Source: https://www.leg.state.nv.us/NRS/NRS-689B.html
Timestamp: 2019-04-26 07:43:10+00:00

Document:
NRS 689B.010 Short title; scope.
NRS 689B.015 Contracts between insurer and provider of health care: Prohibiting insurer from charging provider of health care fee for inclusion on list of providers given to insureds; form to obtain information on provider of health care; modification; schedule of fees.
NRS 689B.020 “Group health insurance” defined; eligible groups and benefits.
NRS 689B.026 Delivery of policy to group formed to purchase health insurance prohibited; exception.
NRS 689B.0265 Policy to guaranteed association.
NRS 689B.0283 Coverage for prescription drugs: Provision of notice and information regarding use of formulary.
NRS 689B.0285 System for resolving complaints: Approval; requirements; examination.
NRS 689B.029 Annual report regarding system for resolving complaints; insurer to maintain records of complaints concerning something other than health care services.
NRS 689B.0295 Written notice to insured explaining right to file complaint; notice to insured required when insurer denies coverage of health care service.
NRS 689B.0303 Required provision concerning coverage for continued medical treatment.
NRS 689B.0306 Required provision concerning coverage for treatment received as part of clinical trial or study.
NRS 689B.031 Required provision concerning coverage of certain gynecological or obstetrical services without authorization or referral from primary care physician.
NRS 689B.0313 Required coverage for certain tests and vaccines relating to human papillomavirus; prohibited acts.
NRS 689B.0317 Required provision concerning coverage for prostate cancer screening.
NRS 689B.033 Required provision concerning coverage for newly born and adopted children and children placed for adoption.
NRS 689B.034 Required provision concerning effect of benefits under other valid group coverage; subrogation.
NRS 689B.0345 Required provision concerning coverage for employee or member on leave without pay as result of total disability.
NRS 689B.035 Required provision concerning termination of coverage on dependent child.
NRS 689B.0353 Required provision concerning coverage for treatment of certain inherited metabolic diseases.
NRS 689B.0357 Required provision concerning coverage for management and treatment of diabetes.
NRS 689B.0362 Required provision concerning coverage for orally administered chemotherapy.
NRS 689B.0365 Required provision concerning coverage for use of certain drugs for treatment of cancer.
NRS 689B.0367 Required provision concerning coverage for screening for colorectal cancer.
NRS 689B.0368 Required provision concerning coverage for prescription drug previously approved for medical condition of insured.
NRS 689B.0369 Required provision concerning coverage for services provided through telehealth.
NRS 689B.0374 Required provision concerning coverage for mammograms for certain women; prohibited acts.
NRS 689B.0375 Required provision concerning coverage relating to mastectomy.
NRS 689B.0376 Policy covering prescription drugs or devices to provide coverage of hormone replacement therapy in certain circumstances; prohibited actions by insurer; exception.
NRS 689B.03762 Policy covering prescription drugs to provide coverage for drugs irregularly dispensed for purpose of synchronization of chronic medications.
NRS 689B.03764 Policy covering prescription drugs to provide coverage for early refills of topical ophthalmic products.
NRS 689B.0377 Policy covering outpatient care to provide coverage for health care services related to hormone replacement therapy; prohibited actions by insurer.
NRS 689B.0378 Required provision concerning coverage for drug or device for contraception and related health services; prohibited acts; exceptions.
NRS 689B.03785 Required provisions concerning coverage for certain services, screenings and tests relating to wellness; prohibited acts.
NRS 689B.0379 Required provision concerning coverage for treatment of temporomandibular joint.
NRS 689B.038 Reimbursement for treatments by licensed psychologist.
NRS 689B.0383 Reimbursement for treatments by licensed marriage and family therapist or licensed clinical professional counselor.
NRS 689B.0385 Reimbursement for treatments by licensed associate in social work, social worker, independent social worker or clinical social worker.
NRS 689B.039 Reimbursement for treatments by chiropractor.
NRS 689B.0393 Reimbursement for treatments by podiatrist.
NRS 689B.0397 Reimbursement for treatment by licensed clinical alcohol and drug abuse counselor.
NRS 689B.040 Direct payment for hospital and medical services and home health care; payment to assignee.
NRS 689B.045 Reimbursement for services provided by certain nurses; prohibited limitations; exception.
NRS 689B.047 Reimbursement to provider of medical transportation.
NRS 689B.049 Reimbursement for acupuncture.
NRS 689B.050 Extended disability benefit.
NRS 689B.060 Readjustment of premiums; dividends.
NRS 689B.061 Limitations on deductibles and copayments charged under policy which offers difference of payment between preferred providers of health care and providers who are not preferred.
NRS 689B.063 Primary and secondary policies: Determination of benefits.
NRS 689B.064 Primary and secondary policies: Order of benefits.
NRS 689B.065 Policy issued to replace discontinued policy or coverage: Requirements; notice of reduction of benefits; statement of benefits; applicability of section.
NRS 689B.067 Provision in policy requiring binding arbitration for disputes with insurer authorized; procedure for arbitration; declaratory relief.
NRS 689B.068 Insurer prohibited from denying coverage solely because person was victim of domestic violence.
NRS 689B.069 Insurer prohibited from requiring or using information concerning genetic testing; exceptions.
NRS 689B.070 “Blanket accident and health insurance” defined.
NRS 689B.080 Authority to issue; required provisions.
NRS 689B.090 Application and certificates.
NRS 689B.100 Payment of benefits.
NRS 689B.110 Legal liability of policyholders for death of or injury to insured member unaffected.
NRS 689B.250 Acceptance of uniform forms for billing and claims.
NRS 689B.255 Approval or denial of claims; payment of claims and interest; requests for additional information; award of costs and attorney’s fees; compliance with requirements.
NRS 689B.260 Required provision concerning coverage relating to complications of pregnancy.
NRS 689B.270 Required procedure for arbitration of disputes concerning independent medical, dental or chiropractic evaluations.
NRS 689B.275 Contents, approval and provision of summary of coverage; provision of information about guaranteed availability of certain plans for benefits.
NRS 689B.280 Disclosure of information concerning medication of insured prohibited.
NRS 689B.285 Offering policy of health insurance for purposes of establishing health savings account.
NRS 689B.287 Insurer prohibited from denying coverage solely because insured was intoxicated or under influence of controlled substance; exceptions.
NRS 689B.300 Effect of eligibility for medical assistance under Medicaid; assignment of rights to state agency.
NRS 689B.310 Insurer prohibited from asserting certain grounds to deny enrollment of child of insured pursuant to order.
NRS 689B.320 Certain accommodations to be made when child is covered under policy of noncustodial parent.
NRS 689B.330 Insurer to authorize enrollment of child of parent who is required by order to provide medical coverage for child.
NRS 689B.350 “Affiliation period” defined.
NRS 689B.355 “Blanket accident and health insurance” defined.
NRS 689B.380 “Creditable coverage” defined.
NRS 689B.390 “Group health plan” defined.
NRS 689B.400 “Group participation” defined.
NRS 689B.430 “Open enrollment” defined.
NRS 689B.440 “Plan sponsor” defined.
NRS 689B.450 “Preexisting condition” defined.
NRS 689B.460 “Waiting period” defined.
NRS 689B.480 Determination of applicable creditable coverage of person; determination of period of creditable coverage of person; required statement.
NRS 689B.490 Written certification of coverage required for purpose of determining period of creditable coverage accumulated by person.
NRS 689B.500 Coverage of preexisting conditions.
NRS 689B.510 Carrier authorized to modify coverage for insurance product under certain circumstances.
NRS 689B.520 Group plan or coverage that includes coverage for maternity care and pediatric care: Required to allow minimum stay in hospital in connection with childbirth; prohibited acts.
NRS 689B.530 Carrier required to permit eligible employee or dependent of employee to enroll for coverage under certain circumstances.
NRS 689B.540 Manner and period for enrollment of dependent of covered employee; period of special enrollment.
NRS 689B.550 Carrier prohibited from imposing restriction on participation inconsistent with chapter; restrictions on rules of eligibility that may be established; premiums to be equitable.
NRS 689B.560 Carrier required to renew coverage at option of plan sponsor; exceptions; discontinuation of product; discontinuation of group health insurance through bona fide association.
NRS 689B.570 Carrier that offers coverage through network plan not required to offer coverage to employer that does not employ enrollees who reside or work in geographic service area for which carrier is authorized to transact insurance.
NRS 689B.580 Plan sponsor of governmental plan authorized to elect to exclude governmental plan from compliance with certain statutes; duties of plan sponsor.
1. This chapter may be cited as the Group or Blanket Health Insurance Law.
2. This chapter applies only to group health insurance contracts and to blanket accident and health insurance contracts as provided in this chapter.
NRS 689B.015 Contracts between insurer and provider of health care: Prohibiting insurer from charging provider of health care fee for inclusion on list of providers given to insureds; form to obtain information on provider of health care; modification; schedule of fees.
1. An insurer that issues a policy of group health insurance shall not charge a provider of health care a fee to include the name of the provider on a list of providers of health care given by the insurer to its insureds.
