reglab/housing_qa huggingface dataset:
NV Rev Stat § 695G.163 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.163 - Coverage for prescription drugs: Provision of notice and information regarding use of formulary.

  1. A managed care organization that offers or issues a health care plan which provides coverage for prescription drugs shall include with any summary, certificate or evidence of that coverage provided to an insured, notice of whether a formulary is used and, if so, of the opportunity to secure information regarding the formulary from the organization pursuant to subsection 2. The notice required by this subsection must:  (a) Be in a language that is easily understood and in a format that is easy to understand;  (b) Include an explanation of what a formulary is; and  (c) If a formulary is used, include:  (1) An explanation of:  (I) How often the contents of the formulary are reviewed; and  (II) The procedure and criteria for determining which prescription drugs are included in and excluded from the formulary; and  (2) The telephone number of the organization for making a request for information regarding the formulary pursuant to subsection 2.  2. If a managed care organization offers or issues a health care plan which provides coverage for prescription drugs and a formulary is used, the organization shall:  (a) Provide to any insured or participating provider of health care, upon request:  (1) Information regarding whether a specific drug is included in the formulary.  (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 organization shall notify the requester that a choice of formulary lists is available.  (b) Notify each person who requests information regarding the formulary, that the inclusion of a drug in the formulary does not guarantee that a provider of health care will prescribe that drug for a particular medical condition.  (Added to NRS by 2001, 866)
NV Rev Stat § 695G.166 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.166 - Required provision concerning coverage for prescription drug previously approved for medical condition of insured.

  1. Except as otherwise provided in this section, a health care plan which provides coverage for prescription drugs must not limit or exclude coverage for a drug if the drug:  (a) Had previously been approved for coverage by the managed care organization for a medical condition of an insured and the insured’s provider of health care determines, after conducting a reasonable investigation, that none of the drugs which are otherwise currently approved for coverage are medically appropriate for the insured; and  (b) Is appropriately prescribed and considered safe and effective for treating the medical condition of the insured.  2. The provisions of subsection 1 do not:  (a) Apply to coverage for any drug that is prescribed for a use that is different from the use for which that drug has been approved for marketing by the Food and Drug Administration;  (b) Prohibit:  (1) The organization from charging a deductible, copayment or coinsurance for the provision of benefits for prescription drugs to the insured or from establishing, by contract, limitations on the maximum coverage for prescription drugs;  (2) A provider of health care from prescribing another drug covered by the plan that is medically appropriate for the insured; or  (3) The substitution of another drug pursuant to NRS 639.23286 or 639.2583 to 639.2597, inclusive; or  (c) Require any coverage for a drug after the term of the plan.  3. Any provision of a health care plan 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.  (Added to NRS by 2001, 866; A 2003, 2301; 2017, 640)
NV Rev Stat § 695G.1665 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.1665 - Required provision concerning coverage for prescription drugs irregularly dispensed for purpose of the synchronization of chronic medications.

  1. A managed care organization that offers or issues a health care plan which provides coverage for prescription drugs:  (a) Must authorize coverage for and may apply a copayment and deductible to a prescription that is dispensed by a pharmacy for less than a 30-day supply if, for the purpose of synchronizing the insured’s chronic medications:  (1) The prescriber or pharmacist determines that filling or refilling the prescription in that manner is in the best interest of the insured; and  (2) The insured requests less than a 30-day supply.  (b) May not deny coverage for a prescription described in paragraph (a) which is otherwise approved for coverage by the managed care organization.  (c) Unless otherwise provided by a contract or other agreement, may not prorate any pharmacy dispensing fees for a prescription described in paragraph (a).  2. An evidence of coverage 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 evidence of coverage or renewal which is in conflict with this section is void.  3. The provisions of this section do not apply to unit-of-use packaging for which synchronization is not practicable or to a controlled substance.  4. As used in this section:  (a) "Chronic medication" means any drug that is prescribed to treat any disease or other condition which is determined to be permanent, persistent or lasting indefinitely.  (b) "Synchronization" means the alignment of the dispensing of multiple medications by a single contracted pharmacy for the purpose of improving a patient’s adherence to a prescribed course of medication.  (c) "Unit-of-use packaging" means medication that is prepackaged by the manufacturer in blister packs, compliance packs, course-of-therapy packs or any other packaging which is designed and intended to be dispensed directly to the patient without modification by the dispensing pharmacy, except for the addition of a prescription label.  (Added to NRS by 2015, 2129)
NV Rev Stat § 695G.167 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.167 - Required provision concerning coverage for orally administered chemotherapy.

  1. A managed care organization that offers or issues a health care plan which provides coverage for the treatment of cancer through the use of chemotherapy shall not:  (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. An evidence of coverage for a health care plan 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 evidence of coverage or renewal which is in conflict with this section is void.  3. Nothing in this section shall be construed as requiring a managed care organization 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.  (Added to NRS by 2013, 2001; A 2013, 3660)
NV Rev Stat § 695G.168 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.168 - Required provision concerning coverage for screening for colorectal cancer.

