reglab/statecodes huggingface dataset:
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.125 - Contract between health maintenance organization and provider of health care: Organization required to use form to obtain information on provider of health care; modification; submission by organization of schedule of payments to provider.

1. A health maintenance organization shall not contract with a provider of health care to provide health care to an insured unless the health maintenance organization 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.
2. A contract between a health maintenance organization and a provider of health care may be modified:
(a) At any time pursuant to a written agreement executed by both parties.
(b) Except as otherwise provided in this paragraph, by the health maintenance organization upon giving to the provider 45 days’ written notice of the modification of the health maintenance organization’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).
3. If a health maintenance organization contracts with a provider of health care to provide health care to an enrollee, the health maintenance organization shall:
(a) If requested by the provider of health care at the time the contract is made, submit to the provider of health care the schedule of payments applicable to the provider of health care; or
(b) If requested by the provider of health care at any other time, submit to the provider of health care the schedule of payments, including any changes to the fee schedule applicable to the provider’s practice, specified in paragraph (a) within 7 days after receiving the request.
4. As used in this section, "provider of health care" means a provider of health care who is licensed pursuant to chapter 630, 631, 632 or 633 of NRS.
(Added to NRS by 1999, 1651; A 2001, 2735; 2003, 3367; 2011, 2535)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.128 - Contracts to provide services pursuant to certain state programs: Payment of interest on claims.

Any contract or other agreement entered into or renewed by a health maintenance organization on or after October 1, 2001:
1. To provide health care services through managed care to recipients of Medicaid under the state plan for Medicaid; or
2. With the Division of Health Care Financing and Policy of the Department of Health and Human Services to provide insurance pursuant to the Children’s Health Insurance Program,
must require the health maintenance organization to pay interest to a provider of health care services on a claim that is not paid within the time provided in the contract or agreement 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.
(Added to NRS by 2001, 2734)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.130 - Notice and approval required for exercise of powers; rules or regulations.

1. A health maintenance organization shall file notice, with adequate supporting information, with the Commissioner prior to the exercise of any power granted in subsections 1 and 2 of NRS 695C.120. The Commissioner shall disapprove such exercise of power if in the opinion of the Commissioner it would substantially and adversely affect the financial soundness of the health maintenance organization and endanger its ability to meet its obligations. If the Commissioner does not disapprove within 60 days of the filing, it is deemed approved.
2. The Commissioner may promulgate rules or regulations.
(Added to NRS by 1973, 1250)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.140 - Notice and approval required for modification of operations; regulations.

1. A health maintenance organization shall, unless otherwise provided for in this chapter, file notice with the Commissioner before any material modification of the operations described in the information required by NRS 695C.070. If the Commissioner does not disapprove within 90 days after filing of the notice, the modification is deemed approved.
2. The Commissioner may adopt regulations to carry out the provisions of this section.
(Added to NRS by 1973, 1248; A 1995, 1632; 2013, 3640)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.145 - Accounting principles required for certain reports and transactions; health maintenance organization subject to requirements for certain insurers.

1. A health maintenance organization shall use accounting principles that are recognized by the laws of this state or approved by the Commissioner for:
(a) All financial reports;
(b) The accounting of investments and deposits; and
(c) Transactions between affiliates and holding companies.
2. A health maintenance organization is subject to the requirements for insurers for:
(a) Administrators, agents, brokers and solicitors, pursuant to chapter 683A of NRS;
(b) Borrowing, pursuant to NRS 693A.180;
(c) Impairment of capital, surplus or assets, pursuant to NRS 693A.260, 693A.270 and 693A.280;
(d) Management and agency contracts executed on or after January 1, 1992; and
(e) Officers, pursuant to NRS 693A.120 and 693A.130.
3. A domestic health maintenance organization is subject to the requirements for insurers for corporations pursuant to NRS 693A.040 to 693A.070, inclusive.
(Added to NRS by 1991, 2036)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.150 - Fiduciary responsibilities.