2. An insurer specified in subsection 1 shall not contract with a provider of health care to provide health care to an insured unless the insurer uses the form prescribed by the Commissioner pursuant to NRS 629.095 to obtain any information related to the credentials of the provider of health care.
(b) Except as otherwise provided in this paragraph, by the insurer upon giving to the provider 45 days’ written notice of the modification of the insurer’s schedule of payments, including any changes to the fee schedule applicable to the provider’s practice. If the provider fails to object in writing to the modification within the 45-day period, the modification becomes effective at the end of that period. If the provider objects in writing to the modification within the 45-day period, the modification must not become effective unless agreed to by both parties as described in paragraph (a).
1. “Group health insurance” is hereby declared to be that form of health insurance covering groups of two or more persons, formed for a purpose other than obtaining insurance.
2. Any group health policy which contains provisions for the payment by the insurer of benefits for expenses incurred on account of hospital, nursing, medical, dental or surgical services, home health care or health supportive services for members of the family or dependents of a person in the insured group may provide for the continuation of such benefit provisions, or any part or parts thereof, after the death of the person in the insured group.
3. The Commissioner may, in the discretion of the Commissioner, require the form of each certificate proposed to be delivered in this state under a group health policy not made under the laws of this state to be filed with the Commissioner by the insurer for informational purposes only.
NRS 689B.026 Delivery of policy to group formed to purchase health insurance prohibited; exception.
1. Except as otherwise provided in this section, no policy of group health insurance may be delivered or issued for delivery in this state to a group which was formed for the purpose of purchasing one or more policies of group health insurance.
(c) All policy rates and forms are filed with and approved by the Division before marketing to a resident or employer in this State.
3. The Commissioner shall use the provisions of this chapter and chapter 689C of NRS to review insurance products marketed to employers in this State. The Commissioner shall use the provisions of chapter 689A of NRS to review insurance products marketed to natural persons in this State.
4. The provisions of this section apply to the offering in this state of a policy issued in another state.
1. An insurer may offer a policy of group health insurance to a guaranteed association if the policy provides coverage for 200 or more members, employees of members or employees of the guaranteed association or their dependents.
2. When an insurer offers coverage to a guaranteed association pursuant to subsection 1, the insurer shall offer coverage to all members, employees of members and employees of the guaranteed association and all dependents thereof without regard to the actual or expected health status of any such member or employee or dependent thereof. The provisions of this subsection apply only for the purpose of requiring coverage to be offered to all such members, employees and dependents.
(a) For the initial 12-month period of coverage, the insurer shall submit to the Commissioner the opinion of a qualified actuary that the rates charged by the guaranteed association for premiums are actuarially sound. The opinion must certify the accuracy of the rating methodology as established by the American Academy of Actuaries or a successor organization approved by the Commissioner. The Commissioner by regulation may further define or enlarge the scope of this opinion.
(b) For any subsequent 12-month period of coverage, according to a rating methodology as established by the American Academy of Actuaries or a successor organization approved by the Commissioner.
(c) After meeting any additional eligibility requirements agreed upon by the guaranteed association and the insurer.
5. If a member, employee of a member or employee of a guaranteed association or a dependent thereof terminates coverage offered pursuant to subsection 1, the member, employee or dependent must be excluded from such coverage until the beginning of the next annual enrollment period. During the next annual enrollment period or any annual enrollment period thereafter, such a member or employee may enroll for coverage of the member or employee or dependent thereof pursuant to subsection 4.
6. The provisions of this section do not apply to or affect the status of a person, including, without limitation, whether the person is an employee, self-employed or an independent contractor, for the purposes of industrial insurance or any other law relating to labor or employment.
(3) Has been in existence for at least 5 years.
(b) “Qualified actuary” means a member in good standing of the American Academy of Actuaries, or a successor organization approved by the Commissioner.
NRS 689B.0283 Coverage for prescription drugs: Provision of notice and information regarding use of formulary.
(2) The telephone number of the insurer for making a request for information regarding the formulary pursuant to subsection 2.
(2) Access to the most current list of prescription drugs in the formulary, organized by major therapeutic category, with an indication of whether any listed drugs are preferred over other listed drugs. If more than one formulary is maintained, the insurer shall notify the requester that a choice of formulary lists is available.
NRS 689B.0285 System for resolving complaints: Approval; requirements; examination.
1. Except as otherwise provided in subsection 4, each insurer that issues a policy of group health insurance in this State shall establish a system for resolving any complaints of an insured concerning health care services covered under the policy. The system must be approved by the Commissioner.
2. A system for resolving complaints established pursuant to subsection 1 must include an initial investigation, a review of the complaint by a review board and a procedure for appealing a determination regarding the complaint. The majority of the members on a review board must be insureds who receive health care services pursuant to a policy of group health insurance issued by the insurer.
3. The Commissioner may examine the system for resolving complaints established pursuant to subsection 1 at such times as the Commissioner deems necessary or appropriate.
4. Each insurer that issues a policy of group health insurance in this State that provides, delivers, arranges for, pays for or reimburses any cost of health care services through managed care shall provide a system for resolving any complaints of an insured concerning the health care services that complies with the provisions of NRS 695G.200 to 695G.310, inclusive.
NRS 689B.029 Annual report regarding system for resolving complaints; insurer to maintain records of complaints concerning something other than health care services.
(d) The average amount of time that was needed to resolve a complaint and an appeal, if any.
2. Each insurer shall maintain records of complaints filed with it which concern something other than health care services and shall submit to the Commissioner a report summarizing such complaints at such times and in such format as the Commissioner may require.
NRS 689B.0295 Written notice to insured explaining right to file complaint; notice to insured required when insurer denies coverage of health care service.
(c) Any other time deemed necessary by the Commissioner.
(c) The right of the insured to file a written complaint and the procedure for filing such a complaint.
3. A written notice which is approved by the Commissioner shall be deemed to be in clear and comprehensible language that is understandable to an ordinary layperson.
1. A provision that, in the absence of fraud, all statements made by applicants or the policyholders or by an insured person are representations and not warranties, and that no statement made for the purpose of effecting insurance voids the insurance or reduces its benefits unless the statement is contained in a written instrument signed by the policyholder or the insured person, a copy of which has been furnished to the policyholder or insured person or a beneficiary of the policyholder or insured person.
2. A provision that the insurer will furnish to the policyholder for delivery to each employee or member of the insured group a statement in summary form of the essential features of the insurance coverage of that employee or member and to whom benefits thereunder are payable. If dependents are included in the coverage, only one statement need be issued for each family.
3. A provision that to the group originally insured may be added from time to time eligible new employees or members or dependents, as the case may be, in accordance with the terms of the policy.
4. A provision for benefits for expense arising from care at home or health supportive services if the care or service was prescribed by a physician and would have been covered by the policy if performed in a medical facility or facility for the dependent as defined in chapter 449 of NRS.
5. A provision for benefits for expenses arising from hospice care.
NRS 689B.0303 Required provision concerning coverage for continued medical treatment.
1. The provisions of this section apply to a policy of group health insurance offered or issued by an insurer if an insured covered by the policy receives health care through a defined set of providers of health care who are under contract with the insurer.
(2) The provider of health care and the insured agree that the continuity of care is desirable.
(2) Not to seek payment from the insured for any medical service provided by the provider of health care that the provider of health care could not have received from the insured were the provider of health care still under contract with the insurer.
(2) If the pregnancy does not end in delivery, the date of the end of the pregnancy.
(b) The insurer did not enter into another contract with the provider of health care after the contract was terminated pursuant to paragraph (a).
5. A policy subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 2003, has the legal effect of including the coverage required by this section, and any provision of the policy or renewal thereof that is in conflict with this section is void.
6. The Commissioner shall adopt regulations to carry out the provisions of this section.
NRS 689B.0306 Required provision concerning coverage for treatment received as part of clinical trial or study.
(3) The risks associated with participation in the clinical trial or study, including, without limitation, the general nature and extent of such risks.
(a) Coverage for any drug or device that is approved for sale by the Food and Drug Administration without regard to whether the approved drug or device has been approved for use in the medical treatment of the insured person.
(b) The cost of any reasonably necessary health care services that are required as a result of the medical treatment provided in a Phase II, Phase III or Phase IV clinical trial or study or as a result of any complication arising out of the medical treatment provided in a Phase II, Phase III or Phase IV clinical trial or study, to the extent that such health care services would otherwise be covered under the policy of group health insurance.
(c) The cost of any routine health care services that would otherwise be covered under the policy of group health insurance for an insured participating in a Phase I clinical trial or study.
(d) The initial consultation to determine whether the insured is eligible to participate in the clinical trial or study.
(e) Health care services required for the clinically appropriate monitoring of the insured during a Phase II, Phase III or Phase IV clinical trial or study.
(f) Health care services which are required for the clinically appropriate monitoring of the insured during a Phase I clinical trial or study and which are not directly related to the clinical trial or study.
Ê Except as otherwise provided in NRS 689B.0303, the services provided pursuant to paragraphs (b), (c), (e) and (f) must be covered only if the services are provided by a provider with whom the insurer has contracted for such services. If the insurer has not contracted for the provision of such services, the insurer shall pay the provider the rate of reimbursement that is paid to other providers with whom the insurer has contracted for similar services and the provider shall accept that rate of reimbursement as payment in full.
