2005 Nevada Revised Statutes - Chapter 695F — Prepaid Limited Health Service Organizations

CHAPTER 695F - PREPAID LIMITED HEALTHSERVICE ORGANIZATIONS

GENERAL PROVISIONS

NRS 695F.010 Definitions.

NRS 695F.020 Enrolleedefined.

NRS 695F.030 Evidenceof coverage defined.

NRS 695F.040 Limitedhealth service defined.

NRS 695F.043 Medicaiddefined.

NRS 695F.047 Orderfor medical coverage defined.

NRS 695F.050 Prepaidlimited health service organization defined.

NRS 695F.060 Providerdefined.

NRS 695F.070 Subscriberdefined.

NRS 695F.080 Generalapplicability of title 57 of NRS.

NRS 695F.090 Applicablestatutory provisions. [Effective through June 30, 2006.]

NRS 695F.090 Applicablestatutory provisions. [Effective July 1, 2006.]

CERTIFICATE OF AUTHORITY

NRS 695F.100 Certificaterequired.

NRS 695F.110 Applicationfor certificate.

NRS 695F.120 Reviewof application; issuance of certificate.

NRS 695F.130 Applicationof person who is licensed as insurer or holds another certificate of authority.

NRS 695F.140 Denialof application; hearing.

OPERATION

NRS 695F.150 Evidenceof coverage: Issuance; contents; amendment.

NRS 695F.153 Coveragefor prescription drugs: Provision of notice and information regarding use offormulary.

NRS 695F.156 Coveragefor prescription drug previously approved for medical condition of enrollee.

NRS 695F.160 Ratesand charges: Reasonableness.

NRS 695F.170 Procedurefor modification of rates, charges, benefits, organization, operations,documents or services.

NRS 695F.180 Investments.

NRS 695F.190 Requirementsfor reserve.

NRS 695F.200 Maintenanceof capital account and surety.

NRS 695F.210 Maintenanceof fidelity bond or deposit in lieu of bond.

NRS 695F.215 Requiredcontract with insurance company for provision of insurance, indemnity orreimbursement against cost of health care services.

NRS 695F.220 Contractbetween organization and provider or subcontractor for provision of services toenrollees.

NRS 695F.230 Establishmentof system for resolution of complaints.

REGULATION AND ENFORCEMENT

NRS 695F.300 Regulationsof Commissioner.

NRS 695F.310 Examinationof affairs of organization.

NRS 695F.320 Reportsto Commissioner; fine and suspension for noncompliance.

NRS 695F.330 Paymentof tax.

NRS 695F.340 Fees.

NRS 695F.350 Suspensionor revocation of certificate of authority.

NRS 695F.360 Violationsof chapter: Order to cease and desist; fine.

MISCELLANEOUS PROVISIONS

NRS 695F.400 Licenserequired to apply, procure, negotiate or place for another any policy orcontract of organization.

NRS 695F.410 Confidentialityand disclosure of information.

NRS 695F.420 Certaininsurers and organizations may exclude coverage duplicated pursuant to thischapter.

NRS 695F.430 Provisionof services excluded from practice of any healing arts; solicitation excludedfrom statutory provisions regarding solicitation or advertising by practitionerof healing art.

ELIGIBILITY FOR COVERAGE

NRS 695F.440 Effectof eligibility for medical assistance under Medicaid; assignment of rights tostate agency.

NRS 695F.450 Organizationprohibited from asserting certain grounds to deny enrollment of child pursuantto order if parent is insured.

NRS 695F.460 Certainaccommodations to be made when child is covered under evidence of coverage ofnoncustodial parent.

NRS 695F.470 Organizationto authorize enrollment of child of parent who is required by order to providemedical coverage under certain circumstances; termination of coverage of child.

NRS 695F.480 Organizationprohibited from restricting coverage of child based on preexisting condition ifperson who is eligible for group coverage adopts or assumes legal obligationfor child.

_________

GENERAL PROVISIONS

NRS 695F.010 Definitions. As used in this chapter, unless the context otherwiserequires, the words and terms defined in NRS695F.020 to 695F.070, inclusive,have the meanings ascribed to them in those sections.

(Added to NRS by 1991, 1113; A 1995, 2439)

NRS 695F.020 Enrolleedefined. Enrollee means a person, includinghis dependents, who is entitled to a limited health service pursuant to acontract with a person authorized to provide or arrange for that servicepursuant to this chapter.