Any director, officer, partner, member or employee of a health maintenance organization who receives, collects, disburses or invests funds in connection with the activities of such organization shall be responsible for such funds in a fiduciary relationship to the enrollees.
(Added to NRS by 1973, 1250)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.160 - Investments.

With the exception of investments made in accordance with subsections 1 and 2 of NRS 695C.120 and NRS 695C.130, the investable funds of a health maintenance organization shall be invested only in securities or other investments permitted by the laws of this state for the investment of assets constituting the legal reserves of life insurance companies or such other securities or investments as the Commissioner may permit.
(Added to NRS by 1973, 1253)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.161 - Definitions.

As used in NRS 695C.161 to 695C.169, inclusive, unless the context otherwise requires:
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 health care plan to a child pursuant to the provisions of 42 U.S.C. § 1396g-1.
(Added to NRS by 1995, 2435)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.163 - Effect of eligibility for medical assistance under Medicaid; assignment of rights to state agency.

1. A health maintenance organization shall not, when considering eligibility for coverage or making payments under a health care plan, consider the availability of, or eligibility of a person for, medical assistance under Medicaid.
2. To the extent that payment has been made by Medicaid for health care, a health maintenance organization:
(a) Shall treat Medicaid as having a valid and enforceable assignment of benefits due an enrollee or claimant under the enrollee regardless of any exclusion of Medicaid or the absence of a written assignment; and
(b) May, as otherwise allowed by its plan, evidence of coverage or contract and applicable law or regulation concerning subrogation, seek to enforce any rights of a recipient of Medicaid to reimbursement against any other liable party if:
(1) It is so authorized pursuant to a contract with Medicaid for managed care; or
(2) It has reimbursed Medicaid in full for the health care provided by Medicaid to its enrollee.
3. If a state agency is assigned any rights of a person who is:
(a) Eligible for medical assistance under Medicaid; and
(b) Covered by a health care plan,
the organization responsible for the health care plan shall not impose any requirements upon the state agency except requirements it imposes upon the agents or assignees of other persons covered by the same plan.
4. If a state agency is assigned any rights of an enrollee who is eligible for medical assistance under Medicaid, a health maintenance organization shall:
(a) Upon request of the state agency, provide to the state agency information regarding the enrollee to determine:
(1) Any period during which the enrollee, the spouse or a dependent of the enrollee may be or may have been covered by the health care plan; and
(2) The nature of the coverage that is or was provided by the organization, including, without limitation, the name and address of the enrollee and the identifying number of the health care plan;
(b) Respond to any inquiry by the state agency regarding a claim for payment for the provision of any medical item or service not later than 3 years after the date of the provision of the medical item or service; and
(c) Agree not to deny a claim submitted by the state agency solely on the basis of the date of submission of the claim, the type or format of the claim form or failure to present proper documentation at the point of sale that is the basis for the claim if:
(1) The claim is submitted by the state agency not later than 3 years after the date of the provision of the medical item or service; and
(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.
(Added to NRS by 1995, 2435; A 2007, 2406)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.165 - Health maintenance organization prohibited from asserting certain grounds to deny enrollment of child pursuant to order if parent is enrolled in health care plan.

An organization shall not deny the enrollment of a child pursuant to an order for medical coverage under a health care plan in which a parent of the child is enrolled, on the ground that the child:
1. Was born out of wedlock;
2. Has not been claimed as a dependent on the parent’s federal income tax return; or
3. Does not reside with the parent or within the organization’s geographic area of service.
(Added to NRS by 1995, 2436)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.167 - Certain accommodations required to be made when child is covered under health care plan of noncustodial parent.

If a child has coverage under a health care plan in which a noncustodial parent of the child is enrolled, the organization responsible for that plan shall:
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 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 or an agency of this or another state responsible for the administration of Medicaid.
(Added to NRS by 1995, 2436)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.169 - Health maintenance organization required to authorize enrollment of child of parent who is required by order to provide medical coverage under certain circumstances; termination of coverage of child.