3. Particular medical treatment described in subsection 2 and provided to a person insured under the group policy is not required to be covered pursuant to this section if that particular medical treatment is provided by the sponsor of the clinical trial or study free of charge to the person insured under the group policy.
(a) Any portion of the clinical trial or study that is customarily paid for by a government or a biotechnical, pharmaceutical or medical industry.
(b) Coverage for a drug or device described in paragraph (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 excluded from coverage under the insured’s policy of group health insurance, regardless of whether such services are provided under the clinical trial or study.
(d) Health care services that are customarily provided by the sponsors of the clinical trial or study free of charge to the participants in the trial or study.
(e) Extraneous expenses related to participation in the clinical trial or study including, without limitation, travel, housing and other expenses that a participant may incur.
(f) Any expenses incurred by a person who accompanies the insured during the clinical trial or study.
(g) Any item or service that is provided solely to satisfy a need or desire for data collection or analysis that is not directly related to the clinical management of the insured.
(h) Any costs for the management of research relating to the clinical trial or study.
5. An insurer who delivers or issues for delivery a policy of group health insurance specified in subsection 1 may require copies of the approval or certification issued pursuant to paragraph (b) of subsection 1, the statement of consent signed by the insured, protocols for the clinical trial or study and any other materials related to the scope of the clinical trial or study relevant to the coverage of medical treatment pursuant to this section.
(a) Include in any disclosure of the coverage provided by the policy notice to each group policyholder of the availability of the benefits required by this section.
(b) Provide the coverage required by this section subject to the same deductible, copayment, coinsurance and other such conditions for coverage that are required under the policy.
7. A policy of group health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2006, has the legal effect of including the coverage required by this section, and any provision of the policy that conflicts with this section is void.
(2) An act or omission by a provider of health care who provides medical treatment or supervises the provision of medical treatment to the insured in connection with his or her participation in a clinical trial or study described in this section.
(b) Any adverse or unanticipated outcome arising out of an insured’s participation in a clinical trial or study described in this section.
(2) The Community Clinical Oncology Program.
(7) Is capable of responding to audits instituted by federal and state agencies.
(2) A person licensed pursuant to chapter 630, 631 or 633 of NRS.
NRS 689B.031 Required provision concerning coverage of certain gynecological or obstetrical services without authorization or referral from primary care physician.
1. A policy of group health insurance must include a provision authorizing a woman covered by the policy to obtain covered gynecological or obstetrical services without first receiving authorization or a referral from her primary care physician.
2. The provisions of this section do not authorize a woman covered by a policy of group health insurance to designate an obstetrician or gynecologist as her primary care physician.
3. A policy subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 1999, has the legal effect of including the coverage required by this section, and any provision of the policy or the renewal which is in conflict with this section is void.
4. As used in this section, “primary care physician” has the meaning ascribed to it in NRS 695G.060.
NRS 689B.0313 Required coverage for certain tests and vaccines relating to human papillomavirus; prohibited acts.
2. An insurer must ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the insurer.
4. A policy subject to the provisions of this chapter which is delivered, issued for delivery or renewed on or after January 1, 2018, has the legal effect of including the coverage required by subsection 1, and any provision of the policy or the renewal which is in conflict with this section is void.
5. Except as otherwise provided in this section and federal law, an insurer may use medical management techniques, including, without limitation, any available clinical evidence, to determine the frequency of or treatment relating to any benefit required by this section or the type of provider of health care to use for such treatment.
(c) “Network plan” means a policy of group health insurance offered by an insurer under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the insurer. The term does not include an arrangement for the financing of premiums.
NRS 689B.0317 Required provision concerning coverage for prostate cancer screening.
(b) Other guidelines or reports concerning prostate cancer screening which are published by nationally recognized professional organizations and which include current or prevailing supporting scientific data.
2. A policy of group health insurance that provides coverage for the treatment of prostate cancer must not require an insured to obtain prior authorization for any service provided pursuant to subsection 1.
3. A policy of group health insurance that provides coverage for the treatment of prostate cancer which is delivered, issued for delivery or renewed on or after July 1, 2007, has the legal effect of including the coverage required by subsection 1, and any provision of the policy or the renewal which is in conflict with subsection 1 is void.
NRS 689B.033 Required provision concerning coverage for newly born and adopted children and children placed for adoption.
(c) A child placed with the insured for the purpose of adoption from the moment of placement as certified by the public or private agency making the placement. The coverage of such a child ceases if the adoption proceedings are terminated as certified by the public or private agency making the placement.
Ê The policies must provide the coverage specified in subsection 3 and must not exclude premature births.
Ê and payments of the required premium or fees, if any, must be furnished to the insurer or welfare plan within 31 days after the date of birth, adoption or placement for adoption in order to have the coverage continue beyond the 31-day period.
3. The coverage for newly born and adopted children and children placed for adoption consists of coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities and, within the limits of the policy, necessary transportation costs from place of birth to the nearest specialized treatment center under major medical policies, and with respect to basic policies to the extent such costs are charged by the treatment center.
1. A health benefit plan must provide coverage for screening for and diagnosis of autism spectrum disorders and for treatment of autism spectrum disorders to persons covered by the policy of group health insurance under the age of 18 years or, if enrolled in high school, until the person reaches the age of 22 years.
(b) Copayment, deductible and coinsurance provisions and any other general exclusion or limitation of a policy of group health insurance to the same extent as other medical services or prescription drugs covered by the policy.
(b) Refuse to issue a policy of group health insurance or cancel a policy of group health insurance solely because the person applying for or covered by the policy uses or may use in the future any of the services listed in subsection 1.
4. Except as otherwise provided in subsections 1 and 2, an insurer shall not limit the number of visits an insured may make to any person, entity or group for treatment of autism spectrum disorders.
Ê An insurer may request a copy of and review a treatment plan created pursuant to this subsection.
6. A policy subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2011, has the legal effect of including the coverage required by subsection 1, and any provision of the policy or the renewal which is in conflict with subsection 1 or 2 is void.
7. Nothing in this section shall be construed as requiring an insurer to provide reimbursement to a school for services delivered through school services.
NRS 689B.034 Required provision concerning effect of benefits under other valid group coverage; subrogation.
1. Every policy of group health insurance must contain a provision which reduces the insurer’s liability because of benefits under other valid group coverage. To the extent authorized by the Commissioner, such a provision may include subrogation.
2. A provision for subrogation may include a lien upon any recovery by an insured from a third person for the cost of medical benefits paid by the insurer for injuries incurred as a result of the actions of the third person. The lien may not exceed the amount paid by the insurer.
3. An insurer may not deny payment for services because of the inclusion of a provision required by this section.
NRS 689B.0345 Required provision concerning coverage for employee or member on leave without pay as result of total disability.
1. As used in this section, “total disability” and “totally disabled” mean the continuing inability of the employee or member, because of an injury or illness, to perform substantially the duties related to his or her employment for which the employee or member is otherwise qualified.
2. No group policy of health insurance may be delivered or issued for delivery in this state unless it provides continuing coverage for an employee or member of the insured group, and the dependents of the employee or member who are otherwise covered by the policy, while the employee or member is on leave without pay as a result of a total disability. The coverage must be for any injury or illness suffered by the employee or member which is not related to the total disability or for any injury or illness suffered by the dependent of the employee or member. The coverage for such injury or illness must be equal to or greater than the coverage otherwise provided by the policy.
NRS 689B.035 Required provision concerning termination of coverage on dependent child.
(b) Dependent on the member of the insured group for support and maintenance.
2. Proof of such child’s incapacity and dependency shall be furnished to the insurer by the member of the insured group within 31 days after such child attains the specified limiting age and as often as the insurer may thereafter require, but no more than once a year beginning 2 years after such child attains the specified limiting age.
NRS 689B.0353 Required provision concerning coverage for treatment of certain inherited metabolic diseases.
(b) At least $2,500 per year for special food products which are prescribed or ordered by a physician as medically necessary for the treatment of a person described in paragraph (a).
2. The coverage required by subsection 1 must be provided whether or not the condition existed when the policy was purchased.
3. A policy subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 1998, has the legal effect of including the coverage required by this section, and any provision of the policy or the renewal which is in conflict with this section is void.
(a) “Inherited metabolic disease” means a disease caused by an inherited abnormality of the body chemistry of a person.
(b) “Special food product” means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be consumed under the direction of a physician for the dietary treatment of an inherited metabolic disease. The term does not include a food that is naturally low in protein.
NRS 689B.0357 Required provision concerning coverage for management and treatment of diabetes.
1. No group policy of health insurance that provides coverage for hospital, medical or surgical expenses may be delivered or issued for delivery in this state unless the policy includes coverage for the management and treatment of diabetes, including, without limitation, coverage for the self-management of diabetes.
(a) Shall include in any disclosure of the coverage provided by the policy notice to each policyholder and subscriber under the policy of the availability of the benefits required by this section.
(b) Shall provide the coverage required by this section subject to the same deductible, copayment, coinsurance and other such conditions for coverage that are required under the policy.
3. A policy subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 1998, has the legal effect of including the coverage required by this section, and any provision of the policy that conflicts with this section is void.
