pursuant toparagraph (c) of subsection 2 of NRS695C.080 in such form as required by the State Board of Health; and

(f ) Such otherinformation relating to the performance of the health maintenance organizationas is necessary to enable the Commissioner to carry out his duties pursuant tothis chapter.

3. Every health maintenance organization shall filewith the Commissioner annually an audited financial statement of theorganization prepared by an independent certified public accountant. Thestatement must cover the preceding 12-month period and must be filed with theCommissioner within 120 days after the end of the organizations fiscal year.Upon written request, the Commissioner may grant a 30-day extension.

4. If an organization fails to file timely the reportor financial statement required by this section, it shall pay an administrativepenalty of $100 per day until the report or statement is filed, except that thetotal penalty must not exceed $3,000. The Attorney General shall recover thepenalty in the name of the State of Nevada.

5. The Commissioner may grant a reasonable extensionof time for filing the report or financial statement required by this section,if the request for an extension is submitted in writing and shows good cause.

(Added to NRS by 1973, 1252; A 1991, 2204; 1995,1632, 2681)

NRS 695C.220 Applications,filings and reports open to public inspection. Allapplications, filings and reports required under this chapter shall be treatedas public documents except as otherwise provided in this chapter.

(Added to NRS by 1973, 1258)

NRS 695C.230 Fees.

1. Every health maintenance organization subject tothis chapter shall pay to the Commissioner the following fees:

(a) For filing an application for a certificate ofauthority, $2,450.

(b) For issuance of a certificate of authority, $250.

(c) For an amendment to a certificate of authority,$100.

(d) For the renewal of a certificate of authority,$2,450.

(e) For filing each annual report, $25.

2. At the time of filing the annual report the healthmaintenance organization shall forward to the department of taxation the taxand any penalty for nonpayment or delinquent payment of the tax in accordancewith the provisions of chapter 680B of NRS.

3. All fees paid pursuant to this section shall bedeemed earned when paid and may not be refunded.

(Added to NRS by 1973, 1257; A 1987, 470; 1991, 1634;1993, 1923)

NRS 695C.240 Informationrequired to be available for inspection. Everyhealth maintenance organization shall have available for inspection the followinginformation:

1. A current statement of financial conditionincluding a balance sheet and summary of receipts and disbursements;

2. A description of the organizational structure andoperation of the health maintenance organization and a summary of any materialchanges since the issuance of the last report;

3. A description of services and information as towhere and how to secure them; and

4. A clear and understandable description of thehealth maintenance organizations method for resolving enrollee complaints.

(Added to NRS by 1973, 1252)

NRS 695C.250 Openenrollment.

1. After a health maintenance organization has been inoperation 24 months, it shall have an annual open enrollment commensurate withcommon practices in the area in which it operates.

2. Health maintenance organizations providing servicesto a specified group or groups may limit the open enrollment to all members ofsuch group or groups. Specified groups may include:

(a) Employees of one or more specified employers;

(b) Members of one or more specified employeeorganizations;

(c) Members of one or more specified associations; and

(d) Participants in one or more specified grouppolicies issued by one or more specified insurers if the insurer is involved inthe operation, management or conduct of the health maintenance organization.

(Added to NRS by 1973, 1252)

NRS 695C.260 Complaintsystem. Each health maintenance organizationshall establish:

1. A system for resolving complaints which complieswith the provisions of NRS 695G.200 to695G.230, inclusive; and

2. A system for conducting external reviews of finaladverse determinations that complies with the provisions of NRS 695G.241 to 695G.310, inclusive.

(Added to NRS by 1973, 1253; A 1997, 311; 2003, 778)

NRS 695C.265 Requiredprocedure for arbitration of disputes concerning independent medicalevaluations.