If a parent is required by an order for medical coverage to provide coverage for a child and the parent is eligible for coverage of members of the parent’s family under a health care plan, the organization responsible for that plan:
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.
2. Shall, if:
(a) The child is otherwise eligible for that coverage; and
(b) The parent is enrolled in that coverage but fails to apply for enrollment of the child,
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.
3. Shall not terminate the enrollment of the child in that coverage or otherwise eliminate that coverage of the child unless the organization has written proof that:
(a) The order for medical coverage is no longer in effect; or
(b) The child is or will be enrolled in comparable coverage through another insurer on or before the effective date of the termination of enrollment or elimination of coverage.
(Added to NRS by 1995, 2436)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.1694 - Required provision in plan covering prescription drugs or devices concerning coverage of hormone replacement therapy in certain circumstances; prohibited acts; exception.

1. A health maintenance organization which offers or issues a health care plan that provides coverage for prescription drugs or devices shall include in the plan 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.
2. A health maintenance organization that offers or issues a health care plan that provides coverage for prescription drugs shall not:
(a) Require an enrollee to pay a higher deductible, any copayment or coinsurance or require a longer waiting period or other condition for coverage for hormone replacement therapy;
(b) Refuse to issue a health care plan or cancel a health care plan solely because the person applying for or covered by the plan uses or may use in the future hormone replacement therapy;
(c) Offer or pay any type of material inducement or financial incentive to an enrollee to discourage the enrollee from accessing hormone replacement therapy;
(d) Penalize a provider of health care who provides hormone replacement therapy to an enrollee, including, without limitation, reducing the reimbursement of the provider of health care; or
(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 enrollee.
3. Evidence of coverage 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 evidence of coverage or the renewal which is in conflict with this section is void.
4. The provisions of this section do not require a health maintenance organization 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.
(Added to NRS by 1999, 2001; A 2017, 1847, 3954)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.16945 - Plan covering prescription drugs: Required actions by health maintenance organization related to acquisition of prescription drugs for certain insureds residing in area for which emergency or disaster has been declared.

1. If the Governor or the Legislature proclaims the existence of a state of emergency or issues a declaration of disaster pursuant to NRS 414.070, a health maintenance organization that has issued a health care plan which provides coverage for prescription drugs shall, notwithstanding any provision of the health care plan to the contrary:
(a) Waive any provision of the health care plan restricting the time within which an enrollee may refill a covered prescription if the enrollee:
(1) Has not exceeded the number of refills authorized by the prescribing practitioner;
(2) Resides in the area for which the emergency or disaster has been declared; and
(3) Requests the refill not later than the end of the state of emergency or disaster or 30 days after the issuance of the proclamation or declaration, whichever is later; and
(b) Authorize payment for, and may apply a copayment, coinsurance or deductible to, a supply of a covered prescription drug for up to 30 days for an enrollee who requests a refill pursuant to paragraph (a).
2. The Commissioner may extend the time periods prescribed by subsection 1 in increments of 15 or 30 days as he or she determines to be necessary.
3. As used in this section, "practitioner" has the meaning ascribed to it in NRS 639.0125.
(Added to NRS by 2021, 826)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.16946 - Required provision concerning coverage of recipients of Medicaid for antipsychotic or anticonvulsant medication that is not on list of preferred prescription drugs upon failure of drug on list to treat condition.

A health maintenance organization that provides health care services to recipients of Medicaid under the State Plan for Medicaid pursuant to a contract with the Division of Health Care Financing and Policy of the Department of Health and Human Services shall automatically cover any typical or atypical antipsychotic medication or anticonvulsant medication that is not on the list of preferred prescription drugs developed pursuant to NRS 422.4025 upon the demonstrated therapeutic failure of one drug on that list to adequately treat the condition of a recipient of Medicaid.
(Added to NRS by 2023, 524)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.16947 - Plan covering prescription drugs: Submission to step therapy for drug to treat psychiatric condition prohibited in certain circumstances.