(Added to NRS by 1991, 1113)

NRS 695F.030 Evidenceof coverage defined. Evidence of coveragemeans any certificate, agreement or contract issued to an enrollee which setsforth the coverage he is entitled to receive.

(Added to NRS by 1991, 1113)

NRS 695F.040 Limitedhealth service defined. Limited healthservice means:

1. Chiropractic, dental, hospital, medical,optometric, pharmaceutical, podiatric or surgical care;

2. Treatment relating to mental health or the abuse ofdrugs or alcohol; or

3. Such other care or treatment as may be determinedby the Commissioner to be a limited health service.

(Added to NRS by 1991, 1113; A 1993, 2402)

NRS 695F.043 Medicaiddefined. Medicaid means a program establishedin any state pursuant to Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) to provide assistance for part or all of the cost of medical carerendered on behalf of indigent persons.

(Added to NRS by 1995, 2437)

NRS 695F.047 Orderfor medical coverage defined. Order formedical coverage means an order of a court or administrative tribunal toprovide medical coverage to a child pursuant to the provisions of 42 U.S.C. 1396g-1.

(Added to NRS by 1995, 2437)

NRS 695F.050 Prepaidlimited health service organization defined.

1. Prepaid limited health service organization meansany person who, in return for a prepayment, agrees to provide or arrange forthe provision of one or more limited health services to enrollees.

2. The term does not include:

(a) A person otherwise authorized pursuant to the lawsof this state to provide a limited health service on a prepayment basis or anyother basis or to indemnify for any limited health service;

(b) A person who complies with the requirements of NRS 695F.130; or

(c) A provider who provides or arranges for theprovision of a limited health service pursuant to a contract with a prepaidlimited health service organization or person described in paragraph (a) or(b).

(Added to NRS by 1991, 1113)

NRS 695F.060 Providerdefined. Provider means any physician, dentistor any other person who is licensed or otherwise authorized in this state to providea limited health service.

(Added to NRS by 1991, 1114)

NRS 695F.070 Subscriberdefined. Subscriber means a person whoseemployment or other status, except for family dependency, is the basis for hisentitlement to receive a limited health service pursuant to a contract with aperson authorized to provide or arrange for that service pursuant to thischapter.

(Added to NRS by 1991, 1114)

NRS 695F.080 Generalapplicability of title 57 of NRS. Except asotherwise provided in this chapter or in specific provisions of this title, theprovisions of this title are not applicable to any prepaid limited healthservice organization granted a certificate of authority pursuant to thischapter. This section does not apply to an insurer licensed and regulatedpursuant to this title except with respect to its activities as a prepaidlimited health service organization authorized and regulated pursuant to thischapter.

(Added to NRS by 1991, 1114)

NRS 695F.090 Applicablestatutory provisions. [Effective through June 30, 2006.] Prepaid limited health service organizations are subjectto the provisions of this chapter and to the following provisions, to theextent reasonably applicable:

1. NRS 687B.310to 687B.420, inclusive, concerningcancellation and nonrenewal of policies.

2. NRS 687B.122to 687B.128, inclusive, concerningreadability of policies.

3. The requirements of NRS 679B.152.

4. The fees imposed pursuant to NRS 449.465.

5. NRS 686A.010to 686A.310, inclusive, concerningtrade practices and frauds.

6. The assessment imposed pursuant to NRS 679B.700.

7. Chapter 683A ofNRS.

8. To the extent applicable, the provisions of NRS 689B.340 to 689B.590, inclusive, and chapter 689C of NRS relating to the portabilityand availability of health insurance.

9. NRS 689A.035,689A.410 and 689A.413.

10. NRS 680B.025to 680B.039, inclusive, concerningpremium tax, premium tax rate, annual report and estimated quarterly taxpayments. For the purposes of this subsection, unless the context otherwiserequires that a section apply only to insurers, any reference in those sectionsto insurer must be replaced by a reference to prepaid limited health serviceorganization.

