reglab/statecodes huggingface dataset:
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › FINANCIAL REQUIREMENTS; INSURANCE › Section 695C.135 - Contract of insurance for health maintenance organization: Amount required; provision concerning insolvency of organization; notice of cancellation (Repealed)

Current through June 11, 2024
Added to NAC by Comm'r
				of Insurance, eff. 6-11-86; A 5-27-92; R129-96, 10-29-97; R148-99, 1-27-2000;
				R248-03, 11-12-2004;	R
				by
				R161-22A,
				eff. 12/16/2022
NRS 679B.130,
				  689C.155 and
				  695C.080
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › FINANCIAL REQUIREMENTS; INSURANCE › Section 695C.136 - Contract of insurance for provider-sponsored organization: Amount determined by Commissioner; provision concerning insolvency of organization; notice of cancellation

Current through June 11, 2024
1. A
			 provider-sponsored organization shall obtain a contract of insurance for the
			 cost of providing a Medicare + Choice plan which exceeds, per enrollee, an
			 amount to be determined by the Commissioner.
2. The contract of insurance may have an
			 aggregate limit in an amount to be determined by the Commissioner. Subject to
			 that aggregate limit, the contract of insurance must:
(a) Include a provision which states that, in
			 case of the insolvency of the provider-sponsored organization, the insurer will
			 pay all claims made by an enrollee for the period during which a premium was
			 paid to the provider-sponsored organization.
(b) Specifically provide for:
(1) The continuation of benefits to enrollees
			 for the period during which prepayments were made to the provider-sponsored
			 organization;
(2) The continuation
			 of benefits for enrollees confined in a medical facility or facility for the
			 dependent at the time of the insolvency of the provider-sponsored organization
			 until the enrollee is discharged from the facility; and
(3) The payment of a provider who is not
			 affiliated with the provider-sponsored organization and who provided medically
			 necessary services, as described in the evidence of coverage, to an enrollee
			 during the time in which payments were made to the provider-sponsored
			 organization.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › FINANCIAL REQUIREMENTS; INSURANCE › Section 695C.137 - Health maintenance organization: Reserves (Repealed)

Current through June 11, 2024
Added to NAC by Comm'r
				of Insurance, eff. 6-11-86; A by R148-99 & R194-99,
				1-27-2000;	R
				by
				R161-22A,
				eff. 12/16/2022
NRS 679B.130,
				  689C.155 and
				  695C.080
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › SALE OF HEALTH CARE PLANS › Section 695C.140 - Advertising and solicitation

Current through June 11, 2024
1. An organization
			 which advertises its benefits must, in that same advertisement, plainly state
			 the exclusions or limitations of the plan.
2. Any period of waiting required before an
			 enrollee is eligible to receive benefits under a health care plan must be
			 stated clearly in boldface type in any advertisement.
3. An organization shall not solicit persons
			 door to door.
4. Any printed
			 advertisement used by an organization must refer to the health care plan being
			 sold by the number used to file that plan with the Division.
5. Advertisements by organizations must
			 comply with the provisions of NAC 689A.010 to 689A.270, inclusive.
Comm'r of Insurance,
				LH-4 § VI, eff. 7-1-74-NAC A 6-11-86
NRS
				  679B.130,
				  695C.275,
				  695C.300
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › SALE OF HEALTH CARE PLANS › Section 695C.150 - Qualifications of agent or broker

Current through June 11, 2024
A person shall not solicit or sell to any group or person any
				health care plan which provides for comprehensive health care services unless
				he or she:
1. Has a valid agent's or
			 broker's license to sell health insurance issued by the Commissioner;
2. Has, if licensed as an agent, been
			 appointed by the organization; and
3. Meets all other requirements for an agent
			 or broker licensed to sell health insurance.
Comm'r of Insurance,
				LH-4 § VII, eff. 7-1-74-NAC A 6-11-86; R082-98,
				1-27-2000
NRS
				  679B.130,
				  695C.280
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › SERVICES AND BENEFITS › Section 695C.160 - Geographic area of service: Definition (Repealed)

Current through June 11, 2024
Added to NAC by Comm'r
				of Insurance, eff. 6-11-86; A 5-27-92; R025-08, 6-17-2008; R by
				R049-14,
				eff. 4/4/2016
NRS
				  679B.130,
				  695C.130,
				  695C.275
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › SERVICES AND BENEFITS › Section 695C.165 - Geographic area of service: Expansion