1. A health care plan which provides coverage for prescription drugs must not require an enrollee to submit to a step therapy protocol before covering a drug approved by the Food and Drug Administration that is prescribed to treat a psychiatric condition of the enrollee, if:
(a) The drug has been approved by the Food and Drug Administration with indications for the psychiatric condition of the enrollee or the use of the drug to treat that psychiatric condition is otherwise supported by medical or scientific evidence;
(b) The drug is prescribed by:
(1) A psychiatrist;
(2) A physician assistant under the supervision of a psychiatrist;
(3) An advanced practice registered nurse who has the psychiatric training and experience prescribed by the State Board of Nursing pursuant to NRS 632.120; or
(4) A primary care provider that is providing care to an enrollee in consultation with a practitioner listed in subparagraph (1), (2) or (3), if the closest practitioner listed in subparagraph (1), (2) or (3) who participates in the network plan of the health maintenance organization is located 60 miles or more from the residence of the enrollee; and
(c) The practitioner listed in paragraph (b) who prescribed the drug knows, based on the medical history of the enrollee, or reasonably expects each alternative drug that is required to be used earlier in the step therapy protocol to be ineffective at treating the psychiatric condition.
2. 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 July 1, 2023, which is in conflict with this section is void.
3. As used in this section:
(a) "Medical or scientific evidence" has the meaning ascribed to it in NRS 695G.053.
(b) "Network plan" means a health care plan offered by a health maintenance organization under which the financing and delivery of medical care is provided, in whole or in part, through a defined set of providers under contract with the health maintenance organization. The term does not include an arrangement for the financing of premiums.
(c) "Step therapy protocol" means a procedure that requires an enrollee to use a prescription drug or sequence of prescription drugs other than a drug that a practitioner recommends for treatment of a psychiatric condition of the enrollee before his or her health care plan provides coverage for the recommended drug.
(Added to NRS by 2023, 1786)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.1695 - Required provision in plan covering outpatient care concerning coverage of health care services related to hormone replacement therapy; prohibited acts.

1. A health maintenance organization that offers or issues a health care plan which provides coverage for outpatient care shall include in the plan coverage for any health care service related to hormone replacement therapy.
2. A health maintenance organization that offers or issues a health care plan that provides coverage for outpatient care shall not:
(a) Require an enrollee to pay a higher deductible, any copayment or coinsurance or require a longer waiting period or other condition for coverage for outpatient care related to hormone replacement therapy;
(b) Refuse to issue a health care plan or cancel a health care plan solely because the person applying for or covered by the plan uses or may use in the future hormone replacement therapy;
(c) Offer or pay any type of material inducement or financial incentive to an enrollee to discourage the enrollee from accessing hormone replacement therapy;
(d) Penalize a provider of health care who provides hormone replacement therapy to an enrollee, including, without limitation, reducing the reimbursement of the provider of health care; or
(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 enrollee.
3. Evidence of coverage 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 evidence of coverage or the renewal which is in conflict with this section is void.
4. As used in this section, "provider of health care" has the meaning ascribed to it in NRS 629.031.
(Added to NRS by 1999, 2002; A 2017, 1848, 3955)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.170 - Evidence of coverage: Issuance; form and contents.