11. Chapter 692C ofNRS, concerning holding companies.

12. NRS 689A.637,concerning health centers.

(Added to NRS by 1991, 1121; A 1993, 2402; 1997,1097, 2960, 2962, 3036; 1999,631, 1652; 2001, 480, 1924)

NRS 695F.090 Applicable statutory provisions.[Effective July 1, 2006.] Prepaid limitedhealth service organizations are subject to the provisions of this chapter andto the following provisions, to the extent reasonably applicable:

1. NRS 687B.310to 687B.420, inclusive, concerningcancellation and nonrenewal of policies.

2. NRS 687B.122to 687B.128, inclusive, concerningreadability of policies.

3. The requirements of NRS 679B.152.

4. The fees imposed pursuant to NRS 449.465.

5. NRS 686A.010to 686A.310, inclusive, concerningtrade practices and frauds.

6. The assessment imposed pursuant to NRS 679B.700.

7. Chapter 683A ofNRS.

8. To the extent applicable, the provisions of NRS 689B.340 to 689B.590, inclusive, and chapter 689C of NRS relating to the portabilityand availability of health insurance.

9. NRS 689A.035,689A.410, 689A.413 and 689A.415.

10. NRS 680B.025to 680B.039, inclusive, concerningpremium tax, premium tax rate, annual report and estimated quarterly taxpayments. For the purposes of this subsection, unless the context otherwiserequires that a section apply only to insurers, any reference in those sectionsto insurer must be replaced by a reference to prepaid limited health serviceorganization.

11. Chapter 692C ofNRS, concerning holding companies.

12. NRS 689A.637,concerning health centers.

(Added to NRS by 1991, 1121; A 1993, 2402; 1997,1097, 2960, 2962, 3036; 1999,631, 1652; 2001, 480, 1924; 2005, 2346, effectiveJuly 1, 2006)

CERTIFICATE OF AUTHORITY

NRS 695F.100 Certificaterequired. A person shall not operate a prepaidlimited health service organization in this state unless he has been issued acertificate of authority by the Commissioner pursuant to this chapter.

(Added to NRS by 1991, 1114)

NRS 695F.110 Applicationfor certificate. An application for acertificate of authority to operate a prepaid limited health serviceorganization must be filed with the Commissioner on a form prescribed by him.The application must be verified by an officer or authorized representative ofthe applicant and include:

1. A copy of the applicants basic organizationaldocument, including any articles of incorporation, articles of association,partnership agreement, trust agreement or any other applicable document oramendment thereto.

2. A copy of the bylaws, rules and regulations orsimilar documents, if any, which regulate the conduct of the internal affairsof the applicant.

3. A list of the names, addresses, official positionsand biographical information of the persons responsible for conducting theapplicants affairs, including, but not limited to:

(a) The members of the board of directors;

(b) The members of the board of trustees;

(c) The members of the executive committee or othergoverning board or committee;

(d) The principal officers;

(e) Any person owning or having the right to acquire 10percent or more of the voting securities of the applicant; and

(f) If the applicant is a partnership or association,the partners or members of that partnership or association.

4. A statement generally describing the applicant, itsfacilities, employees and the limited health service or services to be offered.

5. A copy of any contract made or to be made betweenthe applicant and any provider concerning the provision of a limited healthservice to enrollees.

6. A copy of any contract made, or to be made betweenthe applicant and any person described in subsection 3 of this section.

7. A copy of any contract made or to be made betweenthe applicant and any person for the performance on the applicants behalf ofany functions, including, but not limited to, marketing, administration,enrollment, management of investments and subcontracting for the provision of alimited health service to enrollees.

8. A copy of the form of any group contract which isto be issued to employers, unions, trustees or other organizations.

9. A copy of any form for evidence of coverage to beissued to subscribers.

10. A copy of the applicants most recent financialstatements which have been audited by an independent certified publicaccountant. If the financial affairs of the parent company of the applicant areaudited by an independent certified public accountant and the financial affairsof the applicant are not audited, the applicant must submit a copy of the mostrecently audited financial statement of the parent company which was certifiedby an independent certified public accountant and the consolidating financialstatements of the applicant, unless the Commissioner determines that additionalor more recent financial information is required.

11. A copy of the applicants financial plan,including a 3-year projection of the anticipated operating results, a statementof the sources of working capital and any other sources of funding and any planfor contingencies.

12. A schedule of the rates and charges for thelimited health service.

13. A description of the proposed method of marketing.

14. A statement acknowledging that any process in anylegal action or proceeding against the applicant on a cause of action arisingin this state is valid if lawfully served.

15. A description of the procedure for the resolutionof complaints submitted by enrollees concerning the limited health serviceprovided by the prepaid limited health service organization.