  1. A health care plan issued by a managed care organization that provides coverage for the treatment of colorectal cancer must provide coverage for colorectal cancer screening in accordance with:  (a) The guidelines concerning colorectal cancer screening which are published by the American Cancer Society; or  (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. An evidence of coverage for a health care plan 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 evidence of coverage that conflicts with the provisions of this section is void.  (Added to NRS by 2003, 1337)
NV Rev Stat § 695G.170 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.170 - Required provision concerning coverage for medically necessary emergency services; prohibitions.

  1. Each managed care organization shall provide coverage for medically necessary emergency services provided at any hospital.  2. A managed care organization shall not require prior authorization for medically necessary emergency services.  3. As used in this section, "medically necessary emergency services" means health care services that are provided to an insured by a provider of health care after the sudden onset of a medical condition that manifests itself by symptoms of such sufficient severity that a prudent person would believe that the absence of immediate medical attention could result in:  (a) Serious jeopardy to the health of an insured;  (b) Serious jeopardy to the health of an unborn child;  (c) Serious impairment of a bodily function; or  (d) Serious dysfunction of any bodily organ or part.  4. A health care plan subject to the provisions of this section 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 plan or the renewal which is in conflict with this section is void.  (Added to NRS by 1997, 304; A 1999, 3097)
NV Rev Stat § 695G.1716 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.1716 - Health care plan that includes coverage for maternity care must not deny coverage for gestational carrier; status of child in relation to intended parent. [Effective January 1, 2020.]

  1. A managed care organization that offers or issues a health care plan that includes coverage for maternity care shall not deny, limit or seek reimbursement for maternity care because the insured is acting as a gestational carrier.  2. If an insured acts as a gestational carrier, the child shall be deemed to be a child of the intended parent, as defined in NRS 126.590, for purposes related to the health care plan.  3. As used in this section, "gestational carrier" has the meaning ascribed to it in NRS 126.580.  (Added to NRS by 2019, 1008, effective January 1, 2020)
NV Rev Stat § 695G.172 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.172 - Required provision concerning coverage for early refills of topical ophthalmic products.

  1. A managed care organization which offers or issues a health care plan that provides coverage for prescription drugs shall not deny coverage for a topical ophthalmic product which is otherwise approved for coverage by the managed care organization when the insured, pursuant to NRS 639.2395, receives a refill of the product:  (a) After 21 days or more but before 30 days after receiving any 30-day supply of the product;  (b) After 42 days or more but before 60 days after receiving any 60-day supply of the product; or  (c) After 63 days or more but before 90 days after receiving any 90-day supply of the product.  2. The provisions of this section do not affect any deductibles, copayments or coinsurance authorized or required pursuant to the health care plan.  3. An evidence of coverage 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 evidence of coverage or renewal which is in conflict with this section is void.  4. As used in this section, "topical ophthalmic product" means a liquid prescription drug which is applied directly to the eye from a bottle or by means of a dropper.  (Added to NRS by 2015, 210)
NV Rev Stat § 695G.174 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.174 - Required provision concerning coverage for management and treatment of sickle cell disease.

  1. A managed care organization that issues a health care plan shall include in the plan coverage for:  (a) Necessary case management services for an insured diagnosed with sickle cell disease and its variants; and  (b) Medically necessary care for an insured who has been diagnosed with sickle cell disease and its variants.  2. A managed care organization that issues a health care plan which provides coverage for prescription drugs shall include in the plan coverage for medically necessary prescription drugs to treat sickle cell disease and its variants.  3. A managed care organization shall establish a plan for each insured under 18 years of age who has been diagnosed with sickle cell disease and its variants to transition the insured from pediatric care to adult care when the insured reaches 18 years of age.  4. A managed care organization 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.  5. As used in this section:  (a) "Case management services" means medical or other health care management services to assist patients and providers of health care, including, without limitation, identifying and facilitating additional resources and treatments, providing information about treatment options and facilitating communication between providers of services to a patient.  (b) "Medical management technique" means a practice which is used to control the cost or utilization of health care services. The term includes, without limitation, the use of step therapy, prior authorization or categorizing drugs and devices based on cost, type or method of administration.  (c) "Sickle cell disease and its variants" has the meaning ascribed to it in NRS 439.4927.  (Added to NRS by 2019, 2175)
NV Rev Stat § 695G.175 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.175 - Certain actions of managed care organization prohibited.