1. If a health maintenance organization, for any finaldetermination of benefits or care, requires an independent evaluation of themedical or chiropractic care of any person for whom such care is provided underthe evidence of coverage:

(a) The evidence of coverage must include a procedurefor binding arbitration to resolve disputes concerning independent medicalevaluations pursuant to the rules of the American Arbitration Association; and

(b) Only a physician or chiropractor who is certifiedto practice in the same field of practice as the primary treating physician orchiropractor or who is formally educated in that field may conduct theindependent evaluation.

2. The independent evaluation must include a physicalexamination of the patient, unless he is deceased, and a personal review of allX rays and reports prepared by the primary treating physician or chiropractor.A certified copy of all reports of findings must be sent to the primarytreating physician or chiropractor and the insured person within 10 workingdays after the evaluation. If the insured person disagrees with the finding ofthe evaluation, he must submit an appeal to the insurer pursuant to theprocedure for binding arbitration set forth in the evidence of coverage within30 days after he receives the finding of the evaluation. Upon its receipt of anappeal, the insurer shall so notify in writing the primary treating physicianor chiropractor.

3. 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 2concerning the appeal of the insured person.

(Added to NRS by 1989, 2116)

NRS 695C.267 Provisionrequiring binding arbitration authorized; procedures for arbitration;declaratory relief.

1. Except as otherwise provided in NRS 695C.265 and subject to the approvalof the Commissioner, a health maintenance organization may include in any evidenceof coverage issued by the organization a provision which requires an enrolleeto whom the evidence of coverage is issued and the health maintenanceorganization to submit for binding arbitration any dispute between the enrolleeand the organization concerning any matter directly or indirectly related to,or associated with, the evidence of coverage or the health care plan or healthcare services of the health maintenance organization. If such a provision isincluded in the evidence of coverage:

(a) An enrollee must be given the opportunity todecline to participate in binding arbitration at the time of his enrollment.

(b) It must clearly state that the health maintenanceorganization and an enrollee who has not declined to participate in bindingarbitration agree to forego their right to resolve any such dispute in a courtof 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 health maintenanceorganization is responsible for any administrative fees and expenses relatingto the arbitration, except that the health maintenance organization is notresponsible for attorneys fees and fees for expert witnesses unless those feesare awarded by the arbitrator.

3. If a dispute required to be submitted to bindingarbitration requires an immediate resolution to protect the physical health ofan enrollee, any party to the dispute may waive arbitration and seekdeclaratory relief in a court of competent jurisdiction.

4. If a provision described in subsection 1 isincluded in any evidence of coverage issued by a health maintenanceorganization, 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, 2559)

NRS 695C.270 Bondrequired; waiver. Each health maintenanceorganization shall furnish a surety bond in an amount satisfactory to theCommissioner or deposit with the Commissioner cash or securities acceptable tohim in at least the same amount as a guarantee that the obligations to theenrollees will be performed. The Commissioner may waive this requirementwhenever satisfied that the assets of the organization and its contracts withinsurers, governments, or other organizations are sufficient to reasonablyassure the performance of its obligations.

(Added to NRS by 1973, 1253)

NRS 695C.275 Commissionerto adopt regulations for licensing of provider-sponsored organizations.

1. To the extent authorized by federal law, theCommissioner shall adopt regulations for the licensing of provider-sponsoredorganizations in this State.

2. As used in this section, provider-sponsoredorganization has the meaning ascribed to it in 42 U.S.C. 1395w-25(d).

(Added to NRS by 1999, 2817)

NRS 695C.280 Commissionerauthorized to adopt regulations for licensing of agents or brokers. The Commissioner may adopt such reasonable regulations asare necessary to provide for the licensing of agents or brokers. An agent is aperson directly or indirectly associated with a health care plan who engages insolicitation or enrollment. A broker is a person who is directly involved withthe insured in the manner provided in chapter683A of NRS.

(Added to NRS by 1973, 1254; A 1981, 107; 1993, 2401)

NRS 695C.290 Insurancecompany may establish or contract with health maintenance organization.