16. A description of the procedures to be establishedfor quality assessment and utilization review.

17. A description of the applicants plan to complywith the provisions of NRS 695F.200.

18. The fee for filing an application for acertificate of authority.

19. Such other information as the Commissioner mayrequire to make the determination required by this chapter.

(Added to NRS by 1991, 1114)

NRS 695F.120 Reviewof application; issuance of certificate.

1. The Commissioner shall review each application andnotify the applicant of any deficiency contained in the application.

2. The Commissioner shall issue a certificate ofauthority to an applicant if:

(a) The applicant has complied with the requirementsset forth in NRS 695F.110;

(b) The persons responsible for conducting theapplicants affairs are competent, trustworthy and possess good reputations,and have the appropriate experience, training or education;

(c) The applicant is financially responsible and mayreasonably be expected to carry out its obligations to enrollees andprospective enrollees; and

(d) The agreements with providers for the limitedhealth service include the provisions required by NRS 695F.220.

3. The Commissioner may, when determining whether anapplicant complies with the requirements of paragraph (c) of subsection 2,consider:

(a) The financial soundness of the applicantsarrangements for the provision of a limited health service and the schedule ofrates, deductibles, copayments and other charges used in connection therewith;

(b) The adequacy of working capital, any other sourcesof funding and any provisions for contingencies;

(c) Any agreement for paying the cost of a limitedhealth service or for alternative coverage if the prepaid limited healthservice organization becomes insolvent; and

(d) The applicants manner of compliance with therequirements of NRS 695F.200.

(Added to NRS by 1991, 1115)

NRS 695F.130 Applicationof person who is licensed as insurer or holds another certificate of authority. Any person who is licensed as an insurer pursuant to chapter 680A of NRS or issued a certificate ofauthority pursuant to chapter 695A, 695B or 695Cof NRS may submit an application to the Commissioner for a certificate ofauthority to provide a limited health service in this state. The applicationmust include the information requested by subsections 4, 5, 7, 8, 10, 11, 12and 15 of NRS 695F.110 and anysubsequent material changes or additions thereto.

(Added to NRS by 1991, 1116)

NRS 695F.140 Denialof application; hearing.

1. If the Commissioner denies an application for acertificate of authority of a person who files an application pursuant to NRS 695F.120 or 695F.130, he shall send a written noticeto the applicant. The notice must include the reason for the denial of thecertificate.

2. The applicant may, within 30 days after it receivesthe notice, submit to the Commissioner a written request for a hearing on thematter. The Commissioner shall hold a hearing within 30 days after he receivesthe request.

3. The hearing must be held in the manner set forth inNRS 679B.310 to 679B.370, inclusive. The decision of theCommissioner is a final decision for the purpose of judicial review.

(Added to NRS by 1991, 1116)

OPERATION

NRS 695F.150 Evidenceof coverage: Issuance; contents; amendment.

1. A prepaid limited health service organization shallissue evidence of coverage to each subscriber. Each evidence of coverage mustcontain a clear and complete statement of:

(a) The limited health service which the enrollee isentitled to receive;

(b) Any limitation of that service, type of service orbenefits to be provided, and exclusions, including any deductible, copayment orother charges;

(c) Where and in what manner information is availableconcerning the location of and manner in which the limited health service maybe obtained; and

(d) The method established for the resolution ofcomplaints submitted by enrollees concerning the provision of the limitedhealth service.

2. A prepaid limited health service organization mayprovide to a subscriber any amendment to the evidence of coverage in a separatedocument.

(Added to NRS by 1991, 1116)

NRS 695F.153 Coveragefor prescription drugs: Provision of notice and information regarding use offormulary.

1. A prepaid limited health service organization thatoffers or issues evidence of coverage which provides coverage for prescriptiondrugs shall include with any evidence of that coverage provided to asubscriber, notice of whether a formulary is used and, if so, of theopportunity to secure information regarding the formulary from the organizationpursuant to subsection 2. The notice required by this subsection must:

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

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

(c) If a formulary is used, include:

(1) An explanation of:

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

(II) The procedure and criteria fordetermining which prescription drugs are included in and excluded from theformulary; and

(2) The telephone number of the organization formaking a request for information regarding the formulary pursuant to subsection2.

2. If a prepaid limited health service organizationoffers or issues evidence of coverage which provides coverage for prescriptiondrugs and a formulary is used, the organization 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 shall notifythe 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, 864)

NRS 695F.156 Coveragefor prescription drug previously approved for medical 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 theprepaid limited health service organization 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 organization from charging a deductible,copayment or coinsurance for the provision of benefits for prescription drugsto the enrollee or from establishing, by contract, limitations on the maximumcoverage 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, 865; A 2003, 2301)

NRS 695F.160 Ratesand charges: Reasonableness. The rates andcharges for a limited health service must be reasonable. The commissioner mayrequest information from the prepaid limited health service organization todetermine the reasonableness of those rates and charges.