(a) “Coverage for the management and treatment of diabetes” includes coverage for medication, equipment, supplies and appliances that are medically necessary for the treatment of diabetes.
(3) Training and education which is medically necessary because of the development of new techniques and treatment for diabetes.
(c) “Diabetes” includes type I, type II and gestational diabetes.
NRS 689B.0362 Required provision concerning coverage for orally administered chemotherapy.
(a) Require a copayment, deductible or coinsurance amount for chemotherapy administered orally by means of a prescription drug in a combined amount that is more than $100 per prescription. The limitation on the amount of the deductible that may be required pursuant to this paragraph does not apply to a health benefit plan, as defined in NRS 687B.470, if the health benefit plan is a high deductible health plan, as defined in 26 U.S.C. § 223, and the amount of the annual deductible has not been satisfied.
(b) Make the coverage subject to monetary limits that are less favorable for chemotherapy administered orally by means of a prescription drug than the monetary limits applicable to chemotherapy which is administered by injection or intravenously.
(c) Decrease the monetary limits applicable to chemotherapy administered orally by means of a prescription drug or to chemotherapy which is administered by injection or intravenously to meet the requirements of this section.
2. A policy subject to the provisions of this chapter which provides coverage for the treatment of cancer through the use of chemotherapy and that is delivered, issued for delivery or renewed on or after January 1, 2015, has the legal effect of providing that coverage subject to the requirements of this section, and any provision of the policy or renewal which is in conflict with this section is void.
3. Nothing in this section shall be construed as requiring an insurer to provide coverage for the treatment of cancer through the use of chemotherapy administered by injection or intravenously or administered orally by means of a prescription drug.
(b) Supported by at least two articles reporting the results of scientific studies that are published in scientific or medical journals, as defined in 21 C.F.R. § 99.3.
(a) Includes coverage for any medical services necessary to administer the drug to the employee or member of the insured group.
(2) Use of a drug that is contraindicated by the Food and Drug Administration.
3. A policy subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 1999, has the legal effect of including the coverage required by this section, and any provision of the policy that conflicts with the provisions of this section is void.
NRS 689B.0367 Required provision concerning coverage for screening for colorectal cancer.
(b) Other guidelines or reports concerning colorectal cancer screening which are published by nationally recognized professional organizations and which include current or prevailing supporting scientific data.
2. A policy of group health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 2003, has the legal effect of including the coverage required by this section, and any provision of the policy that conflicts with the provisions of this section is void.
NRS 689B.0368 Required provision concerning coverage for prescription drug previously approved for medical condition of insured.
(c) Require any coverage for a drug after the term of the policy.
3. Any provision of a policy subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 2001, which is in conflict with this section is void.
NRS 689B.0369 Required provision concerning coverage for services provided through telehealth.
1. A policy of group or blanket health insurance must include coverage for services provided to an insured through telehealth to the same extent as though provided in person or by other means.
3. A policy of group or blanket health insurance must not require an insured to obtain prior authorization for any service provided through telehealth that is not required for that service when provided in person. A policy of group or blanket health insurance may require prior authorization for a service provided through telehealth if such prior authorization would be required if the service were provided in person or by other means.
(c) Enter into a contract with any provider of health care or cover any service if the insurer is not otherwise required by law to do so.
5. A policy of group or blanket health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2015, has the legal effect of including the coverage required by this section, and any provision of the policy or the renewal which is in conflict with this section is void.
NRS 689B.0374 Required provision concerning coverage for mammograms for certain women; prohibited acts.
1. A policy of group health insurance must provide coverage for benefits payable for expenses incurred for a mammogram every 2 years, or annually if ordered by a provider of health care, for women 40 years of age or older.
(b) “Network plan” means a policy of group health insurance offered by an insurer under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the insurer. The term does not include an arrangement for the financing of premiums.
(c) Prostheses and physical complications for all stages of mastectomy, including lymphedemas.
2. The provision of services must be determined by the attending physician and the patient.
3. The plan or issuer may require deductibles and coinsurance payments if they are consistent with those established for other benefits.
(b) Penalize, or limit reimbursement to, a provider of care, or provide incentives to a provider of care, in order to induce the provider not to provide the care listed in subsections 1 to 4, inclusive.
6. A plan or issuer may negotiate rates of reimbursement with providers of care.
7. If reconstructive surgery is begun within 3 years after a mastectomy, the amount of the benefits for that surgery must equal those amounts provided for in the policy at the time of the mastectomy. If the surgery is begun more than 3 years after the mastectomy, the benefits provided are subject to all of the terms, conditions and exclusions contained in the policy at the time of the reconstructive surgery.
8. A policy subject to the provisions of this chapter which 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, and any provision of the policy or the renewal which is in conflict with this section is void.
9. For the purposes of this section, “reconstructive surgery” means a surgical procedure performed following a mastectomy on one breast or both breasts to re-establish symmetry between the two breasts. The term includes augmentation mammoplasty, reduction mammoplasty and mastopexy.
NRS 689B.0376 Policy covering prescription drugs or devices to provide coverage of hormone replacement therapy in certain circumstances; prohibited actions by insurer; exception.
1. An insurer that offers or issues a policy of group health insurance which provides coverage for prescription drugs or devices shall include in the policy coverage for any type of hormone replacement therapy which is lawfully prescribed or ordered and which has been approved by the Food and Drug Administration.
(e) Offer or pay any type of material inducement, bonus or other financial incentive to a provider of health care to deny, reduce, withhold, limit or delay hormone replacement therapy to an insured.
3. A policy subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 1999, has the legal effect of including the coverage required by subsection 1, and any provision of the policy or the renewal which is in conflict with this section is void.
4. The provisions of this section do not require an insurer to provide coverage for fertility drugs.
5. As used in this section, “provider of health care” has the meaning ascribed to it in NRS 629.031.
NRS 689B.03762 Policy covering prescription drugs to provide coverage for drugs irregularly dispensed for purpose of synchronization of chronic medications.
(b) May not deny coverage for a prescription described in paragraph (a) which is otherwise approved for coverage by the insurer.
2. A policy subject to the provisions of this chapter which provides coverage for prescription drugs and that is delivered, issued for delivery or renewed on or after January 1, 2017, has the legal effect of providing that coverage subject to the requirements of this section, and any provision of the policy or renewal which is in conflict with this section is void.
NRS 689B.03764 Policy covering prescription drugs to provide coverage for early refills of topical ophthalmic products.
2. The provisions of this section do not affect any deductibles, copayments or coinsurance authorized or required pursuant to the policy of group health insurance.
3. A policy of group health insurance subject to the provisions of this chapter which provides coverage for prescription drugs and that is delivered, issued for delivery or renewed on or after January 1, 2016, has the legal effect of including the coverage required by this section, and any provision of the policy or renewal which is in conflict with this section is void.
NRS 689B.0377 Policy covering outpatient care to provide coverage for health care services related to hormone replacement therapy; prohibited actions by insurer.
1. An insurer that offers or issues a policy of group health insurance which provides coverage for outpatient care shall include in the policy coverage for any health care service related to hormone replacement therapy.
4. As used in this section, “provider of health care” has the meaning ascribed to it in NRS 629.031.
NRS 689B.0378 Required provision concerning coverage for drug or device for contraception and related health services; prohibited acts; exceptions.
3. If a covered therapeutic equivalent listed in subsection 1 is not available or a provider of health care deems a covered therapeutic equivalent to be medically inappropriate, an alternate therapeutic equivalent prescribed by a provider of health care must be covered by the insurer.
6. Except as otherwise provided in subsection 7, a policy subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2018, has the legal effect of including the coverage required by subsection 1, and any provision of the policy or the renewal which is in conflict with this section is void.
7. An insurer that offers or issues a policy of group health insurance and which is affiliated with a religious organization is not required to provide the coverage required by subsection 1 if the insurer objects on religious grounds. Such an insurer shall, before the issuance of a policy of group health insurance and before the renewal of such a policy, provide to the group policyholder or prospective insured, as applicable, written notice of the coverage that the insurer refuses to provide pursuant to this subsection.
8. If an insurer refuses, pursuant to subsection 7, to provide the coverage required by subsection 1, an employer may otherwise provide for the coverage for the employees of the employer.
9. An insurer may require an insured to pay a higher deductible, copayment or coinsurance for a drug for contraception if the insured refuses to accept a therapeutic equivalent of the drug.
10. For each of the 18 methods of contraception listed in subsection 11 that have been approved by the Food and Drug Administration, a policy of group health insurance must include at least one drug or device for contraception within each method for which no deductible, copayment or coinsurance may be charged to the insured, but the insurer may charge a deductible, copayment or coinsurance for any other drug or device that provides the same method of contraception.
12. Except as otherwise provided in this section and federal law, an insurer may use medical management techniques, including, without limitation, any available clinical evidence, to determine the frequency of or treatment relating to any benefit required by this section or the type of provider of health care to use for such treatment.
13. An insurer shall not use medical management techniques to require an insured to use a method of contraception other than the method prescribed or ordered by a provider of health care.