Current through June 11, 2024
1. Any organization
			 which wants to expand its geographic area of service from that stated in its
			 application shall submit to the Division:
(a)
			 A copy of a written description of the area it proposes to serve;
(b) A list of the providers who will offer
			 comprehensive health care services to the enrollees of the organization in that
			 area;
(c) A copy of the contract
			 with those providers;
(d) A
			 statement describing the effect of the expansion on the operation and financial
			 position of the organization and certifying that the organization is
			 financially able to expand;
(e) A
			 statement describing the method of marketing and the projected number of
			 enrollees from the new area;
(f)
			 Proof that the organization has notified its insurers for its contracts of
			 surety, fidelity and stop-loss insurance of the proposed changes; and
(g) The fee for amending its certificate of
			 authority.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › SERVICES AND BENEFITS › Section 695C.170 - Health maintenance organization: Required services; optional plans

Current through June 11, 2024
1. The comprehensive health care services
			 offered by a health maintenance organization in its evidence of coverage must
			 provide for basic and preventive medical care for the enrollee which is
			 medically necessary, including:
(a) Services
			 in an emergency provided by a hospital or physician;
(b) Any care received as an admitted patient
			 at a hospital;
(c) Care by a
			 physician; and
(d) Medical services
			 as an outpatient.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › SERVICES AND BENEFITS › Section 695C.175 - Health maintenance organization: Removal of prescription drug from approved formulary prohibited; exception; movement to different tier in formulary; addition of drug to formulary

Current through June 11, 2024
1. Except as
			 otherwise provided in this section, a health maintenance organization that
			 offers a health benefit plan in the individual market which provides coverage
			 for prescription drugs and uses a formulary that has been approved by the
			 Commissioner pursuant to
			 NRS
			 687B.120 shall not:
(a) Remove a prescription drug from the
			 formulary; or
(b) If the formulary
			 includes two or more tiers of benefits providing for different deductibles,
			 copayments or coinsurance applicable to the prescription drugs in each tier,
			 move a drug to a tier with a larger deductible, copayment or coinsurance,
			 during the plan year for which the formulary was approved by the
			 Commissioner.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › SERVICES AND BENEFITS › Section 695C.180 - Coordination of benefits; lien against recovery from third person

Current through June 11, 2024
1. An organization may coordinate its
			 benefits with any policy of individual or group health insurance offered by an
			 insurance company, trust established by an employer to pay for health care for
			 his or her employees, group contract for hospital, medical or dental service
			 offered by a nonprofit corporation for hospital, medical or dental service, or
			 evidence of coverage offered by another health maintenance organization. Before
			 an organization may seek coordination for the payment of the cost of benefits,
			 it must first provide those benefits to its enrollees. If an organization
			 intends to coordinate its benefits, it shall do so based upon standards filed
			 with and approved by the Division.
2. Except as otherwise provided by specific
			 federal or state statute or regulation, an organization may include in its
			 evidence of coverage a provision for subrogation regarding the right of an
			 enrollee to recover, and the imposition of a lien upon any recovery by an
			 enrollee, from a third person for the cost of the medical benefits which were
			 provided by the organization to the enrollee because of injuries incurred by
			 the enrollee as a result of the actions of the third person. The amount of the
			 lien must not be more than the reasonable value of the services rendered by the
			 organization.
Added to NAC by Comm'r
				of Insurance, eff. 6-11-86; A 5-27-92; 12-15-94; A by
				R089-17AP,
				eff. 5/16/2018
NRS 679B.130,
				695C.275
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › SERVICES AND BENEFITS › Section 695C.185 - Benefits payable by more than one insurer to provider; restrictions

Current through June 11, 2024
When the benefits set forth in any evidence of coverage are
				payable by more than one insurer to a provider, the evidence of coverage must
				not require the insured, or any secondary insurer who is a:
1. Group health insurer;
2. Health maintenance organization;
			 or
3. Nonprofit corporation for
			 hospital, medical or dental service, to pay more than the remaining deductible
			 and coinsurance, if any, based upon the rates established by the primary
			 insurer for its payment of that provider.
Added to NAC by Comm'r
				of Insurance, eff. 12-15-94
NRS
				  679B.130,
				  695C.275
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › PROVIDERS OF MEDICAL CARE › Section 695C.190 - Requirements for agreement between provider and organization