1. Every enrollee residing in this state is entitled to evidence of coverage under a health care plan. If the enrollee obtains coverage under a health care plan through an insurance policy, whether by option or otherwise, the insurer shall issue the evidence of coverage. Otherwise, the health maintenance organization shall issue the evidence of coverage.
2. Evidence of coverage or amendment thereto must not be issued or delivered to any person in this state until a copy of the form of the evidence of coverage or amendment thereto has been filed with and approved by the Commissioner.
3. An evidence of coverage:
(a) Must not contain any provisions or statements which are unjust, unfair, inequitable, misleading, deceptive, which encourage misrepresentation or which are untrue, misleading or deceptive as defined in subsection 1 of NRS 695C.300; and
(b) Must contain a clear and complete statement, if a contract, or a reasonably complete summary if a certificate, of:
(1) The health care services and the insurance or other benefits, if any, to which the enrollee is entitled under the health care plan;
(2) Any limitations on the services, kind of services, benefits, or kind of benefits, to be provided, including any deductible or copayment feature;
(3) Where and in what manner the services may be obtained; and
(4) The total amount of payment for health care services and the indemnity or service benefits, if any, which the enrollee is obligated to pay.
Any subsequent change may be evidenced in a separate document issued to the enrollee.
4. A copy of the form of the evidence of coverage to be used in this state and any amendment thereto is subject to the requirements for filing and approval of subsection 2 unless it is subject to the jurisdiction of the Commissioner under the laws governing health insurance, in which event the provisions for filing and approval of those laws apply. To the extent that such provisions do not apply to the requirements in subsection 3, such provisions are amended to incorporate the requirements of subsection 3 in approving or disapproving an evidence of coverage required by subsection 2.
(Added to NRS by 1973, 1251; A 1975, 1852; 1979, 1182; 1983, 2041; 2009, 1817)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.1703 - Evidence of coverage covering prescription drugs: Provision of notice and information regarding use of formulary.

1. A health maintenance organization or insurer that offers or issues evidence of coverage which provides coverage for prescription drugs shall include with any evidence of that coverage provided to an enrollee, notice of whether a formulary is used and, if so, of the opportunity to secure information regarding the formulary from the organization or insurer 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 or insurer for making a request for information regarding the formulary pursuant to subsection 2.
2. If a health maintenance organization or insurer offers or issues evidence of coverage which provides coverage for prescription drugs and a formulary is used, the organization or insurer shall:
(a) Provide to any enrollee 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 or insurer 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, 863)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.1705 - Group health care plan issued to replace discontinued policy or coverage: Requirements; notice of reduction of benefits; statement of benefits; applicability to self-insured employer.

Except as otherwise provided in the provisions of NRS 689B.340 to 689B.580, inclusive, and chapter 689C of NRS relating to the portability and accountability of health insurance:
1. A group health care plan issued by a health maintenance organization to replace any discontinued policy or coverage for group health insurance must:
(a) Provide coverage for all persons who were covered under the previous policy or coverage on the date it was discontinued; and
(b) Except as otherwise provided in subsection 2, provide benefits which are at least as extensive as the benefits provided by the previous policy or coverage, except that benefits may be reduced or excluded to the extent that such a reduction or exclusion was permissible under the terms of the previous policy or coverage,
if that plan is issued within 60 days after the date on which the previous policy or coverage was discontinued.
2. If an employer obtains a replacement plan 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 pursuant to NRS 608.1577.
3. Any health maintenance organization which issues a replacement plan pursuant to subsection 1 may submit a written request to the insurer which 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 shall give a written statement to the organization indicating what benefits were provided and what exclusions or reductions were in effect under the previous policy or coverage.
4. If an employee or enrollee was a recipient of benefits under the coverage provided pursuant to NRS 695C.1709, the employee or enrollee is not entitled to have issued to him or her by a health maintenance organization a replacement plan unless the employee or enrollee has reported for his or her normal employment for a period of 90 consecutive days after last being eligible to receive any benefits under the coverage provided pursuant to NRS 695C.1709.
5. The provisions of this section apply to a self-insured employer who provides health benefits to the employees of the self-insured employer and replaces those benefits with a group health care plan issued by a health maintenance organization.
(Added to NRS by 1987, 850; A 1989, 1253; 1997, 2958; 2013, 3644)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.1709 - Required provision in group insurance policy concerning continuing coverage for enrollee 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 enrollee, because of an injury or illness, to perform substantially the duties related to his or her employment for which the enrollee is otherwise qualified.
2. No policy of group insurance to which an enrollee is entitled under a health care plan provided by a health maintenance organization may be delivered or issued for delivery in this state unless it provides continuing coverage for an enrollee and dependents of the enrollee who are otherwise covered by the policy while the enrollee is on leave without pay as a result of a total disability. The coverage must be for any injury or illness suffered by the enrollee which is not related to the total disability or for any injury or illness suffered by a dependent of the enrollee. The coverage must be equal to or greater than the coverage otherwise provided by the policy.
3. The coverage required pursuant to subsection 2 must continue until:
(a) The date on which the employment of the enrollee is terminated;
(b) The date on which the enrollee obtains another policy of health insurance;
(c) The date on which the policy of group insurance is terminated; or
(d) After a period of 12 months in which benefits under such coverage are provided to the enrollee,
whichever occurs first.
(Added to NRS by 1989, 1253)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.171 - Required provision in plan covering mastectomies concerning coverage relating to mastectomy; prohibited acts.