14. An insurer must provide an accessible, transparent and expedited process which is not unduly burdensome by which an insured, or the authorized representative of the insured, may request an exception relating to any medical management technique used by the insurer to obtain any benefit required by this section without a higher deductible, copayment or coinsurance.
NRS 689B.03785 Required provisions concerning coverage for certain services, screenings and tests relating to wellness; prohibited acts.
(k) Such well-woman preventative visits as recommended by the Health Resources and Services Administration, which must include at least one such visit per year beginning at 14 years of age.
4. A policy subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2018, has the legal effect of including the coverage required by subsection 1, and any provision of the policy or the renewal which is in conflict with this section is void.
NRS 689B.0379 Required provision concerning coverage for treatment of temporomandibular joint.
1. Except as otherwise provided in this section, no policy of group health insurance may be delivered or issued for delivery in this state if it contains an exclusion of coverage of the treatment of the temporomandibular joint whether by specific language in the policy or by a claims settlement practice. A policy may exclude coverage of those methods of treatment which are recognized as dental procedures, including, but not limited to, the extraction of teeth and the application of orthodontic devices and splints.
3. Any provision of a policy subject to the provisions of this chapter and issued or delivered on or after January 1, 1990, which is in conflict with this section is void.
NRS 689B.038 Reimbursement for treatments by licensed psychologist. If any policy of group health insurance provides coverage for treatment of an illness which is within the authorized scope of the practice of a qualified psychologist, the insured is entitled to reimbursement for treatment by a licensed psychologist.
NRS 689B.0383 Reimbursement for treatments by licensed marriage and family therapist or licensed clinical professional counselor. If any policy of group health insurance provides coverage for treatment of an illness which is within the authorized scope of practice of a licensed marriage and family therapist or licensed clinical professional counselor, the insured is entitled to reimbursement for treatment by a marriage and family therapist or clinical professional counselor who is licensed pursuant to chapter 641A of NRS.
NRS 689B.0385 Reimbursement for treatments by licensed associate in social work, social worker, independent social worker or clinical social worker. If any policy of group health insurance provides coverage for treatment of an illness which is within the authorized scope of the practice of a licensed associate in social work, social worker, independent social worker or clinical social worker, the insured is entitled to reimbursement for treatment by an associate in social work, social worker, independent social worker or clinical social worker who is licensed pursuant to chapter 641B of NRS.
1. If any group policy of health insurance provides coverage for treatment of an illness which is within the authorized scope of practice of a qualified chiropractor, the insured is entitled to reimbursement for treatments by a chiropractor who is licensed pursuant to chapter 634 of NRS.
(a) Coverage for treatments by a chiropractor to a number less than for treatments by other physicians.
(b) Reimbursement for treatments by a chiropractor to an amount less than that charged for similar treatments by other physicians.
NRS 689B.0393 Reimbursement for treatments by podiatrist.
1. If any group policy of health insurance provides coverage for treatment of an illness which is within the authorized scope of practice of a qualified podiatrist, the insured is entitled to reimbursement for treatments by a podiatrist who is licensed pursuant to chapter 635 of NRS.
(a) Coverage for treatments by a podiatrist to a number less than for treatments by other physicians.
(b) Reimbursement for treatments by a podiatrist to an amount less than that reimbursed for similar treatments by other physicians.
2. Any other applicable assignment of benefits.
NRS 689B.040 Direct payment for hospital and medical services and home health care; payment to assignee.
Ê be paid directly to the hospital or person rendering the services. Payments made in this manner discharge the insurer’s obligation.
2. If the insured assigns his or her benefits pursuant to this section but the insurer after receiving a copy of the assignment pays the benefits to the insured, the insurer shall also pay the benefits to the assignee as soon as the insurer receives the notice of the incorrect payment.
NRS 689B.045 Reimbursement for services provided by certain nurses; prohibited limitations; exception.
1. If any group policy of health insurance provides coverage for services which are within the authorized scope of practice of a registered nurse who is authorized pursuant to chapter 632 of NRS to perform additional acts in an emergency or under other special conditions as prescribed by the State Board of Nursing, and which are reimbursed when provided by another provider of health care, the insured is entitled to reimbursement for services provided by such a registered nurse.
3. An insurer is not required to pay for services provided by such a registered nurse which duplicate services provided by another provider of health care.
1. Except as otherwise provided in subsection 3, every policy of group health insurance amended, delivered or issued for delivery in this State after October 1, 1989, that provides coverage for medical transportation, must contain a provision for the direct reimbursement of a provider of medical transportation for covered services if that provider does not receive reimbursement from any other source.
2. The insured or the provider may submit the claim for reimbursement. The provider shall not demand payment from the insured until after that reimbursement has been granted or denied.
3. Subsection 1 does not apply to any agreement between an insurer and a provider of medical transportation for the direct payment by the insurer for the provider’s services.
NRS 689B.049 Reimbursement for acupuncture. If any policy of group health insurance provides coverage for acupuncture performed by a physician, the insured is entitled to reimbursement for acupuncture performed by a person who is licensed pursuant to chapter 634A of NRS.
NRS 689B.050 Extended disability benefit. Any group health policy may provide for payment not exceeding three times the amount of the monthly benefit under the policy as an extended disability benefit upon the insured’s death from any cause. The extended disability benefit must not be construed as life insurance.
1. Any contract of group health insurance may provide for the readjustment of the rate of premium based upon the experience thereunder. If a policy dividend is declared after January 1, 1972, or a reduction in rate is made after January 1, 1972, or continued for the first or any subsequent year of insurance under any policy of group health insurance issued before, on or after January 1, 1972, to any policyholder, the excess, if any, of the aggregate dividends or rate reductions under such a policy and all other group insurance policies of the policyholder over the aggregate expenditure for insurance under such policies made from money contributed by the policyholder, or by an employer of insured persons, or by a union or association to which the insured persons belong, including expenditures made in connection with administration of such policies, must be applied by the policyholder for the sole benefit of insured employees or members.
2. This section does not apply as to debtor groups.
1. May not require an insured, another insurer who issues policies of group health insurance, a nonprofit medical service corporation or a health maintenance organization to pay any amount in excess of the deductible or coinsurance due from the insured based on the rates agreed upon with a provider.
2. Must require that the deductible and payment for coinsurance paid by the insured to a preferred provider of health care be applied to the negotiated reduced rates of that provider.
3. Must provide that if there is a particular service which a preferred provider of health care does not provide and the provider of health care who is treating the insured requests the service and the insurer determines that the use of the service is necessary for the health of the insured, the service shall be deemed to be provided by the preferred provider of health care.
4. Must require the insurer to process a claim of a provider of health care who is not preferred not later than 30 working days after the date on which proof of the claim is received.
1. When a policy of group insurance is primary, its benefits are determined before those of another policy and the benefits of another policy are not considered. When a policy of group insurance is secondary, its benefits are determined after those of another policy. Secondary benefits may not be reduced because of benefits under the primary policy. When there are more than two policies, a policy may be primary as to one and may be secondary as to another.
2. The benefits payable under a policy of group health insurance may not be reduced because of any benefits payable under health insurance on a franchise plan or first-party coverage under an automobile insurance policy.
3. As used in this section, “a policy of group insurance” includes Medicare.
1. A policy that does not coordinate with other policies is always the primary policy.
2. The benefits of the policy which covers a person as an employee, member or subscriber, other than a dependent, is the primary policy. The policy which covers the person as a dependent is the secondary policy.
3. When more than one policy covers the same child as a dependent of different parents who are not divorced or separated, the primary policy is the policy of the parent whose birthday falls earlier in the year. The secondary policy is the policy of the parent whose birthday falls later in the year. If both parents have the same birthday, the benefits of the policy which covered the parent the longer is the primary policy. The policy which covered the parent the shorter time is the secondary policy.
Ê unless the specific terms of a court decree state that one parent is responsible for the health care expenses of the child, in which case, the policy of that parent is the primary policy. A parent responsible for the health care pursuant to a court decree must notify the insurer of the terms of the decree.
5. The primary policy is the policy which covers a person as an employee who is neither laid off or retired, or that employee’s dependent. The secondary policy is the policy which covers that person as a laid off or retired employee, or that employee’s dependent.
6. If none of the rules in subsections 1 to 5, inclusive, determines the order of benefits, the primary policy is the policy which covered an employee, member or subscriber longer. The secondary policy is the policy which covered that person the shorter time.
Ê When a policy is determined to be a secondary policy it acts to provide benefits in excess of those provided by the primary policy. The secondary policy may not reduce benefits based upon payments by the primary policy, except that this provision does not require duplication of benefits.
NRS 689B.065 Policy issued to replace discontinued policy or coverage: Requirements; notice of reduction of benefits; statement of benefits; applicability of section.
Ê if that replacement policy is issued within 60 days after the date on which the previous policy or coverage was discontinued.
2. If an employer obtains a replacement policy pursuant to subsection 1 to cover the employees of the employer, any benefits provided by the previous policy or coverage may be reduced if notice of the reduction is given to the employees of the employer pursuant to NRS 608.1577.