Current through June 11, 2024
Each agreement between a provider and an organization
				must:
1. Adequately and completely
			 describe the responsibilities of the provider and organization under the
			 agreement.
2. Specify that the
			 provider releases the enrollee from liability for the cost of services rendered
			 pursuant to the organization's health care plan except for any nominal payment
			 made by the enrollee or for a service not covered under the evidence of
			 coverage.
3. Be effective for not
			 less than 1 year, subject to any right of termination stated in the
			 agreement.
4. Require the provider
			 to participate in the program to assure the quality of health care provided to
			 enrollees by the organization through its providers.
5. Require the provider to provide all
			 medically necessary services required by the evidence of coverage and the
			 agreement to each enrollee for the period for which a premium has been paid to
			 the organization.
6. Require the
			 provider to give evidence of a contract of insurance against loss resulting
			 from injuries resulting to third persons from the practice of his or her
			 profession or a reasonable substitute for it as determined by the organization.
			 The organization may require the provider to indemnify the organization for any
			 liability resulting from the health care services rendered by the
			 provider.
7. Require a provider who
			 is a physician to transfer or otherwise arrange for the maintenance of the
			 records of enrollees who are his or her patients if the provider leaves the
			 panel of physicians associated with the organization.
Added to NAC by Comm'r
				of Insurance, eff. 6-11-86
NRS
				  679B.130,
				  695C.275
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › PROVIDERS OF MEDICAL CARE › Section 695C.195 - Per capita payments

Current through June 11, 2024
1. An agreement
			 between a primary physician or delivery system intermediary and an organization
			 may provide for per capita payments. If an agreement provides for per capita
			 payments, such payments must be:
(a) Paid in
			 advance without regard to the time services are rendered or the extent of those
			 services; and
(b) Based upon an
			 actuarial computation of the expected cost of those services.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › PROVIDERS OF MEDICAL CARE › Section 695C.200 - List of providers: Submission; changes; extension of submission date; excessive reduction (Repealed)

Current through June 11, 2024
Added to NAC by Comm'r
				of Insurance, eff. 6-11-86; A 5-27-92; R082-98 & R148-99, 1-27-2000; R by
				R049-14,
				eff. 4/4/2016; R by
				R081-16A,
				eff. 11/2/2016
NRS
				679B.130
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › PROVIDERS OF MEDICAL CARE › Section 695C.205 - Restriction of choice of primary physician or other provider

Current through June 11, 2024
Any organization may restrict the enrollee's or subscriber's
				choice of a primary physician or other provider to those in a preselected group
				specified in its evidence of coverage or in a list or addendum to that evidence
				of coverage.
Added to NAC by Comm'r
				of Insurance, eff. 6-11-86
NRS
				  679B.130,
				  695C.275
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › PROVIDERS OF MEDICAL CARE › Section 695C.215 - Cost sharing

Current through June 11, 2024
1. An organization
			 may establish schedules for cost sharing between an enrollee and the
			 organization. For a benefit provided pursuant to a health care plan by a
			 provider who is under contract with the organization to provide services on a
			 preferred basis, commonly referred to as a "preferred" or "in-network" benefit,
			 cost sharing may be not more than 50 percent of the usual and customary charges
			 for providing any single service or supplying an item to an enrollee, but in no
			 case more than 50 percent of the maximum benefits provided by the evidence of
			 coverage for such service or item, after any applicable deductible has been
			 met.
2. The amount of the cost
			 sharing listed in the schedule given to the enrollee and submitted to the
			 Division for approval must be:
(a) Stated in
			 dollars; or
(b) Expressed as a
			 percentage of the cost of the service or the item supplied.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › ADMINISTRATION OF ORGANIZATION › Section 695C.217 - Approval of contract for marketing, enrollment, administration or health care services; effect of agreement

Current through June 11, 2024
1. Any organization
			 contracting with a third party for services for marketing, enrollment,
			 administration or health care services shall submit a copy of the contract to
			 the Division for its review and approval.
2. The Division will consider the contract to
			 be an agreement by the third party contracting with the organization to:
(a) Submit to the jurisdiction of the
			 Division for its review of the contract; and
(b) Authorize the Division to examine that
			 person concerning his or her duties under the contract to the organization and
			 the payment and handling of money pursuant to the contract.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › ADMINISTRATION OF ORGANIZATION › Section 695C.220 - Enrollment, cancellation and termination

Current through June 11, 2024
1. The period of
			 open enrollment to allow eligible persons to become enrolled must be:
(a) For any individual contract, at least 30
			 days per year;
(b) For any group
			 contract, at least 30 days per year; and
(c) For any member of a group, a period set
			 by the agreement between the organization and the subscriber but not less than
			 15 days per year.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › ADMINISTRATION OF ORGANIZATION › Section 695C.230 - System for resolving complaints of enrollees of health maintenance organizations: Requirements for approval

Current through June 11, 2024
1. To obtain
			 approval of a system for resolving complaints of enrollees concerning health
			 care services covered by a health maintenance organization as required pursuant
			 to
			 NRS 695C.260 and
			 695G.200,
			 the health maintenance organization must submit to the Division:
(a) The name and title of the employee
			 responsible for the system;
(b) A
			 description of the procedure used to notify an enrollee of the decision
			 regarding his or her complaint; and
(c) A copy of the explanation of rights and
			 procedures which is to be provided to an enrollee pursuant to
			 NRS 695C.260 and
			 695G.230.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › ADMINISTRATION OF ORGANIZATION › Section 695C.235 - System for resolving complaints of enrollees of health maintenance organizations: Annual report