1. An insurance company licensed in this State mayeither directly or through a subsidiary or affiliate organize and operate ahealth maintenance organization under the provisions of this chapter.Notwithstanding any other law which may be inconsistent herewith, any two ormore such insurance companies or subsidiaries or affiliates thereof may jointlyorganize and operate a health maintenance organization. The business ofinsurance is deemed to include the providing of health care by a healthmaintenance organization owned or operated by an insurer or a subsidiarythereof.

2. An insurer may contract with a health maintenanceorganization to provide insurance or similar protection against the cost ofcare provided through health maintenance organizations and to provide coveragein the event of the failure of the health maintenance organization to meet itsobligations. Among other things, under such contracts the insurer may makebenefit payments to health maintenance organizations for health care servicesrendered by providers pursuant to the health care plan.

(Added to NRS by 1973, 1254)

NRS 695C.300 Prohibitedpractices.

1. No health maintenance organization orrepresentative thereof may cause or knowingly permit the use of advertisingwhich is untrue or misleading, solicitation which is untrue or misleading orany form of evidence of coverage which is deceptive. For purposes of thischapter:

(a) A statement or item of information shall be deemedto be untrue if it does not conform to fact in any respect which is or may besignificant to an enrollee of, or person considering enrollment in, a healthcare plan.

(b) A statement or item of information shall be deemedto be misleading, whether or not it may be literally untrue if, in the totalcontext in which such statement is made or such item of information iscommunicated, such statement or item of information may be reasonablyunderstood by a reasonable person not possessing special knowledge regardinghealth care coverage, as indicating any benefit or advantage or the absence ofany exclusion, limitation or disadvantage of possible significance to anenrollee of, or person considering enrollment in, a health care plan if suchbenefit or advantage or absence of limitation, exclusion or disadvantage doesnot in fact exist.

(c) An evidence of coverage shall be deemed to bedeceptive if the evidence of coverage taken as a whole, and with considerationgiven to typography and format as well as language, shall be such as to cause areasonable person not possessing special knowledge regarding health care plansand evidences of coverage therefor to expect benefits, services, charges orother advantages which the evidence of coverage does not provide or which thehealth care plan issuing such evidence of coverage does not regularly makeavailable for enrollees covered under such evidence of coverage.

2. NRS 686A.010to 686A.310, inclusive, shall beconstrued to apply to health maintenance organizations, health care plans andevidences of coverage except to the extent that the nature of healthmaintenance organizations, health care plans and evidences of coverage renderthe sections therein clearly inappropriate.

3. An enrollee may not be cancelled or not renewedexcept for the failure to pay the charge for such coverage or for cause asdetermined in the master contract.

4. No health maintenance organization, unless licensedas an insurer, may use in its name, contracts, or literature any of the wordsinsurance, casualty, surety, mutual or any other words descriptive ofthe insurance, casualty or surety business or deceptively similar to the nameor description of any insurance or surety corporation doing business in thisState.

5. No person not certificated under this chapter shalluse in its name, contracts or literature the phrase health maintenanceorganization or the initials HMO.

(Added to NRS by 1973, 1253)

NRS 695C.310 Examinations.

1. The Commissioner shall make an examination of theaffairs of any health maintenance organization and providers with whom suchorganization has contracts, agreements or other arrangements pursuant to itshealth care plan as often as he deems it necessary for the protection of theinterests of the people of this State. An examination must be made not lessfrequently than once every 3 years.

2. The State Board of Health shall make an examinationconcerning the quality of health care services of any health maintenanceorganization and providers with whom such organization has contracts,agreements or other arrangements pursuant to its health care plan as often asit deems necessary for the protection of the interests of the people of thisState. An examination must be made not less frequently than once every 3 years.

3. Every health maintenance organization and providershall submit its books and records relating to the health care plan to an examinationmade pursuant to subsection 1 or 2 and in every way facilitate the examination.Medical records of natural persons and records of physicians providing servicepursuant to a contract to the health maintenance organization are not subjectto such examination, although the records are subject to subpoena upon ashowing of good cause. For the purpose of examinations, the Commissioner andthe State Board of Health may administer oaths to, and examine the officers andagents of the health maintenance organization and the principals of suchproviders concerning their business.