1. A health maintenance plan which provides coverage for the surgical procedure known as a mastectomy must also provide commensurate coverage for:
(a) Reconstruction of the breast on which the mastectomy has been performed;
(b) Surgery and reconstruction of the other breast to produce a symmetrical structure; and
(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.
4. Written notice of the availability of the coverage must be given upon enrollment and annually thereafter. The notice must be sent to all participants:
(a) In the next mailing made by the plan or issuer to the participant or beneficiary; or
(b) As part of any annual information packet sent to the participant or beneficiary,
whichever is earlier.
5. A plan or issuer may not:
(a) Deny eligibility, or continued eligibility, to enroll or renew coverage, in order to avoid the requirements of subsections 1 to 4, inclusive; or
(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, but is not limited to, augmentation mammoplasty, reduction mammoplasty and mastopexy.
(Added to NRS by 1983, 615; A 1989, 1891; 2001, 2250)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.1712 - Health care plan covering maternity care: Prohibited acts by organization if enrollee is acting as gestational carrier; child deemed child of intended parent for purposes of plan.

1. A health maintenance 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 enrollee is acting as a gestational carrier.
2. If an enrollee 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, 1007)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.1713 - Required provision concerning coverage of certain gynecological and obstetrical services without authorization or referral from primary care physician.

1. A health care plan must include a provision authorizing a woman covered by the plan 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 health care plan to designate an obstetrician or gynecologist as her primary care physician.
3. An evidence of coverage 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 evidence of coverage 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.
(Added to NRS by 1999, 1944)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.172 - Evidence of coverage containing exclusion, reduction or limitation of coverage relating to complications of pregnancy; prohibited acts; exception.

1. No health maintenance organization may issue evidence of coverage under a health care plan to any enrollee 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 and complies with the provisions of NRS 689B.340 to 689B.580, inclusive, and chapter 689C of NRS relating to the portability and accountability of health insurance.
2. As used in this section, the term "complications of pregnancy" includes any condition which requires hospital confinement for medical treatment and:
(a) If the pregnancy is not terminated, is caused by an injury or sickness not directly related to the pregnancy or by acute nephritis, nephrosis, cardiac decompensation, missed abortion or similar medically diagnosed conditions; or
(b) If the pregnancy is terminated, results in nonelective cesarean section, ectopic pregnancy or spontaneous termination.
3. Evidence of coverage under a health care plan subject to the provisions of this chapter which is issued on or after July 1, 1977, has the legal effect of including the coverage required by this section, and any provision which is in conflict with this section is void.
(Added to NRS by 1977, 416; A 1997, 2959; 2013, 3644)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.1723 - Required provision concerning coverage for treatment of certain inherited metabolic diseases.