Current through June 11, 2024
1. A health
			 maintenance organization shall submit its annual report regarding its system
			 for resolving complaints as required pursuant to
			 NRS 695C.260 and
			 695G.220
			 on or before June 1 of each year. The health maintenance organization shall
			 retain a copy of the annual report for at least 3 years or until the next
			 examination conducted by the Division, whichever is longer.
2. The health maintenance organization is not
			 required to include in the annual report information concerning an oral inquiry
			 by an enrollee relating to a misunderstanding or miscommunication if the
			 misunderstanding or miscommunication was resolved within 1 working day after
			 the inquiry was made. If the misunderstanding or miscommunication was not
			 resolved within 1 working day, the health maintenance organization shall report
			 it as a complaint in the annual report.
Added to NAC by Comm'r
				of Insurance by R132-98, eff. 3-30-99; A by R148-99, 1-27-2000; R008-02,
				5-23-2002
NRS
				  679B.130,
				  695C.260
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › ADMINISTRATION OF ORGANIZATION › Section 695C.240 - Health maintenance organization: Joint board on consumer satisfaction

Current through June 11, 2024
A health maintenance organization shall notify the Division of
				the names and addresses of enrollees nominated to its joint board on consumer
				satisfaction within 6 months after the health maintenance organization first
				enrolls persons in its health care plan.
Added to NAC by Comm'r
				of Insurance, eff. 6-11-86; A 5-27-92; R148-99,
				1-27-2000
NRS
				  679B.130
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › ADMINISTRATION OF ORGANIZATION › Section 695C.250 - Records: Segregation from records of related corporation

Current through June 11, 2024
The records of an organization holding a certificate of
				authority in Nevada must be segregated from the records of any subsidiary or
				related corporation and treated as separate corporate documents.
Added to NAC by Comm'r
				of Insurance, eff. 6-11-86
NRS
				  679B.130,
				  695C.275
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › ADMINISTRATION OF ORGANIZATION › Section 695C.260 - Records: Retention

Current through June 11, 2024
1. The organization
			 shall retain indefinitely the minutes of the meetings of its governing body,
			 any advisory panel and the joint board on consumer satisfaction by microfilm or
			 any other means.
2. An organization
			 shall retain for 3 years or until the next examination of the organization
			 conducted by the Division a copy of all:
(a)
			 Published material used to market the organization; and
(b) Scripts used for advertising on radio or
			 television.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › ADMINISTRATION OF ORGANIZATION › Section 695C.270 - Reports and financial statements

Current through June 11, 2024
1. As a condition
			 of doing business in this State, each health maintenance organization must file
			 with the Commissioner an annual report required by
			 NRS
			 695C.210 that:
(a) Conforms to the format prescribed by the
			 National Association of Insurance Commissioners in the Annual
and
			 Quarterly
Statement Instructions for Health and the Accounting
			 Practices and Procedures Manual, which have been adopted by reference in NAC
			 679B.033;
(b) Contains exhibits and schedules that
			 follow the specifications developed by the National Association of Insurance
			 Commissioners; and
(c) Contains any
			 other information relating to the organization required by the
			 Commissioner.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › ADMINISTRATION OF ORGANIZATION › Section 695C.275 - Quality and performance indicators to be included in report of health maintenance organization

Current through June 11, 2024
1. On or before
			 March 1 of each year, each health maintenance organization which receives a
			 certificate of authority shall file with the Commissioner the quality and
			 performance indicators selected by the Commissioner for the immediately
			 preceding calendar year. The Commissioner will select the indicators from the
			 reporting set data domains set forth in Technical Specifications
for
			 Health Plans
, Healthcare Effectiveness Data and Information Set
			 (HEDIS), volume 2, in the form most recently published by the National
			 Committee for Quality Assurance (NCQA), unless the Commissioner gives notice
			 that the most recent revision is not suitable for this State pursuant to
			 subsection 2. Volume 2 of HEDIS may be obtained from the National Committee for
			 Quality Assurance, NCQA, 1100 13th Street N.W., Washington, D.C. 20005, for the
			 price of $355 plus $33 for shipping and handling or by ordering via telephone
			 at (888) 275-7585 or on the Internet at
http://store.ncqa.org/
2. The Commissioner will review each revision
			 of the reporting set data domains set forth in Technical Specifications
for Health Plans
, Healthcare Effectiveness Data and
			 Information Set (HEDIS), volume 2, to ensure their suitability for this
			 State.
Added to NAC by Bd. of
				Health, eff. 11-1-95; A by R058-99, 11-4-99; A by Comm'r of Insurance by
				R148-99, 1-27-2000; R248-03, 11-12-2004; R106-08, 9-18-2008; A by
				R089-17AP,
				eff. 5/16/2018
NRS 679B.130,
				695C.210
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › ADMINISTRATION OF ORGANIZATION › Section 695C.285 - Limitation on frequency of increases in premium rates; exceptions