3. Any insurer which issues a replacement policy pursuant to subsection 1 may submit a written request to the insurer who provided the previous policy or coverage for a statement of benefits which were provided under that policy or coverage. Upon receiving such a request, the insurer who provided the previous policy or coverage shall give a written statement to the insurer providing the replacement policy which indicates what benefits were provided and what exclusions or reductions were in effect under the previous policy or coverage.
(a) Apply to a self-insured employer who provides health benefits to the employees of the employer and replaces those benefits with a policy of group health insurance.
(b) Do not apply to the Public Employees’ Benefits Program established pursuant to NRS 287.0402 to 287.049, inclusive.
NRS 689B.067 Provision in policy requiring binding arbitration for disputes with insurer authorized; procedure for arbitration; declaratory relief.
(a) A member and any dependent of the member must be given the opportunity to decline to participate in binding arbitration at the time they elect to be covered by the policy.
(b) It must clearly state that the insurer and a member or dependent of a member of the insured group who has not declined to participate in binding arbitration agree to forego their right to resolve any such dispute in a court of law or equity.
2. Except as otherwise provided in subsection 3, the arbitration must be conducted pursuant to the rules for commercial arbitration established by the American Arbitration Association. The insurer is responsible for any administrative fees and expenses relating to the arbitration, except that the insurer is not responsible for attorney’s fees and fees for expert witnesses unless those fees are awarded by the arbitrator.
3. If a dispute required to be submitted to binding arbitration requires an immediate resolution to protect the physical health of a member or a dependent of a member, any party to the dispute may waive arbitration and seek declaratory relief in a court of competent jurisdiction.
4. If a provision described in subsection 1 is included in a policy of group health insurance, the provision shall not be deemed unenforceable as an unreasonable contract of adhesion if the provision is included in compliance with the provisions of subsection 1.
NRS 689B.068 Insurer prohibited from denying coverage solely because person was victim of domestic violence. An insurer shall not deny a claim, refuse to issue a policy of group health insurance or cancel a policy of group health insurance solely because the claim involves an act that constitutes domestic violence pursuant to NRS 33.018, or because the person applying for or covered by the policy of group health insurance was the victim of such an act of domestic violence, regardless of whether the insured or applicant contributed to any loss or injury.
NRS 689B.069 Insurer prohibited from requiring or using information concerning genetic testing; exceptions.
2. The provisions of this section do not apply to an insurer who issues a policy of group health insurance that provides coverage for long-term care or disability income.
1. Any common carrier or to any operator, owner or lessee of a means of transportation, who or which shall be deemed the policyholder, covering a group of persons who may become passengers defined by reference to their travel status on the common carrier or means of transportation.
2. An employer, who shall be deemed the policyholder, covering any group of employees, dependents or guests, defined by reference to specified hazards incident to an activity or activities or operations of the policyholder.
3. A college, school or other institution of learning, a school district or districts, or school jurisdictional unit, or to the head, principal or governing board of any such educational unit, who or which shall be deemed the policyholder, covering students, teachers or employees.
4. A religious, charitable, recreational, educational or civic organization, or branch thereof, which shall be deemed the policyholder, covering any group of members or participants defined by reference to specified hazards incident to an activity or activities or operations sponsored or supervised by the policyholder.
5. A sports team, camp or sponsor thereof, which shall be deemed the policyholder, covering members, campers, employees, officials or supervisors.
6. A volunteer fire department, organization providing first aid, organization for emergency management or other such volunteer organization, which shall be deemed the policyholder, covering any group of members or participants defined by reference to specified hazards incident to an activity or activities or operations sponsored or supervised by the policyholder.
7. A newspaper or other publisher, which shall be deemed the policyholder, covering its carriers.
8. An association, including a labor union, which has a constitution and bylaws and which has been organized and is maintained in good faith for purposes other than that of obtaining insurance, which shall be deemed the policyholder, covering any group of members or participants defined by reference to specified hazards incident to an activity or activities or operations sponsored or supervised by the policyholder.
9. Cover any other risk or class of risks which, in the discretion of the Commissioner, may be properly eligible for blanket accident and health insurance. The discretion of the Commissioner may be exercised on the basis of an individual risk or class of risks, or both.
1. A provision that the policy, including endorsements and a copy of the application, if any, of the policyholder and the persons insured constitutes the entire contract between the parties, and that any statement made by the policyholder or by a person insured is in the absence of fraud a representation and not a warranty, and that no such statements may be used in defense to a claim under the policy, unless contained in a written application. The insured or the beneficiary or assignee of the insured has the right to make a written request to the insurer for a copy of an application, and the insurer shall, within 15 days after the receipt of a request at its home office or any branch office of the insurer, deliver or mail to the person making the request a copy of the application. If a copy is not so delivered or mailed, the insurer is precluded from introducing the application as evidence in any action based upon or involving any statements contained therein.
2. A provision that written notice of sickness or of injury must be given to the insurer within 20 days after the date when the sickness or injury occurred. Failure to give notice within that time does not invalidate or reduce any claim if it is shown that it was not reasonably possible to give notice and that notice was given as soon as was reasonably possible.
3. A provision that the insurer will furnish to the claimant or to the policyholder for delivery to the claimant such forms as are usually furnished by it for filing proof of loss. If the forms are not furnished before the expiration of 15 days after giving written notice of sickness or injury, the claimant shall be deemed to have complied with the requirements of the policy as to proof of loss upon submitting, within the time fixed in the policy for filing proof of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made.
4. A provision that in the case of a claim for loss of time for disability, written proof of the loss must be furnished to the insurer within 90 days after the commencement of the period for which the insurer is liable, and that subsequent written proofs of the continuance of the disability must be furnished to the insurer at such intervals as the insurer may reasonably require, and that in the case of a claim for any other loss, written proof of the loss must be furnished to the insurer within 90 days after the date of the loss. Failure to furnish such proof within that time does not invalidate or reduce any claim if it is shown that it was not reasonably possible to furnish proof and that the proof was furnished as soon as was reasonably possible.
5. A provision that all benefits payable under the policy other than benefits for loss of time will be payable immediately upon receipt of written proof of loss, and that, subject to proof of loss, all accrued benefits payable under the policy for loss of time will be paid not less frequently than monthly during the continuance of the period for which the insurer is liable, and that any balance remaining unpaid at the termination of that period will be paid immediately upon receipt of proof.
6. A provision that the insurer at its own expense has the right and opportunity to examine the person of the insured when and so often as it may reasonably require during the pendency of claim under the policy and also the right and opportunity to make an autopsy where it is not prohibited by law.
7. A provision, if applicable, setting forth the provisions of NRS 689B.035.
8. A provision for benefits for expense arising from care at home or health supportive services if that care or service was prescribed by a physician and would have been covered by the policy if performed in a medical facility or facility for the dependent as defined in chapter 449 of NRS.
9. A provision that no action at law or in equity may be brought to recover under the policy before the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of the policy and that no such action may be brought after the expiration of 3 years after the time written proof of loss is required to be furnished.
1. An individual application need not be required from a person covered under a blanket health policy or contract, nor shall it be necessary for the insurer to furnish each person a certificate, if such person does not pay all or part of the premium for such insurance.
2. The Commissioner may, by rule or regulation, require the delivery of an individual certificate or a statement of the coverage to individuals insured under such a blanket policy or contract who are either required to make an individual written application or pay part or all of the premium therefor, and applying to such classes of cases and circumstances, specified in such rule or regulation, as the Commissioner may find such delivery to be reasonably necessary and practicable.
1. Except as provided in subsection 2, all benefits under any blanket health policy or contract must be payable to the person insured, or to the designated beneficiary or beneficiaries of the person insured, or to the estate of the person insured, except that if the person insured is a minor or otherwise not competent to give a valid release, these benefits may be made payable to the parent or guardian of the person insured or to another person actually supporting the person insured.
Ê be paid directly to the hospital or person rendering those services. The policy may not require that the service be rendered by a particular hospital or person. Payment so made discharges the obligation of the insurer with respect to the amount of insurance so paid.
3. If the insured assigns his or her benefits pursuant to this section but the insurer after receiving a copy of the assignment pays the benefits to the insured, the insurer shall also pay the benefits to the assignee as soon as the insurer receives the notice of the incorrect payment.
NRS 689B.110 Legal liability of policyholders for death of or injury to insured member unaffected. Nothing contained in NRS 689B.070 to 689B.100, inclusive, shall be deemed to affect the legal liability of policyholders for death of or injury to any member insured under a blanket insurance policy.
1. A hospital the Uniform Billing and Claims Forms established by the American Hospital Association in lieu of its individual billing and claims forms.
2. An individual who is licensed to practice one of the health professions regulated by title 54 of NRS such uniform health insurance claims forms as the Commissioner shall prescribe, except in those cases where the Commissioner has excused uniform reporting.
NRS 689B.255 Approval or denial of claims; payment of claims and interest; requests for additional information; award of costs and attorney’s fees; compliance with requirements.
1. Except as otherwise provided in subsection 2, an insurer shall approve or deny a claim relating to a policy of group health insurance or blanket insurance within 30 days after the insurer receives the claim. If the claim is approved, the insurer shall pay the claim within 30 days after it is approved. Except as otherwise provided in this section, if the approved claim is not paid within that period, the insurer shall pay interest on the claim at a rate of interest equal to the prime rate at the largest bank in Nevada, as ascertained by the Commissioner of Financial Institutions, on January 1 or July 1, as the case may be, immediately preceding the date on which the payment was due, plus 6 percent. The interest must be calculated from 30 days after the date on which the claim is approved until the date on which the claim is paid.