4. The expenses of examinations pursuant to thissection must be assessed against the organization being examined and remittedto the Commissioner or the State Board of Health, whichever is appropriate.

5. In lieu of such examination, the Commissioner mayaccept the report of an examination made by the insurance commissioner or thestate board of health of another state.

(Added to NRS by 1973, 1255; A 1991, 2036)

NRS 695C.311 Periodicexamination by Commissioner to determine financial condition of healthmaintenance organization.

1. For the purpose of determining its financialcondition, fulfillment of its contractual obligations and compliance with law,the Commissioner shall, as often as he deems advisable, examine the affairs,transactions, accounts, records and assets of a health maintenance organizationand of any person as to any matter relevant to the financial affairs of thehealth maintenance organization or to the examination. Except as otherwiseprovided in this Code, the Commissioner shall examine each health maintenanceorganization at least once every 3 years.

2. The Commissioner shall examine each healthmaintenance organization applying for an initial certificate of authority.

3. In lieu of making his own examination, theCommissioner may, in his discretion, accept a full report of the last recentexamination of a foreign or alien health maintenance organization, certified toby the supervisory officer of insurance of another state.

4. To the extent that it is practical, the examinationof a foreign or alien health maintenance organization must be made incooperation with the insurance supervisory officers of other states in whichthe organization transacts business.

(Added to NRS by 1991, 2035)

NRS 695C.313 Financialexamination: Procedure; appointment of examiner; maintenance and use ofrecords; penalty for obstruction or interference.

1. If the Commissioner determines to examine a healthmaintenance organization pursuant to NRS695C.311, he shall designate one or more examiners and instruct them as tothe scope of the examination. The examiner shall, upon demand, exhibit hisofficial credentials to the health maintenance organization being examined.

2. The Commissioner shall conduct each examination inan expeditious, fair and impartial manner.

3. The Commissioner, or the examiner if he isauthorized in writing by the Commissioner, may administer oaths and examineunder oath any person concerning any matter relevant to the examination.

4. Every health maintenance organization and itsofficers, attorneys, employees, agents and representatives shall make availableto the Commissioner or his examiners the accounts, records, documents, files,information, assets and matters of the health maintenance organization in hispossession or control relating to the subject of the examination and shallfacilitate the examination.

5. If the Commissioner or examiner finds any accountsor records to be inadequate or inadequately kept or posted, he shall so notifythe health maintenance organization and give the health maintenanceorganization a reasonable opportunity to reconstruct, rewrite, post or balancethe account or record. If the health maintenance organization fails tomaintain, complete or correct the records or accounting after the Commissioneror examiner has given the health maintenance organization written notice and areasonable opportunity to do so, the Commissioner may employ experts toreconstruct, rewrite, post or balance the account or record at the expense ofthe health maintenance organization being examined.

6. The Commissioner or an examiner shall not removeany record, account, document, file or other property of the health maintenanceorganization being examined from the office or place of business of the healthmaintenance organization unless the Commissioner or examiner has the writtenconsent of an officer of the health maintenance organization before the removalor pursuant to an order of court. This provision does not prohibit theCommissioner or examiner from making or removing copies or abstracts of arecord, account, document or file.

7. Any person who, without just cause, refuses to beexamined under oath or who willfully obstructs or interferes with an examinerin the exercise of his authority is guilty of a misdemeanor.

(Added to NRS by 1991, 2035)

NRS 695C.315 Financialexamination: Payment of expense.

1. The health maintenance organization being examinedshall pay the expense of an examination. The expenses to be paid include onlythe reasonable and proper travel and lodging expenses of the Commissioner andhis examiners and assistants, including expert assistance, reasonablecompensation to the examiners and assistants and incidental expenses asnecessarily incurred in the examination. The Commissioner shall consider thescales and limitations recommended by the National Association of InsuranceCommissioners regarding the expense and compensation for an examination.