Current through June 11, 2024
1. Except as otherwise provided in this
			 section, an organization shall not increase the premium rates for a group
			 health care plan more frequently than every 6 months unless the increase in the
			 premium rates is being made because:
(a) An
			 employer has requested a change in its group health care plan;
(b) There has been a change in the number of
			 employees covered by an employer that would affect the insurance premium rate
			 of the employer; or
(c) There has
			 been a change in federal or state law which affects the cost of providing
			 services under the group health care plan.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › ADMINISTRATION OF ORGANIZATION › Section 695C.290 - Filing, contents and delivery of disclosure summarizing coverage by health maintenance organization (Repealed)

Current through June 11, 2024
Added to NAC by Comm'r
				of Insurance, eff. 2-21-90;	R
				by
				R161-22A,
				eff. 12/16/2022
NRS 679B.130,
				  689C.155 and
				  695C.080
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › ADMINISTRATION OF ORGANIZATION › Section 695C.295 - Disclosures in advertising and sales materials; inclusion of certain information in health care plan (Repealed)

Current through June 11, 2024
Added to NAC by Comm'r
				of Insurance by R009-02, eff. 5-23-2002; A by R009-02,
				7-11-2002;	R
				by
				R161-22A,
				eff. 12/16/2022
NRS 679B.130,
				  689C.155 and
				  695C.080
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › EXAMINATIONS › Section 695C.300 - Requirements for conducting examination

Current through June 11, 2024
Each examination of an organization, including one made
				pursuant to
				NRS 695C.310 or NAC
				695C.325, must be conducted in accordance with the requirements found in the
				handbooks and manuals adopted by reference in NAC 679B.033 and the provisions
				of
				NRS
				679B.250 to
				679B.300,
				inclusive.
Added to NAC by Comm'r
				of Insurance, eff. 12-9-91; A by R148-99,
				1-27-2000
NRS
				  679B.130,
				  695C.275,
				  695C.310
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › EXAMINATIONS › Section 695C.310 - Health maintenance organization: Review of examination of organization required; approved examiners; organization to cooperate during examination

Current through June 11, 2024
1. As part of the
			 examination of the quality of health care services for a health maintenance
			 organization required pursuant to
			 NRS 695C.310, the
			 State Board of Health will review or cause the Division of Public and
			 Behavioral Health to review and report the results of an examination of the
			 organization conducted by:
(a) The Federal
			 Government for federal qualification as a health maintenance
			 organization;
(b) A group which is
			 nationally recognized to provide accreditation of health maintenance
			 organizations; or
(c) A person
			 approved by the Board pursuant to subsection 2.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › EXAMINATIONS › Section 695C.320 - Health maintenance organization: Division of Public and Behavioral Health to notify organization of its findings; objections to findings; dispute resolution; distribution of proposed findings

Current through June 11, 2024
1. Not less
			 than 90 days after an examination is completed, the Division of Public and
			 Behavioral Health shall mail to the health maintenance organization by
			 certified mail, return receipt requested, the proposed findings of its review.
			 The proposed findings must include, without limitation, any deficiencies
			 discovered within the health maintenance organization and its proposed
			 recommendations to be given by the State Board of Health to the Commissioner
			 regarding the certification of the health maintenance organization.
2. The health maintenance organization may
			 mail to the Division of Public and Behavioral Health any written objections to
			 the proposed findings of the examination not later than 30 days after the date
			 upon which the proposed findings were mailed pursuant to subsection
			 1.
3. If the health maintenance
			 organization objects to the proposed findings, the Division of Public and
			 Behavioral Health shall attempt to resolve the dispute. If the dispute is not
			 resolved within 30 days from the date upon which the objections were mailed
			 pursuant to subsection 2, the Division of Public and Behavioral Health shall
			 inform the Board of the dispute. The Board will then provide for a hearing as
			 soon as practicable. A written copy of any final decision of a hearing must be
			 sent to the Commissioner.
4. If the
			 health maintenance organization does not object to the proposed findings of the
			 Division of Public and Behavioral Health or if any dispute has been resolved,
			 the Division of Public and Behavioral Health shall provide its proposed
			 findings to the Board. After reviewing the proposed findings, the Board will
			 mail its proposed findings and recommendations to the Commissioner.
Added to NAC by Bd. of
				Health, eff. 11-1-95; A by Comm'r of Insurance by R148-99,
				1-27-2000
NRS
				  439.200,
				  679B.130,
				  695C.310
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › EXAMINATIONS › Section 695C.325 - Provider-sponsored organization: Frequency of examinations; submission of records; acceptance of alternate report