(Added to NRS by 1991, 1117)

NRS 695F.170 Procedurefor modification of rates, charges, benefits, organization, operations,documents or services.

1. A prepaid limited health service organization shallfile with the Commissioner a notice of any change in the rates, charges,benefits or any material change of any matter or document furnished pursuant toNRS 695F.110. The organization shallsubmit any proof necessary to justify the change. No such change is effectiveunless it is approved by the Commissioner. If the Commissioner does notdisapprove of the change within 60 days after the notice is filed, the changeshall be deemed approved.

2. If a prepaid limited health service organizationwishes to add a limited health service, it shall submit:

(a) An application to the Commissioner;

(b) The information required by NRS 695F.110, if the information isdifferent from the information filed with the prepaid limited health serviceorganizations application; and

(c) Proof of compliance with NRS 695F.200, 695F.220 and 695F.340.

A prepaidlimited health service organization may not add a limited health service if theCommissioner determines that adding the service would qualify the organizationas a health maintenance organization pursuant to chapter695C of NRS or as an offeror of a health care plan for which a certificateof authority is required by any other provisions of this title.

3. If the Commissioner does not deny the applicationwithin 60 days after it is filed, the application shall be deemed approved.

4. If the application is denied, the Commissioner shallsend a written notice to the prepaid limited health service organization. Thenotice must include the reason for the denial. The prepaid limited healthservice organization may request a hearing in the manner set forth in NRS 695F.140.

(Added to NRS by 1991, 1116; A 1993, 2402)

NRS 695F.180 Investments. The money of the prepaid limited health serviceorganization must be invested in accordance with the guidelines established bythe National Association of Insurance Commissioners for investments by healthmaintenance organizations.

(Added to NRS by 1991, 1118)

NRS 695F.190 Requirementsfor reserve.

1. A prepaid limited health service organization shallset aside a reserve equal to 3 percent of the premiums collected from itsenrollees in an amount not to exceed $500,000. The reserve is in addition tothe bond or deposit filed with the Commissioner.

2. The reserve:

(a) Must be deposited in a trust account in a financialinstitution which is located in this state and which is federally insured orinsured by a private insurer approved pursuant to NRS 678.755. The income earned on money inthe account must be paid to the organization and used for its operations.

(b) Is in addition to the reserve established by the organizationaccording to good business and accounting practices for incurred but unreportedclaims and other similar claims.

(Added to NRS by 1991, 1118; A 1999, 1554)

NRS 695F.200 Maintenanceof capital account and surety. Each prepaidlimited health service organization which receives a certificate of authorityshall maintain a:

1. Capital account with a net worth of not less than$200,000 unless a lesser amount is permitted in writing by the Commissioner.The account must not be obligated for any accrued liabilities and must consistof cash, securities or a combination thereof which is acceptable to theCommissioner.

2. Surety bond or deposit of cash or securities forthe protection of enrollees of not less than $250,000.

(Added to NRS by 1991, 1118)

NRS 695F.210 Maintenanceof fidelity bond or deposit in lieu of bond.

1. A prepaid limited health service organization shallmaintain in force a fidelity bond in its own name on its officers and employeesin an amount not less than $1,000,000 or in any other amount prescribed by theCommissioner.

2. Except as otherwise provided in subsection 3, thebond must be issued by an insurer licensed to do business in this State.

3. If the fidelity bond is not available from aninsurer licensed to do business in this State, a prepaid limited health serviceorganization may procure a fidelity bond from a surplus lines broker licensedpursuant to chapter 685A of NRS.

4. In lieu of the bond required pursuant to subsection1, a prepaid limited health service organization may deposit with theCommissioner cash, securities or other investments described in NRS 695F.180. The deposit must bemaintained in joint custody with the Commissioner in the amount and subject tothe same conditions required for a bond pursuant to this subsection.

(Added to NRS by 1991, 1119)

NRS 695F.215 Requiredcontract with insurance company for provision of insurance, indemnity orreimbursement against cost of health care services. Aprepaid limited health service organization shall contract with an insurancecompany licensed in this State or authorized to do business in this State forthe provision of insurance, indemnity or reimbursement against the cost ofhealth care services provided by the prepaid limited health serviceorganization.