  1. If a managed care organization contracts for the provision of emergency medical services, outpatient services or inpatient services with a hospital or other licensed health care facility that provides acute care and is located in a city whose population is less than 60,000 or a county whose population is less than 100,000, the managed care organization shall not:  (a) Prohibit an insured from receiving services covered by the health care plan of the insured at that hospital or licensed health care facility if the services are provided by a provider of health care with whom the managed care organization has contracted for the provision of the services;  (b) Refuse to provide coverage for services covered by the health care plan of an insured that are provided to the insured at that hospital or licensed health care facility if the services were provided by a provider of health care with whom the managed care organization has contracted for the provision of the services;  (c) Refuse to pay a provider of health care with whom the managed care organization has contracted for the provision of services for providing services to an insured at that hospital or licensed health care facility if the services are covered by the health care plan of the insured;  (d) Discourage a provider of health care with whom the managed care organization has contracted for the provision of services from providing services to an insured at that hospital or licensed health care facility that are covered by the health care plan of the insured; or  (e) Offer or pay any type of material inducement, bonus or other financial incentive to a provider of health care:  (1) To provide services to an insured that are covered by the health care plan of the insured at another hospital or licensed health care facility; or  (2) Not to provide services to an insured at that hospital or licensed health care facility that are covered by the health care plan of the insured.  2. Nothing in this section prohibits a managed care organization from informing an insured that enhanced health care services are available at a hospital or licensed health care facility other than the hospital or licensed health care facility described in subsection 1 with which the managed care organization contracts for the provision of emergency medical services, outpatient services or inpatient services.  (Added to NRS by 1999, 1945; A 2001, 1998)
NV Rev Stat § 695G.177 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.177 - Required provision concerning coverage for prostate cancer screening.

  1. A health care plan issued by a managed care organization that provides coverage for the treatment of prostate cancer must provide coverage for prostate cancer screening in accordance with:  (a) The guidelines concerning prostate cancer screening which are published by the American Cancer Society; or  (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 health care plan issued by a managed care organization 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. Any evidence of coverage for a health care plan issued by a managed care organization 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 evidence of coverage or the renewal which is in conflict with subsection 1 is void.  (Added to NRS by 2007, 3242)
NV Rev Stat § 695G.180 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.180 - Quality assurance program: Requirements; written description; informing providers; necessary staff; review; responsibility for activities.

  1. Each managed care organization shall establish a quality assurance program designed to direct, evaluate and monitor the effectiveness of health care services provided to its insureds. The program must include, without limitation:  (a) A method for analyzing the outcomes of health care services;  (b) Peer review;  (c) A system to collect and maintain information related to the health care services provided to insureds;  (d) Recommendations for remedial action; and  (e) Written guidelines that set forth the procedures for remedial action when problems related to quality of care are identified.  2. Each managed care organization shall:  (a) Maintain a written description of the quality assurance program established pursuant to subsection 1, including, without limitation, the specific actions used by the managed care organization to promote adequate quality of health care services provided to insureds and the persons responsible for such actions;  (b) Provide information to each provider of health care whom it employs or with whom it contracts to provide health care services to insureds regarding the manner in which the quality assurance program functions;  (c) Provide the necessary staff to implement the quality assurance program and to evaluate the effectiveness of the program; and  (d) At least one time each year, review the continuity and effectiveness of the quality assurance program, review any findings of the quality improvement committee established pursuant to NRS 695G.190 and take any reasonable actions to improve the program.  3. Each managed care organization is responsible for an activity conducted pursuant to its quality assurance program, regardless of whether the managed care organization or another entity performs the activity.  (Added to NRS by 1997, 303)
NV Rev Stat § 695G.190 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.190 - Quality improvement committee: Administration; duties.

  1. As part of a quality assurance program established pursuant to NRS 695G.180, each managed care organization shall create a quality improvement committee directed by a physician who is licensed to practice medicine in the State of Nevada pursuant to chapter 630 or 633 of NRS.  2. Each managed care organization shall:  (a) Establish written guidelines setting forth the procedure for selecting the members of the committee;  (b) Select members pursuant to such guidelines; and  (c) Provide staff to assist the committee.  3. The committee shall:  (a) Select and review appropriate medical records of insureds and other data related to the quality of health care provided to insureds by providers of health care;  (b) Review the clinical processes used by providers of health care in providing services;  (c) Identify any problems related to the quality of health care provided to insureds; and  (d) Advise providers of health care regarding issues related to quality of care.  (Added to NRS by 1997, 303; A 2003, 1182)
NV Rev Stat § 695G.200 (2021)
2021 Nevada Revised Statutes|Chapter 695G - Managed Care|NRS 695G.200 - Approval; requirements; assistance for persons filing complaints; examination.

  1. Each managed care organization shall establish a system for resolving complaints of an insured concerning:  (a) Payment or reimbursement for covered health care services;  (b) Availability, delivery or quality of covered health care services, including, without limitation, an adverse determination made pursuant to utilization review; or  (c) The terms and conditions of a health care plan.  The system must be approved by the Commissioner.  2. If an insured makes an oral complaint, a managed care organization shall inform the insured that if the insured is not satisfied with the resolution of the complaint, the insured must file the complaint in writing to receive further review of the complaint.  3. Each managed care organization shall:  (a) Upon request, assign an employee of the managed care organization to assist an insured or other person in filing a complaint or appealing a decision of the review board;  (b) Authorize an insured who appeals a decision of the review board to appear before the review board to present testimony at a hearing concerning the appeal; and  (c) Authorize an insured to introduce any documentation into evidence at a hearing of a review board and require an insured to provide the documentation required by the health care plan of the insured to the review board not later than 5 business days before a hearing of the review board.  4. The Commissioner may examine the system for resolving complaints established pursuant to this section at such times as the Commissioner deems necessary or appropriate.  (Added to NRS by 1997, 305; A 2013, 3654; 2017, 2401)