2. The health maintenance organization shall promptlypay to the Commissioner the expenses of the examination upon presentation bythe Commissioner of a reasonably detailed written statement thereof.

(Added to NRS by 1991, 2036)

NRS 695C.317 Statutoryprocedures required for examination and hearing. TheCommissioner shall use the procedures required by:

1. NRS 679B.230to 679B.290, inclusive, whenconducting an examination of a health maintenance organization.

2. NRS 679B.310to 679B.370, inclusive, whenconducting a hearing involving a health maintenance organization.

(Added to NRS by 1991, 2036)

NRS 695C.320 Rehabilitation,liquidation or conservation. Any rehabilitation,liquidation or conservation of a health maintenance organization shall bedeemed to be the rehabilitation, liquidation or conservation of an insurancecompany and shall be conducted under the supervision of the Commissionerpursuant to the law governing the rehabilitation, liquidation, or conservationof insurance companies.

(Added to NRS by 1973, 1256)

NRS 695C.325 Authorizationto offer health care plan to small employer for purpose of establishing medicalsavings accounts. A health maintenance organizationmay offer to a small employer who has not less than 2 and not more than 50employees, a health care plan that has a high deductible and that is in compliancewith 26 U.S.C. 220 for the purposes of establishing medical savings accountsfor any person insured by the health care plan.

(Added to NRS by 1997, 2957)

NRS 695C.330 Disciplinaryproceedings: Grounds; effect of suspension or revocation.

1. The Commissioner may suspend or revoke anycertificate of authority issued to a health maintenance organization pursuantto the provisions of this chapter if he finds that any of the followingconditions exist:

(a) The health maintenance organization is operatingsignificantly in contravention of its basic organizational document, its healthcare plan or in a manner contrary to that described in and reasonably inferredfrom any other information submitted pursuant to NRS 695C.060, 695C.070 and 695C.140, unless any amendments to thosesubmissions have been filed with and approved by the Commissioner;

(b) The health maintenance organization issues evidenceof coverage or uses a schedule of charges for health care services which do notcomply with the requirements of NRS695C.1691 to 695C.200, inclusive,or 695C.207;

(c) The health care plan does not furnish comprehensivehealth care services as provided for in NRS695C.060;

(d) The State Board of Health certifies to theCommissioner that the health maintenance organization:

(1) Does not meet the requirements of subsection2 of NRS 695C.080; or

(2) Is unable to fulfill its obligations tofurnish health care services as required under its health care plan;

(e) The health maintenance organization is no longerfinancially responsible and may reasonably be expected to be unable to meet itsobligations to enrollees or prospective enrollees;

(f) The health maintenance organization has failed toput into effect a mechanism affording the enrollees an opportunity toparticipate in matters relating to the content of programs pursuant to NRS 695C.110;

(g) The health maintenance organization has failed toput into effect the system required by NRS695C.260 for:

(1) Resolving complaints in a manner reasonablyto dispose of valid complaints; and

(2) Conducting external reviews of final adversedeterminations that comply with the provisions of NRS 695G.241 to 695G.310, inclusive;

(h) The health maintenance organization or any personon its behalf has advertised or merchandised its services in an untrue, misrepresentative,misleading, deceptive or unfair manner;

(i) The continued operation of the health maintenanceorganization would be hazardous to its enrollees;

(j) The health maintenance organization fails toprovide the coverage required by NRS695C.1691; or

(k) The health maintenance organization has otherwisefailed to comply substantially with the provisions of this chapter.

2. A certificate of authority must be suspended orrevoked only after compliance with the requirements of NRS 695C.340.

3. If the certificate of authority of a healthmaintenance organization is suspended, the health maintenance organization shallnot, during the period of that suspension, enroll any additional groups or newindividual contracts, unless those groups or persons were contracted for beforethe date of suspension.