1. A health maintenance plan must provide coverage for:
(a) Enteral formulas for use at home that are prescribed or ordered by a physician as medically necessary for the treatment of inherited metabolic diseases characterized by deficient metabolism, or malabsorption originating from congenital defects or defects arising shortly after birth, of amino acid, organic acid, carbohydrate or fat; and
(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 health maintenance plan was purchased.
3. Any evidence of coverage subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2021, has the legal effect of including the coverage required by this section, and any provision of the evidence of coverage or the renewal which is in conflict with this section is void.
4. As used in this section:
(a) "Enteral formula" includes, without limitation, a formula that is ingested orally.
(b) "Inherited metabolic disease" means a disease caused by an inherited abnormality of the body chemistry of a person.
(c) "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.
(Added to NRS by 1997, 1527; A 2021, 3624)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.1727 - Required provision in evidence of coverage covering hospital, medical or surgical expenses concerning coverage for management and treatment of diabetes.

1. No evidence of coverage that provides coverage for hospital, medical or surgical expenses may be delivered or issued for delivery in this state unless the evidence of coverage includes coverage for the management and treatment of diabetes, including, without limitation, coverage for the self-management of diabetes.
2. An insurer who delivers or issues for delivery an evidence of coverage specified in subsection 1 shall provide the coverage required by this section subject to the same deductible, copayment, coinsurance and other such conditions for the evidence of coverage that are required under the evidence of coverage.
3. Evidence of coverage 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 evidence of coverage that conflicts with this section is void.
4. As used in this section:
(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.
(b) "Coverage for the self-management of diabetes" includes:
(1) The training and education provided to the enrollee after the enrollee is initially diagnosed with diabetes which is medically necessary for the care and management of diabetes, including, without limitation, counseling in nutrition and the proper use of equipment and supplies for the treatment of diabetes;
(2) Training and education which is medically necessary as a result of a subsequent diagnosis that indicates a significant change in the symptoms or condition of the enrollee and which requires modification of the enrollee’s program of self-management of diabetes; and
(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.
(Added to NRS by 1997, 745; A 2013, 3645)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.1728 - Required provision concerning coverage for management and treatment of sickle cell disease and its variants; plan covering prescription drugs required to provide coverage for medically necessary prescription drugs to treat sickle cell disease and its variants.

1. A health maintenance organization that issues a health care plan shall include in the plan coverage for:
(a) Necessary case management services for an enrollee who has been diagnosed with sickle cell disease and its variants; and
(b) Medically necessary care for an enrollee who has been diagnosed with sickle cell disease and its variants.
2. A health maintenance 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 health maintenance organization shall establish a plan for each enrollee under 18 years of age who has been diagnosed with sickle cell disease and its variants to transition the enrollee from pediatric care to adult care when the enrollee reaches 18 years of age.
4. A health maintenance 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) "Medically necessary" has the meaning ascribed to it in NRS 695G.055.
(d) "Sickle cell disease and its variants" has the meaning ascribed to it in NRS 439.4927.
(Added to NRS by 2019, 2172)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.173 - Plan covering family member of enrollee required to include certain coverage for enrollee’s newly born and adopted children and children placed with enrollee for adoption.

1. All individual and group health care plans which provide coverage for a family member of the enrollee must as to such coverage provide that the health care services applicable for children are payable with respect to:
(a) A newly born child of the enrollee from the moment of birth;
(b) An adopted child from the date the adoption becomes effective, if the child was not placed in the home before adoption; and
(c) A child placed with the enrollee 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.
The plans must provide the coverage specified in subsection 3, and must not exclude premature births.
2. The evidence of coverage may require that notification of:
(a) The birth of a newly born child;
(b) The effective date of adoption of a child; or
(c) The date of placement of a child for adoption,
and payments of the required charge, if any, must be furnished to the health maintenance organization 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 preventive health care services as well as 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.
4. For covered services provided to the child, the health maintenance organization shall reimburse noncontracted providers of health care to an amount equal to the average amount of payment for which the organization has agreements, contracts or arrangements for those covered services.
(Added to NRS by 1975, 1110; A 1989, 741; 1995, 2436; 1997, 2959; 2019, 309)
2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.1731 - Required provision in plan covering treatment of colorectal cancer concerning coverage for colorectal cancer screening.

1. A health care plan issued by a health maintenance 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, 1335)