(Added to NRS by 1997, 3036)

NRS 695F.220 Contractbetween organization and provider or subcontractor for provision of services toenrollees. Each contract between a prepaidlimited health service organization and a provider or other personsubcontracting for the provision of a limited health service to enrollees on aprepayment basis or any other basis must contain the following terms andconditions:

1. If the prepaid limited health service organizationfails to pay for a limited health service for any reason, including, but notlimited to, insolvency or breach of this contract, the enrollees are not liableto the provider for any money owed to the provider pursuant to this contract.

2. A provider, agent, trustee or assignee thereof maynot maintain an action at law or attempt to collect from an enrollee any moneywhich the prepaid limited health service organization owes to the provider.

3. These provisions do not prohibit the collection ofany uncovered charges which an enrollee agreed to pay or the collection of anycopayment from an enrollee.

4. These provisions survive the termination of thiscontract, regardless of the reason for the termination.

5. The termination of this contract does not releasethe provider from its obligation to complete any procedure on an enrollee whois receiving treatment for a specific condition for a period not to exceed 60days, at the same schedule of copayment or any other applicable charge ineffect when this contract is terminated.

6. Any amendment to the provisions of this contractmust be submitted to the Commissioner for approval before the amendment iseffective.

(Added to NRS by 1991, 1118)

NRS 695F.230 Establishmentof system for resolution of complaints.

1. Each prepaid limited health service organizationshall establish a system for the resolution of written complaints submitted byenrollees and providers.

2. The provisions of subsection 1 do not prohibit anenrollee or provider from filing a complaint with the Commissioner or limit theCommissioners authority to investigate such a complaint.

3. Each prepaid limited health service organizationthat issues any evidence of coverage that provides, delivers, arranges for,pays for or reimburses any cost of health care services through managed careshall provide a system for resolving any complaints of an enrollee orsubscriber concerning those health care services that complies with theprovisions of NRS 695G.200 to 695G.310, inclusive.

(Added to NRS by 1991, 1117; A 2003, 779)

REGULATION AND ENFORCEMENT

NRS 695F.300 Regulationsof Commissioner. The Commissioner shall adoptregulations to carry out the provisions of this chapter.

(Added to NRS by 1991, 1121)

NRS 695F.310 Examinationof affairs of organization.

1. The Commissioner may examine the affairs of anyprepaid limited health service organization as often as is reasonably necessaryto protect the interests of the residents of this state, but not lessfrequently than once every 2 years.

2. A prepaid limited health service organization shallmake its books and records available for examination and cooperate with theCommissioner to facilitate the examination.

3. In lieu of such an examination, the Commissionermay accept the report of an examination conducted by the commissioner ofinsurance of another state.

4. The reasonable expenses of an examination conductedpursuant to this section must be charged to the organization being examined andremitted to the Commissioner.

(Added to NRS by 1991, 1117)

NRS 695F.320 Reportsto Commissioner; fine and suspension for noncompliance.

1. Each prepaid limited health service organizationshall file with the Commissioner annually, on or before March 1, a reportshowing its financial condition on the last day of the preceding calendar year.The report must be verified by at least two principal officers of the organization.

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

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

(b) The number of subscribers at the beginning and theend of the year and the number of enrollments terminated during the year; and

(c) Such other information as the Commissioner mayprescribe.

3. Each prepaid limited health service organizationshall file with the Commissioner annually an audited financial statementprepared by an independent certified public accountant. The statement mustcover the most recent fiscal year of the organization and must be filed withthe Commissioner within 120 days after the end of that fiscal year.

4. The Commissioner may require more frequent reportscontaining such information as is necessary to enable him to carry out hisduties pursuant to this chapter.

5. The Commissioner may:

(a) Assess a fine of not more than $100 per day foreach day the report or financial statement required pursuant to this section isnot filed after the report or financial statement is due, but the fine must notexceed $3,000; and

(b) Suspend the organizations certificate of authorityuntil the organization files the report.

(Added to NRS by 1991, 1119; A 1995, 1634, 2683)

NRS 695F.330 Paymentof tax. At the time of filing the annualreport pursuant to NRS 695F.320 theprepaid limited health service organization shall forward to the Department ofTaxation the tax and any penalty for nonpayment or delinquent payment of thetax in accordance with the provisions of chapter680B of NRS.