Current through June 11, 2024
1. The Commissioner
			 will make an examination of the affairs of any provider-sponsored organization
			 and providers with whom such provider-sponsored organization has contracts,
			 agreements or other arrangements pursuant to its health care plan as often as
			 the Commissioner deems it necessary for the protection of the interests of the
			 people of this State. An examination will be made not less frequently than once
			 every 3 years.
2. Every
			 provider-sponsored organization and provider shall submit its books and records
			 relating to the health care plan to an examination made pursuant to subsection
			 1 and in every way facilitate the examination. Medical records of natural
			 persons and records of physicians providing service pursuant to a contract to
			 the provider-sponsored organization are not subject to such examination,
			 although the records are subject to subpoena upon a showing of good cause. For
			 the purpose of examinations, the Commissioner may administer oaths to, and
			 examine the officers and agents of, the provider-sponsored organization and the
			 principals of such providers concerning their business.
3. The expenses of examinations pursuant to
			 this section must be assessed against the provider-sponsored organization being
			 examined and remitted to the Commissioner.
4. In lieu of such examination, the
			 Commissioner may accept the report of an examination made by the insurance
			 commissioner or the state board of health of another state.
Added to NAC by Comm'r
				of Insurance by R148-99, eff. 1-27-2000
NRS
				  679B.130,
				  695C.275
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › EXAMINATIONS › Section 695C.330 - Provider-sponsored organization: Determination of financial condition

Current through June 11, 2024
1. To determine its financial condition,
			 fulfillment of its contractual obligations and compliance with law, the
			 Commissioner will, as often as he or she deems advisable, examine the affairs,
			 transactions, accounts, records and assets of a provider-sponsored organization
			 and of any person as to any matter relevant to the financial affairs of the
			 provider-sponsored organization or to the examination. Except as otherwise
			 provided in the Nevada Insurance Code, the Commissioner will examine each
			 provider-sponsored organization at least once every 3 years.
2. The Commissioner will examine each
			 provider-sponsored organization applying for an initial certificate of
			 authority.
3. In lieu of making his
			 or her own examination, the Commissioner may, in his or her discretion, accept
			 a full report of the last recent examination of a foreign or alien
			 provider-sponsored organization, certified to by the supervisory officer of
			 insurance of another state.
4. To
			 the extent that it is practical, the examination of a foreign or alien
			 provider-sponsored organization must be made in cooperation with the insurance
			 supervisory officers of other states in which the provider-sponsored
			 organization transacts business.
Added to NAC by Comm'r
				of Insurance by R148-99, eff. 1-27-2000
NRS
				  679B.130,
				  695C.275
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › EXAMINATIONS › Section 695C.335 - Provider-sponsored organization: Procedure; appointment of examiner; maintenance and use of records

Current through June 11, 2024
1. If the
			 Commissioner examines a provider-sponsored organization pursuant to NAC
			 695C.330, he or she will designate one or more examiners and instruct them as
			 to the scope of the examination. The examiner shall, upon demand, exhibit his
			 or her official credentials to the provider-sponsored organization being
			 examined.
2. The Commissioner will
			 conduct each examination in an expeditious, fair and impartial
			 manner.
3. The Commissioner, or the
			 examiner if authorized in writing by the Commissioner, may administer oaths and
			 examine under oath any person concerning any matter relevant to the
			 examination.
4. Each
			 provider-sponsored organization and its officers, attorneys, employees, agents
			 and representatives shall make available to the Commissioner or the examiners
			 the accounts, records, documents, files, information, assets and matters of the
			 provider-sponsored organization in his or her possession or control relating to
			 the subject of the examination and shall facilitate the examination.
5. If the Commissioner or examiner finds any
			 accounts or records to be inadequate or inadequately kept or posted, he or she
			 will so notify the provider-sponsored organization and give the
			 provider-sponsored organization a reasonable opportunity to reconstruct,
			 rewrite, post or balance the account or record. If the provider-sponsored
			 organization fails to maintain, complete or correct the records or accounting
			 after the Commissioner or examiner has given the provider-sponsored
			 organization written notice and a reasonable opportunity to do so, the
			 Commissioner may employ experts to reconstruct, rewrite, post or balance the
			 account or record at the expense of the provider-sponsored organization being
			 examined.
6. The Commissioner or an
			 examiner will not remove any record, account, document, file or other property
			 of the provider-sponsored organization being examined from the office or place
			 of business of the provider-sponsored organization unless the Commissioner or
			 examiner has the written consent of an officer of the provider-sponsored
			 organization before the removal or pursuant to an order of a court. This
			 provision does not prohibit the Commissioner or examiner from making or
			 removing copies or abstracts of a record, account, document or file.
Added to NAC by Comm'r
				of Insurance by R148-99, eff. 1-27-2000
NRS
				  679B.130,
				  695C.275
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › EXAMINATIONS › Section 695C.340 - Provider-sponsored organization: Payment of expenses