4. If the certificate of authority of a healthmaintenance organization is revoked, the organization shall proceed,immediately following the effective date of the order of revocation, to wind upits affairs and shall conduct no further business except as may be essential tothe orderly conclusion of the affairs of the organization. It shall engage inno further advertising or solicitation of any kind. The Commissioner may, bywritten order, permit such further operation of the organization as he may findto be in the best interest of enrollees to the end that enrollees are affordedthe greatest practical opportunity to obtain continuing coverage for healthcare.

(Added to NRS by 1973, 1255; A 1985, 1448; 1997, 745,1462, 1629; 1999, 417,419, 761, 2004; 2001, 141, 144; 2003, 778, 1336, 3369, 3532)

NRS 695C.340 Disciplinaryproceedings: Notice; hearing; judicial review.

1. When the Commissioner has cause to believe thatgrounds for the denial of an application for a certificate of authority exist,or that grounds for the suspension or revocation of a certificate of authorityexist, he shall notify the health maintenance organization and the State Boardof Health in writing specifically stating the grounds for denial, suspension orrevocation and fixing a time at least 30 days thereafter for a hearing on thematter.

2. The State Board of Health or its delegatedrepresentative shall be in attendance at the hearing and shall participate inthe proceedings. The recommendation and findings of the State Board of Healthwith respect to matters relating to the quality of health maintenance servicesprovided in connection with any decision regarding denial, suspension orrevocation of a certificate of authority are conclusive and binding upon theCommissioner. After the hearing, or upon the failure of the health maintenanceorganization to appear at the hearing, the Commissioner shall take action as isdeemed advisable on written findings which must be mailed to the healthmaintenance organization with a copy thereof to the State Board of Health. Theaction of the Commissioner and the recommendation and findings of the StateBoard of Health are subject to review by the First Judicial District Court ofthe State of Nevada in and for Carson City. The court may, in disposing of theissue before it, modify, affirm or reverse the order of the Commissioner inwhole or in part.

(Added to NRS by 1973, 1256; A 1981, 107)

NRS 695C.350 Violations:Remedies; penalties.

1. The Commissioner may, in lieu of suspension orrevocation of a certificate of authority under NRS 695C.330, levy an administrativepenalty in an amount not more than $2,500 for each act or violation, ifreasonable notice in writing is given of the intent to levy the penalty.

2. Any person who violates the provisions of thischapter is guilty of a misdemeanor.

3. If the Commissioner or the State Board of Healthfor any reason have cause to believe that any violation of this chapter hasoccurred or is threatened, the Commissioner or the State Board of Health maygive notice to the health maintenance organization and to the representatives,or other persons who appear to be involved in the suspected violation, toarrange a conference with the alleged violators or their authorizedrepresentatives to attempt to determine the facts relating to the suspectedviolation, and, if it appears that any violation has occurred or is threatened,to arrive at an adequate and effective means of correcting or preventing theviolation.

4. The proceedings conducted pursuant to theprovisions of subsection 3 must not be governed by any formal proceduralrequirements, and may be conducted in such manner as the Commissioner or theState Board of Health may deem appropriate under the circumstances.

5. The Commissioner may issue an order directing ahealth maintenance organization or a representative of a health maintenanceorganization to cease and desist from engaging in any act or practice inviolation of the provisions of this chapter.

6. Within 30 days after service of the order to ceaseand desist, the respondent may request a hearing on the question of whetheracts or practices in violation of this chapter have occurred. The hearing mustbe conducted pursuant to the provisions of chapter233B of NRS and judicial review must be available as provided therein.

7. In the case of any violation of the provisions ofthis chapter, if the Commissioner elects not to issue a cease and desist order,or in the event of noncompliance with a cease and desist order issued pursuantto subsection 5, the Commissioner may institute a proceeding to obtaininjunctive relief, or seek other appropriate relief in the district court ofthe judicial district of the county in which the violator resides.

(Added to NRS by 1973, 1257; A 1999, 2817)

 

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