(Added to NRS by 1991, 1121; A 1993, 1923)

NRS 695F.340 Fees. Each prepaid limited health service organization shall payto the Commissioner the following fees:

 

For filing an application for acertificate of authority.................................... $2,450

For issuance of a certificate ofauthority.............................................................. 283

For the renewal of a certificate ofauthority...................................................... 2,450

For filing a material change oraddition of a limited health service.................. 100

For filing an annual report........................................................................................ 25

For filing periodic reports requiredby the Commissioner................................... 25

 

(Added to NRS by 1991, 1121; A 1993, 2403)

NRS 695F.350 Suspensionor revocation of certificate of authority.

1. The Commissioner may suspend or revoke thecertificate of authority of a prepaid limited health service organizationissued pursuant to this chapter if he determines that:

(a) The prepaid limited health service organization isoperating substantially in violation of its basic organizational document or ina manner contrary to the manner described in and reasonably inferred from anyother information submitted pursuant to NRS695F.110 unless any amendment to its basic organization document or otherinformation has been filed with and approved by the Commissioner;

(b) The prepaid limited health service organizationissued an evidence of coverage or used rates or charges which do not complywith the requirements of NRS 695F.150and 695F.160;

(c) The prepaid limited health service organization isnot able to carry out its obligations to provide its limited health service;

(d) The prepaid limited health service organization isnot financially responsible and may reasonably be expected to be unable tocarry out its obligations to enrollees or prospective enrollees;

(e) The capital of the prepaid limited health serviceorganization is less than the amount required by NRS 695F.200 or the organization hasfailed to correct any deficiency concerning its capital as required by theCommissioner;

(f) The prepaid limited health service organization hasfailed to establish and maintain in a reasonable manner the complaint systemrequired by NRS 695F.230;

(g) The continued operation of the prepaid limitedhealth service organization would be hazardous to its enrollees; or

(h) The prepaid limited health service organization hasfailed to comply with any other provision of this chapter.

2. If the Commissioner has cause to believe thatgrounds for the suspension or revocation of a certificate of authority of aprepaid limited health service organization exist, he shall send written noticeto the organization. The notice must include the reason for the suspension orrevocation and a time not more than 30 days thereafter for a hearing on thematter. The hearing must be held in the manner set forth in NRS 695F.140.

3. If the certificate of authority of a prepaidlimited health service organization is revoked, the organization shall proceed,immediately following the effective date of the order of revocation, to wind upits affairs. The organization shall not:

(a) Conduct any further business unless it is essentialfor the orderly conclusion of its affairs; and

(b) Engage in any further advertising or solicitation.

4. The Commissioner may, by written order, permit suchfurther operation of the organization as he considers necessary to enable theenrollees to obtain limited health services from another organization orprovider.

(Added to NRS by 1991, 1119)

NRS 695F.360 Violationsof chapter: Order to cease and desist; fine. Ifthe Commissioner, after a hearing held pursuant to NRS 695F.140, finds that a prepaidlimited health service organization or other person subject to this chapter hasviolated a provision of this chapter, he may:

1. Issue and cause to be served upon the organizationor any other person charged with a violation of this chapter, a copy of hisfindings and an order directing the organization or person to cease and desistfrom engaging in the act or practice which constitutes the violation; and

2. Impose a fine of not more than $1,000 for eachviolation, not to exceed a total amount of $10,000.

(Added to NRS by 1991, 1120)

MISCELLANEOUS PROVISIONS

NRS 695F.400 Licenserequired to apply, procure, negotiate or place for another any policy orcontract of organization. A person shall notapply, procure, negotiate or place for another person any policy or contract ofa prepaid limited health service organization unless he holds a license issuedpursuant to chapter 683A of NRS.

(Added to NRS by 1991, 1118)

NRS 695F.410 Confidentialityand disclosure of information.

1. Any information relating to the diagnosis,treatment or health of any enrollee obtained from the enrollee or from anyprovider by a prepaid limited health service organization and any contract witha provider submitted pursuant to the requirements of this chapter must not bedisclosed to any person except:

(a) To the extent that it is necessary to carry out theprovisions of this chapter;

(b) Upon the written consent of the enrollee orapplicant, provider or prepaid limited health service organization, as appropriate;

(c) Pursuant to a specific statute or court order forthe production of evidence or the discovery thereof; or

(d) For a claim or legal action if that data orinformation is relevant.