Current through June 11, 2024
1. The
			 provider-sponsored organization being examined shall pay the expense of an
			 examination. The expenses to be paid include only the reasonable and proper
			 travel and lodging expenses of the Commissioner and the examiners and
			 assistants, including, without limitation, expert assistance, reasonable
			 compensation to the examiners and assistants and incidental expenses as
			 necessarily incurred in the examination. The Commissioner will consider the
			 scales and limitations recommended by the National Association of Insurance
			 Commissioners regarding the expense and compensation for an
			 examination.
2. The
			 provider-sponsored organization shall promptly pay to the Commissioner the
			 expenses of the examination upon presentation by the Commissioner of a
			 reasonably detailed written statement thereof.
Added to NAC by Comm'r
				of Insurance by R148-99, eff. 1-27-2000
NRS
				  679B.130,
				  695C.275
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › EXAMINATIONS › Section 695C.345 - Provider-sponsored organization: Statutory procedures required for examination and hearing

Current through June 11, 2024
The Commissioner will use the procedures required by:
1.NRS
			 679B.230 to
			 679B.290,
			 inclusive, when conducting an examination of a provider-sponsored
			 organization.
2.NRS
			 679B.310 to
			 679B.370,
			 inclusive, when conducting a hearing involving a provider-sponsored
			 organization.
Added to NAC by Comm'r
				of Insurance by R148-99, eff. 1-27-2000
NRS
				  679B.130,
				  695C.275
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › MISCELLANEOUS PROVISIONS FOR PROVIDER-SPONSORED ORGANIZATIONS › Section 695C.350 - Notice and approval required for modification of operations

Current through June 11, 2024
A provider-sponsored organization shall, unless otherwise
				provided for in this chapter, file a notice with the Commissioner before any
				material modification of the operations described in the information required
				by NAC 695C.115. The provider-sponsored organization shall submit a copy of its
				proposed modification to the Commissioner. The Commissioner may, as a condition
				of approval for the proposed modification by the provider-sponsored
				organization, require the provider-sponsored organization to increase the
				amount of reserves, deposits, bonds or minimum net worth it is required to
				maintain. If the Commissioner does not disapprove the modification within 90
				days after filing of the notice, the modification is deemed approved.
Added to NAC by Comm'r
				of Insurance by R148-99, eff. 1-27-2000
NRS
				  679B.130,
				  695C.275
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › MISCELLANEOUS PROVISIONS FOR PROVIDER-SPONSORED ORGANIZATIONS › Section 695C.355 - Accounting principles required for certain reports and transactions

Current through June 11, 2024
A provider-sponsored organization shall use accounting
				principles that are recognized by the laws of this State or approved by the
				Commissioner for:
1. All financial
			 reports;
2. The accounting of
			 investments and deposits; and
3.
			 Transactions between affiliates and holding companies.
Added to NAC by Comm'r
				of Insurance by R148-99, eff. 1-27-2000
NRS
				  679B.130,
				  695C.275
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › MISCELLANEOUS PROVISIONS FOR PROVIDER-SPONSORED ORGANIZATIONS › Section 695C.360 - Annual report of financial condition and financial statement; administrative penalty for failure to file report or statement; request for extension

Current through June 11, 2024
1. A provider-sponsored organization shall
			 file with the Commissioner on or before March 1 of each year a report showing
			 its financial condition on the last day of the preceding calendar year. The
			 report must be verified by at least two principal officers of the
			 provider-sponsored organization.
2.
			 The report must be on forms prescribed by the Commissioner and must include:
(a) A financial statement of the
			 provider-sponsored organization, including its balance sheet and receipts and
			 disbursements for the preceding calendar year;
(b) Any material changes in the information
			 submitted pursuant to NAC 695C.115;
(c) The number of persons enrolled during the
			 year, the number of enrollees as of the end of the year, the number of
			 enrollments terminated during the year and, if requested by the Commissioner, a
			 compilation of the reasons for such terminations;
(d) The number and amount of malpractice
			 claims initiated against the provider-sponsored organization and any of the
			 providers used by it during the year broken down into claims with and without
			 form of legal process and the disposition, if any, of each such claim, if
			 requested by the Commissioner; and
(e) Such other information relating to the
			 performance of the provider-sponsored organization as is necessary to enable
			 the Commissioner to carry out his or her duties pursuant to this
			 chapter.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › MISCELLANEOUS PROVISIONS FOR PROVIDER-SPONSORED ORGANIZATIONS › Section 695C.365 - Fees