2. If the insurer requires additional information to determine whether to approve or deny the claim, it shall notify the claimant of its request for the additional information within 20 days after it receives the claim. The insurer shall notify the provider of health care of all the specific reasons for the delay in approving or denying the claim. The insurer shall approve or deny the claim within 30 days after receiving the additional information. If the claim is approved, the insurer shall pay the claim within 30 days after it receives the additional information. If the approved claim is not paid within that period, the insurer shall pay interest on the claim in the manner prescribed in subsection 1.
3. An insurer shall not request a claimant to resubmit information that the claimant has already provided to the insurer, unless the insurer provides a legitimate reason for the request and the purpose of the request is not to delay the payment of the claim, harass the claimant or discourage the filing of claims.
4. An insurer shall not pay only part of a claim that has been approved and is fully payable.
6. The payment of interest provided for in this section for the late payment of an approved claim may be waived only if the payment was delayed because of an act of God or another cause beyond the control of the insurer.
7. The Commissioner may require an insurer to provide evidence which demonstrates that the insurer has substantially complied with the requirements set forth in this section, including, without limitation, payment within 30 days of at least 95 percent of approved claims or at least 90 percent of the total dollar amount for approved claims.
8. If the Commissioner determines that an insurer is not in substantial compliance with the requirements set forth in this section, the Commissioner may require the insurer to pay an administrative fine in an amount to be determined by the Commissioner. Upon a second or subsequent determination that an insurer is not in substantial compliance with the requirements set forth in this section, the Commissioner may suspend or revoke the certificate of authority of the insurer.
NRS 689B.260 Required provision concerning coverage relating to complications of pregnancy.
1. No group health or blanket health policy may be delivered or issued for delivery in this state if it contains any exclusion, reduction or other limitation of coverage relating to complications of pregnancy, unless the provision applies generally to all benefits payable under the policy.
(b) If the pregnancy is terminated, results in nonelective cesarean section, ectopic pregnancy or spontaneous termination.
3. A policy subject to the provisions of this chapter which is delivered or issued for delivery on or after July 1, 1977, has the legal effect of including the coverage required by this section, and any provision of the policy which is in conflict with this section is void.
NRS 689B.270 Required procedure for arbitration of disputes concerning independent medical, dental or chiropractic evaluations.
1. Each policy of group or blanket health insurance must include a procedure for binding arbitration to resolve disputes concerning independent medical evaluations pursuant to the rules of the American Arbitration Association.
2. If an insurer, for any final determination of benefits or care, requires an independent evaluation of the medical, dental or chiropractic care of any person for whom such care is covered under the terms of a policy of group or blanket health insurance, only a physician, dentist or chiropractor who is certified to practice in the same field of practice as the primary treating physician, dentist or chiropractor or who is formally educated in that field may conduct the independent evaluation.
3. The independent evaluation must include a physical examination of the patient, unless the patient is deceased, and a personal review of all X-rays and reports prepared by the primary treating physician, dentist or chiropractor. A certified copy of all reports of findings must be sent to the primary treating physician, dentist or chiropractor and the insured person within 10 working days after the evaluation. If the insured person disagrees with the finding of the evaluation, the insured person must submit an appeal to the insurer pursuant to the procedure for binding arbitration set forth in the policy of insurance within 30 days after receiving the finding of the evaluation. Upon its receipt of an appeal, the insurer shall so notify in writing the primary treating physician, dentist or chiropractor.
4. The insurer shall not limit or deny coverage for care related to a disputed claim while the dispute is in arbitration, except that, if the insurer prevails in the arbitration, the primary treating physician, dentist or chiropractor may not recover any payment from either the insurer, insured person or the patient for services that the primary treating physician, dentist or chiropractor provided to the patient after receiving written notice from the insurer pursuant to subsection 3 concerning the appeal of the insured person.
NRS 689B.275 Contents, approval and provision of summary of coverage; provision of information about guaranteed availability of certain plans for benefits.
(f) Other information that the Commissioner finds necessary for full and fair disclosure of the provisions of the policy.
2. The language of the disclosure must be easily understood. The disclosure must state that it is only a summary of the policy and that the policy should be read to ascertain the governing contractual provisions.
3. The Commissioner shall not approve a proposed disclosure that does not satisfy the requirements of this section and of applicable regulations.
4. In addition to the disclosure, the insurer shall provide information about guaranteed availability of basic and standard plans for benefits to an eligible person.
5. The insurer shall provide the summary before the policy is issued.
NRS 689B.280 Disclosure of information concerning medication of insured prohibited.
2. The provisions of subsection 1 do not prohibit disclosure to an administrator who acts as an intermediary for claims for insurance coverage.
NRS 689B.285 Offering policy of health insurance for purposes of establishing health savings account. An insurer may, subject to regulation by the Commissioner, offer a policy of health insurance that has a high deductible and is in compliance with 26 U.S.C. § 223 for the purposes of establishing a health savings account.
NRS 689B.287 Insurer prohibited from denying coverage solely because insured was intoxicated or under influence of controlled substance; exceptions.
(a) Deny a claim under a policy of group health insurance solely because the claim involves an injury sustained by an insured as a consequence of being intoxicated or under the influence of a controlled substance.
(b) Cancel a policy of group health insurance solely because an insured has made a claim involving an injury sustained by the insured as a consequence of being intoxicated or under the influence of a controlled substance.
(c) Refuse to issue a policy of group health insurance to an eligible applicant solely because the applicant has made a claim involving an injury sustained by the applicant as a consequence of being intoxicated or under the influence of a controlled substance.
(c) Refuse to issue a policy of group health insurance to an eligible applicant solely because of such a claim.
3. The provisions of this section do not apply to an insurer under a policy of group health insurance that provides coverage for long-term care or disability income.
1. “Medicaid” means a program established in 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 care rendered on behalf of indigent persons.
2. “Order for medical coverage” means an order of a court or administrative tribunal to provide coverage under a group health policy to a child pursuant to the provisions of 42 U.S.C. § 1396g-1.
NRS 689B.300 Effect of eligibility for medical assistance under Medicaid; assignment of rights to state agency.
1. An insurer shall not, when considering eligibility for coverage or making payments under a group health policy, consider the availability of, or eligibility of a person for, medical assistance under Medicaid.
(2) It has reimbursed Medicaid in full for the health care provided by Medicaid to its insured.
Ê the insurer that issued the policy shall not impose any requirements upon the state agency except requirements it imposes upon the agents or assignees of other persons covered by the policy.
(2) Any action by the state agency to enforce its rights with respect to such claim is commenced not later than 6 years after the submission of the claim.
5. As used in this section, “insurer” includes, without limitation, a self-insured plan, group health plan as defined in section 607(1) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1167(1), service benefit plan or other organization that has issued a group health policy or any other party described in section 1902(a)(25)(A), (G) or (I) of the Social Security Act, 42 U.S.C. § 1396a(a)(25)(A), (G) or (I), as being legally responsible for payment of a claim for a health care item or service.
3. Does not reside with the parent or within the insurer’s geographic area of service.
1. Provide to the custodial parent such information as necessary for the child to obtain any benefits under that coverage.
2. Allow the custodial parent or, with the approval of the custodial parent, a provider of health care to submit claims for covered services without the approval of the noncustodial parent.
3. Make payments on claims submitted pursuant to subsection 2 directly to the custodial parent, the provider of health care or an agency of this or another state responsible for the administration of Medicaid.
1. Shall, if the child is otherwise eligible for that coverage, allow the parent to enroll the child in that coverage without regard to any restrictions upon periods for enrollment.
Ê enroll the child in that coverage upon application by the other parent of the child, or by an agency of this or another state responsible for the administration of Medicaid or a state program for the enforcement of child support established pursuant to 42 U.S.C. §§ 651 et seq., without regard to any restrictions upon periods for enrollment.
NRS 689B.340 Definitions. As used in NRS 689B.340 to 689B.580, inclusive, unless the context otherwise requires, the words and terms defined in NRS 689B.350 to 689B.460, inclusive, have the meanings ascribed to them in those sections.
NRS 689B.350 “Affiliation period” defined. “Affiliation period” means a period not to exceed 60 days for new enrollees and 90 days for late enrollees during which no premiums may be collected from, and coverage issued would not become effective for, an employee or a dependent of the employee, if the affiliation period is applied uniformly and without regard to any health status-related factors.
NRS 689B.355 “Blanket accident and health insurance” defined. “Blanket accident and health insurance” has the meaning ascribed to it in NRS 689B.070.
NRS 689B.360 “Carrier” defined. “Carrier” means any person who provides health insurance in this state, including a fraternal benefit society, a health maintenance organization, a nonprofit hospital and health service corporation, a health insurance company and any other person providing a plan of health insurance or health benefits subject to this Title.
NRS 689B.370 “Contribution” defined. “Contribution” means the minimum employer contribution toward the premium for enrollment of participants and beneficiaries in a health benefit plan.