2. A prepaid limited health service organization mayclaim any privilege against disclosure which the provider who furnished theinformation relating to the diagnosis, treatment or health of an enrollee orapplicant to the organization is entitled to claim.

(Added to NRS by 1991, 1121)

NRS 695F.420 Certaininsurers and organizations may exclude coverage duplicated pursuant to thischapter. Notwithstanding any other provisionof this title, any person who is licensed as an insurer pursuant to chapter 680A of NRS or issued a certificate ofauthority pursuant to chapter 695A, 695B or 695Cof NRS may exclude, in any contract or policy issued to a group, any coveragewhich would duplicate the coverage of a limited health service, whether forservices, supplies or reimbursement, to the extent that the coverage or serviceis provided in accordance with this chapter pursuant to a contract or policyissued to the same group or to a part of that group by a prepaid limited healthservice organization or a person who is licensed as an insurer pursuant to chapter 680A of NRS or issued a certificate ofauthority pursuant to chapter 695A, 695B or 695Cof NRS.

(Added to NRS by 1991, 1117)

NRS 695F.430 Provisionof services excluded from practice of any healing arts; solicitation excludedfrom statutory provisions regarding solicitation or advertising by practitionerof healing art.

1. The provision of limited health services by aprepaid limited health service organization or any other person pursuant tothis chapter shall not be deemed to be the practice of medicine or any otherhealing arts.

2. The solicitation by a prepaid limited healthservice organization to arrange for or provide a limited health service inaccordance with this chapter does not violate any statutory provision relatingto solicitation or advertising by a practitioner of a healing art.

(Added to NRS by 1991, 1117)

ELIGIBILITY FOR COVERAGE

NRS 695F.440 Effectof eligibility for medical assistance under Medicaid; assignment of rights tostate agency.

1. An organization shall not, when consideringeligibility for coverage or making payments under any evidence of coverage,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 prepaid limited health service organization:

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

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

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

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

3. If a state agency is assigned any rights of aperson who is:

(a) Eligible for medical assistance under Medicaid; and

(b) Covered by any evidence of coverage,

the prepaidlimited health service organization that issued the evidence of coverage shallnot impose any requirements upon the state agency except requirements itimposes upon the agents or assignees of other persons covered by any evidenceof coverage.

(Added to NRS by 1995, 2437)

NRS 695F.450 Organizationprohibited from asserting certain grounds to deny enrollment of child pursuantto order if parent is insured. A prepaid limitedhealth service organization shall not deny the enrollment of a child pursuantto an order for medical coverage under any evidence of coverage pursuant towhich a parent of the child is insured on the ground that the child:

1. Was born out of wedlock;

2. Has not been claimed as a dependent on the parentsfederal income tax return; or

3. Does not reside with the parent or within theorganizations geographic area of service.

(Added to NRS by 1995, 2438)

NRS 695F.460 Certainaccommodations to be made when child is covered under evidence of coverage ofnoncustodial parent. If a child has coverage underany evidence of coverage pursuant to which a noncustodial parent of the childis insured, the prepaid limited health service organization issuing thatevidence of coverage 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, 2438)

NRS 695F.470 Organizationto authorize enrollment of child of parent who is required by order to providemedical coverage under certain circumstances; termination of coverage of child. If a parent is required by an order for medical coverageto provide coverage for a child and the parent is eligible for coverage ofmembers of his family under any evidence of coverage, the prepaid limitedhealth service organization that issued the evidence of coverage:

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 theprepaid limited health service organization 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, 2438)

NRS 695F.480 Organizationprohibited from restricting coverage of child based on preexisting condition ifperson who is eligible for group coverage adopts or assumes legal obligationfor child.

1. If a person:

(a) Adopts a dependent child; or

(b) Assumes and retains a legal obligation for thetotal or partial support of a dependent child in anticipation of adopting thechild,

while the person is eligible for group coverage under anyevidence of coverage, the prepaid limited health service organization issuingthat evidence of coverage shall not restrict the coverage of the child basedsolely on a preexisting condition the child has at the time he would otherwisebecome eligible for coverage pursuant to that evidence of coverage. Anyprovision relating to an exclusion for a preexisting condition must comply withNRS 689B.500 or 689C.190, as appropriate.

2. For the purposes of this section, child means aperson who is under 18 years of age at the time of his adoption or theassumption of a legal obligation for his support in anticipation of hisadoption.

(Added to NRS by 1995, 2439; A 1997, 2960)

 

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