Current through June 11, 2024
1. A provider-sponsored organization subject
			 to this chapter shall pay to the Commissioner the following fees:
(a) For filing an application for a
			 certificate of authority, $2,450.
(b) For issuance of a certificate of
			 authority, $250.
(c) For an
			 amendment to a certificate of authority, $100.
(d) For the renewal of a certificate of
			 authority, $2,450.
(e) For filing
			 each annual report, $25.
(f) All
			 applicable fees required pursuant to
			 NRS
			 680C.110.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › MISCELLANEOUS PROVISIONS FOR PROVIDER-SPONSORED ORGANIZATIONS › Section 695C.370 - Availability of information for inspection

Current through June 11, 2024
A provider-sponsored organization shall have available for
				inspection the following information:
1. A current statement of financial condition
			 including a balance sheet and summary of receipts and disbursements;
2. A description of the organizational
			 structure and operation of the provider-sponsored organization and a summary of
			 any material changes since the issuance of the last report;
3. A description of services and information
			 as to where and how to secure the services; and
4. A clear and understandable description of
			 the method of the provider-sponsored organization for resolving enrollee
			 complaints.
Added to NAC by Comm'r
				of Insurance by R148-99, eff. 1-27-2000
NRS
				  679B.130,
				  695C.275
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › MISCELLANEOUS PROVISIONS FOR PROVIDER-SPONSORED ORGANIZATIONS › Section 695C.375 - Prohibited practices

Current through June 11, 2024
1. No
			 provider-sponsored organization or representative thereof may cause or
			 knowingly permit the use of advertising or solicitation which is untrue or
			 misleading. For purposes of this chapter:
(a)
			 A statement or item of information shall be deemed to be untrue if it does not
			 conform to fact in any respect which is or may be significant to an enrollee
			 of, or person considering enrollment in, a health care plan.
(b) A statement or item of information shall
			 be deemed to be misleading, whether or not it may be literally untrue if, in
			 the total context in which such statement is made or such item of information
			 is communicated, such statement or item of information may be reasonably
			 understood by a reasonable person not possessing special knowledge regarding
			 health care coverage as indicating any benefit or advantage or the absence of
			 any exclusion, limitation or disadvantage of possible significance to an
			 enrollee of, or person considering enrollment in, a health care plan if such
			 benefit or advantage or absence of limitation, exclusion or disadvantage does
			 not in fact exist.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › MISCELLANEOUS PROVISIONS FOR PROVIDER-SPONSORED ORGANIZATIONS › Section 695C.380 - Rehabilitation, liquidation or conservation

Current through June 11, 2024
Any rehabilitation, liquidation or conservation of a
				provider-sponsored organization shall be deemed to be the rehabilitation,
				liquidation or conservation of an insurance company and will be conducted under
				the supervision of the Commissioner pursuant to the law governing the
				rehabilitation, liquidation, or conservation of insurance
				companies.
Added to NAC by Comm'r
				of Insurance by R148-99, eff. 1-27-2000
NRS
				  679B.130,
				  695C.275
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › QUALITY ASSURANCE PROGRAM › Section 695C.400 - Requirements; written description of action plan; staff; periodic review of program

Current through June 11, 2024
1. Each
			 organization shall establish a quality assurance program which consists of a
			 method for analyzing the outcomes of health care, peer review, the collection
			 of health care data and appropriate recommendations for remedial
			 action.
2. The program must be
			 designed to direct, evaluate and monitor the effectiveness of the health care
			 provided by the organization.
3.
			 The organization shall maintain a written description of its program which
			 describes the specific actions that will be taken to ensure that the quality of
			 health care provided to members is adequate and the personnel responsible for
			 such actions. The actions may consist of a particular study or methodology for
			 determining the quality of health care.
4. The organization shall inform each
			 provider of health care of the organization of the manner in which the quality
			 assurance program operates.
5. The
			 organization shall provide the necessary staff to implement the program and
			 evaluate the effectiveness of the program.
6. The organization is responsible for all
			 activities conducted pursuant to the quality assurance program regardless of
			 whether the organization performs the activity or the activity is delegated to
			 another entity.
7. Not less than
			 annually, the organization shall review the continuity and effectiveness of the
			 program and any proposed findings of the quality assurance committee. The
			 organization shall take such actions as necessary to improve the
			 program.
Added to NAC by Bd. of
				Health, eff. 11-1-95
NRS
				  439.200