13. A blanket accident and health insurance policy.
(c) Such other similar benefits as are specified in any federal regulations adopted pursuant to Public Law 104-191.
NRS 689B.400 “Group participation” defined. “Group participation” means the minimum number of participants or beneficiaries that must be enrolled in a health benefit plan in relation to a specified percentage or number of eligible persons or employees of the employer.
NRS 689B.430 “Open enrollment” defined. “Open enrollment” means the period designated for enrollment in a health benefit plan.
NRS 689B.440 “Plan sponsor” defined. “Plan sponsor” has the meaning ascribed to it in section 3(16)(B) of the Employee Retirement Income Security Act of 1974, as that section existed on July 16, 1997.
NRS 689B.450 “Preexisting condition” defined. “Preexisting condition” means a condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received during the 6 months immediately preceding the effective date of the new coverage. The term does not include genetic information in the absence of a diagnosis of the condition related to such information.
NRS 689B.460 “Waiting period” defined. “Waiting period” means the period established by a plan of health insurance that must pass before a person who is an eligible participant or beneficiary in a plan is covered for benefits under the terms of the plan. The term includes the period from the date a person submits an application to an individual carrier for coverage under a health benefit plan until the first day of coverage under that health benefit plan.
NRS 689B.480 Determination of applicable creditable coverage of person; determination of period of creditable coverage of person; required statement.
1. In determining the applicable creditable coverage of a person for the purposes of NRS 689B.340 to 689B.580, inclusive, a period of creditable coverage must not be included if, after the expiration of that period but before the enrollment date, there was a 63-day period during all of which the person was not covered under any creditable coverage. To establish a period of creditable coverage, a person must present any certificates of coverage provided to the person in accordance with NRS 689B.490 and such other evidence of coverage as required by regulations adopted by the Commissioner. For the purposes of this subsection, any waiting period for coverage or an affiliation period must not be considered in determining the applicable period of creditable coverage.
2. In determining the period of creditable coverage of a person, a carrier shall include each applicable period of creditable coverage without regard to the specific benefits covered during that period, except that the carrier may elect to include applicable periods of creditable coverage based on coverage of specific benefits as specified in the regulations of the United States Department of Health and Human Services, if such an election is made on a uniform basis for all participants and beneficiaries of the health benefit plan or coverage. Pursuant to such an election, the carrier shall include each applicable period of creditable coverage with respect to any class or category of benefits if any level of benefits is covered within that class or category, as specified by those regulations.
(b) Provided to each person at the time of enrollment in the health benefit plan.
NRS 689B.490 Written certification of coverage required for purpose of determining period of creditable coverage accumulated by person.
NRS 689B.500 Coverage of preexisting conditions. A carrier that issues a group health plan or coverage under blanket accident and health insurance or group health insurance shall not deny, exclude or limit a benefit for a preexisting condition.
NRS 689B.510 Carrier authorized to modify coverage for insurance product under certain circumstances. A carrier may modify the health insurance coverage for a product offered pursuant to a group health plan by the carrier at the time of renewal of such coverage if the modification is consistent with the provisions of this chapter.
NRS 689B.520 Group plan or coverage that includes coverage for maternity care and pediatric care: Required to allow minimum stay in hospital in connection with childbirth; prohibited acts.
Ê If a different length of stay is provided in the guidelines established by the American College of Obstetricians and Gynecologists, or its successor organization, and the American Academy of Pediatrics, or its successor organization, the group health plan or health insurance coverage may follow such guidelines in lieu of following the length of stay set forth above. The provisions of this subsection do not apply to any group health plan or health insurance coverage in any case in which the decision to discharge the mother or newborn infant before the expiration of the minimum length of stay set forth in this subsection is made by the attending physician of the mother or newborn infant.
(a) Prohibits a group health plan or carrier from imposing a deductible, coinsurance or other mechanism for sharing costs relating to benefits for hospital stays in connection with childbirth for a mother or newborn child covered by the plan, except that such coinsurance or other mechanism for sharing costs for any portion of a hospital stay required by this section may not be greater than the coinsurance or other mechanism for any preceding portion of that stay.
(b) Prohibits an arrangement for payment between a group health plan or carrier and a provider of health care that uses capitation or other financial incentives, if the arrangement is designed to provide services efficiently and consistently in the best interest of the mother and her newborn infant.
(c) Prevents a group health plan or carrier from negotiating with a provider of health care concerning the level and type of reimbursement to be provided in accordance with this section.
NRS 689B.540 Manner and period for enrollment of dependent of covered employee; period of special enrollment.
4. In the case of a birth, an adoption or a placement for adoption of a child of an employee, the spouse of the employee may be enrolled as a dependent pursuant to this section if the spouse is otherwise eligible for coverage under the group health plan.
NRS 689B.550 Carrier prohibited from imposing restriction on participation inconsistent with chapter; restrictions on rules of eligibility that may be established; premiums to be equitable.
1. A carrier shall not place any restriction on a person or a dependent of the person as a condition of being a participant in or a beneficiary of a policy of blanket accident and health insurance or group health insurance that is inconsistent with the provisions of this chapter.
(b) Prevent a carrier from establishing limitations or restrictions on the amount, level, extent or nature of the benefits or coverage for similarly situated persons.
4. As a condition of enrollment or continued enrollment under a policy of blanket accident and health insurance or group health insurance, a carrier shall not require an employee to pay a premium or contribution that is greater than the premium or contribution for a similarly situated person covered by similar coverage on the basis of any factor described in subsection 2 in relation to the employee or a dependent of the employee.
(c) Preclude a carrier from establishing rules relating to employer contribution or group participation when offering health insurance coverage to small employers in this state.
NRS 689B.560 Carrier required to renew coverage at option of plan sponsor; exceptions; discontinuation of product; discontinuation of group health insurance through bona fide association.
(1) Provide notice of its intention to the Commissioner and the chief regulatory officer for insurance in each state in which the carrier is licensed to transact insurance at least 60 days before the date on which notice of cancellation or nonrenewal is delivered or mailed to the persons covered by the discontinued insurance pursuant to subparagraph (2).
(2) Provide notice of its intention to all persons covered by the discontinued insurance and to the Commissioner and the chief regulatory officer for insurance in each state in which such a person is known to reside. The notice must be made at least 180 days before the discontinuance of any group health plan by the carrier.
(3) Discontinue all health insurance issued or delivered for issuance for persons in this state and not renew coverage under any group health insurance issued to such persons.
(a) The carrier notifies the Commissioner of its decision pursuant to this subsection to discontinue the product at least 60 days before the carrier notifies the affected employers and persons covered pursuant to paragraph (b).
(b) The carrier notifies each affected employer and person covered of the decision of the carrier to discontinue the product. The notice must be made at least 90 days before the date on which the carrier will discontinue offering the product.
(c) The carrier offers to each affected employer the option to purchase any other health benefit plan currently offered by the carrier to groups in this state.
(d) In exercising the option to discontinue the product and in offering the option to purchase other coverage pursuant to paragraph (c), the carrier acts uniformly without regard to the claim experience of the persons covered by the discontinued product or any health status-related factor relating to those persons or beneficiaries covered by the discontinued product or any person or beneficiary who may become eligible for such coverage.
(c) Coverage is terminated pursuant to this subsection for all such former members uniformly without regard to any health status-related factor relating to the former member.
4. A carrier that elects not to renew group health insurance pursuant to paragraph (d) of subsection 1 shall not write new business pursuant to this chapter for 5 years after the date on which notice is provided to the Commissioner pursuant to subparagraph (2) of paragraph (d) of subsection 1.
5. If the carrier does business in only one geographic service area of this state, the provisions of this section apply only to the operations of the carrier in that service area.
6. As used in this section, “bona fide association” has the meaning ascribed to it in NRS 689A.485.
NRS 689B.570 Carrier that offers coverage through network plan not required to offer coverage to employer that does not employ enrollees who reside or work in geographic service area for which carrier is authorized to transact insurance.
1. A carrier that offers coverage through a network plan is not required to offer coverage to or accept an application from an employer that does not employ or no longer employs any enrollees who reside or work in the geographic service area of the carrier, provided that such coverage is refused or terminated uniformly without regard to any health status-related factor for any employee of the employer.
2. As used in this section, “network plan” means a health benefit plan offered by a health carrier under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the carrier. The term does not include an arrangement for the financing of premiums.
NRS 689B.580 Plan sponsor of governmental plan authorized to elect to exclude governmental plan from compliance with certain statutes; duties of plan sponsor.
(a) Must be made in such a form and in such a manner as the Commissioner prescribes by regulation.
(b) Is effective for a single specified year of the plan or, if the plan is provided pursuant to a collective bargaining agreement, for the term of that agreement.
(d) Excludes the governmental plan from those provisions in this chapter that apply only to group health plans.
(b) Provide certification and disclosure of creditable coverage under the plan with respect to those enrollees pursuant to NRS 689B.490.
3. As used in this section, “governmental plan” has the meaning ascribed to in section 3(32) of the Employee Retirement Income Security Act of 1974, as that section existed on July 16, 1997.

References: § 223
 § 99
 § 223
 § 1396
 § 1167
 § 1396