reglab/statecodes huggingface dataset:
Nevada Administrative Code › Chapter 695B - Nonprofit Corporations for Hospital, Medical and Dental Service › SUMMARY OF COVERAGE › Section 695B.035 - Disclosures in advertising and sales materials; inclusion of certain information in contract for hospital or medical service (Repealed)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 695B - Nonprofit Corporations for Hospital, Medical and Dental Service › PREMIUM RATES › Section 695B.050 - Limitation on frequency of increases; exceptions

Current through June 11, 2024
1.
			 Except as otherwise provided in this section, a nonprofit corporation for
			 hospital, medical or dental services shall not increase the premium rates under
			 a group contract for hospital, medical or dental services 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 contract for hospital, medical or dental services;
(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 contract for hospital, medical or dental
			 services.
Nevada Administrative Code › Chapter 695B - Nonprofit Corporations for Hospital, Medical and Dental Service › PAYMENT OF BENEFITS › Section 695B.100 - Subrogation: Right to recover from third party; lien against recovery; subrogation not basis for denial of payment of benefits

Current through June 11, 2024
1.
			 Except as otherwise provided by specific federal or state statute or
			 regulation, a nonprofit corporation for hospital, medical or dental service may
			 include in a group contract for hospital, medical or dental service issued
			 pursuant to chapter 695B of NRS a provision for subrogation regarding the right
			 of an insured to recover, and the imposition of a lien upon any recovery by an
			 insured, from a third person for the cost of medical benefits reimbursed by the
			 corporation to the insured because of injuries incurred by the insured as a
			 result of the actions of the third person. The amount of the lien must not be
			 more than the amount of the reimbursements paid by the corporation.
2. A nonprofit corporation for hospital,
			 medical or dental service shall not deny the payment of any benefits based upon
			 such a provision for subrogation.
Added to NAC by Comm'r of
				Insurance, eff. 12-15-94
NRS
				  679B.130,
				  695B.280
Nevada Administrative Code › Chapter 695B - Nonprofit Corporations for Hospital, Medical and Dental Service › PAYMENT OF BENEFITS › Section 695B.120 - Group benefits payable by more than one insurer to provider; restrictions

Current through June 11, 2024
When the benefits of a group contract for hospital, medical or
				dental service issued pursuant to chapter 695B of NRS are payable by more than
				one insurer to a provider, the contract 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,
				  695B.280
Nevada Administrative Code › Chapter 695B - Nonprofit Corporations for Hospital, Medical and Dental Service › PAYMENT OF BENEFITS › Section 695B.125 - Determination of benefits; consideration of coverage under another policy not allowed

Current through June 11, 2024
A group contract for hospital, medical or dental service issued
				pursuant to chapter 695B of NRS:
1.
			 Must not, for the determination of benefits payable for the coordination of
			 benefits, provide for the consideration of any benefits payable pursuant to any
			 individual health insurance, health insurance under a franchise plan, no-fault
			 automobile insurance or automobile medical insurance.
2. Must provide for the payment of benefits
			 without regard to any benefits payable pursuant to any individual health
			 insurance, health insurance under a franchise plan, no-fault automobile
			 insurance or automobile medical insurance.
Added to NAC by Comm'r of
				Insurance, eff. 12-15-94
NRS
				  679B.130,
				  695B.280
Nevada Administrative Code › Chapter 695B - Nonprofit Corporations for Hospital, Medical and Dental Service › SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS › Section 695B.200 - Requirements for approval

Current through June 11, 2024
To obtain approval of a system for resolving complaints of
				insureds concerning health care services covered by an insurer from the
				Commissioner as required pursuant to
				NRS
				695B.380, an insurer must:
1. Demonstrate that the system will resolve
			 oral and written complaints concerning:
(a)
			 Payment or reimbursement for covered health care services;
(b) The availability, delivery or quality of
			 covered health care services, including, without limitation, an adverse
			 determination made pursuant to utilization review; and
(c) The terms and conditions of the health
			 care plan of insureds.
Nevada Administrative Code › Chapter 695B - Nonprofit Corporations for Hospital, Medical and Dental Service › SYSTEM FOR RESOLVING COMPLAINTS OF INSUREDS › Section 695B.210 - Annual report

Current through June 11, 2024
1. An insurer shall
			 submit its annual report regarding its system for resolving complaints as
			 required pursuant to
			 NRS
			 695B.390 on or before June 1 of each year.
			 The insurer 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 insurer is not
			 required to include in the annual report information concerning an oral inquiry
			 by an insured 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 insurer 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 R008-02,
				5-23-2002
NRS
				  679B.130,
				  695B.390
Nevada Administrative Code › Chapter 695B - Nonprofit Corporations for Hospital, Medical and Dental Service › POLICIES FOR STOP-LOSS INSURANCE › Section 695B.250 - General provisions

Current through June 11, 2024
1. A policy for
			 stop-loss insurance must:
(a) Not provide
			 direct coverage of the health care expenses of an individual;
(b) Have an annual specific attachment point
			 for claims incurred per individual that is not less than $20,000; and
(c) Have an annual aggregate attachment point
			 for:
(1) Small employer groups that is at
			 least the greater of:
(I) One hundred and
			 twenty percent of expected claims; or
(II) Twenty thousand dollars; or
(2) All other groups that is at
			 least 110 percent of expected claims.
Nevada Administrative Code › Chapter 695B - Nonprofit Corporations for Hospital, Medical and Dental Service › CONDITION AND AFFAIRS › Section 695B.300 - Maintenance of reserve fund

Current through June 11, 2024
All reserves maintained by a nonprofit corporation pursuant to
				NRS
				695B.140:
1. Must be deposited in a trust account in a
			 federally insured financial institution located in this State. All income
			 earned by the account belongs to the nonprofit corporation and may be credited
			 and paid to the nonprofit corporation and used for its operations.
2. Are in addition to those reserves
			 established by the nonprofit corporation according to good business and
			 accounting practices for incurred but not reported claims and other similar
			 claims.
Added to NAC by Comm'r of
				Insurance by R247-03, eff. 11-12-2004
NRS
				  679B.130,
				  695B.140
Nevada Administrative Code › Chapter 695B - Nonprofit Corporations for Hospital, Medical and Dental Service › CONDITION AND AFFAIRS › Section 695B.305 - Capital account

Current through June 11, 2024
Each nonprofit corporation shall maintain a capital account
				with a net worth in an amount which is not less than the amount of risk-based
				capital determined in the manner set forth in NRS 681B.290 and the regulations
				adopted pursuant thereto.
Added to NAC by Comm'r of
				Insurance by R132-13, 6-23-2014, eff. 10-1-2014
NRS
				  679B.130,
				  681B.290
Nevada Administrative Code › Chapter 695B - Nonprofit Corporations for Hospital, Medical and Dental Service › CONDITION AND AFFAIRS › Section 695B.310 - Annual statement of condition and affairs; financial statements; quarterly statement of domestic nonprofit organization; extension of time for filing statement; failure to file statement

Current through June 11, 2024
1. As a condition of
			 doing business in this State, each nonprofit corporation which maintains and
			 operates a hospital, medical or dental service plan must file with the
			 Commissioner an annual statement required by
			 NRS
			 695B.160 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 nonprofit corporation required by the
			 Commissioner.
Nevada Administrative Code › Chapter 695B - Nonprofit Corporations for Hospital, Medical and Dental Service › CONDITION AND AFFAIRS › Section 695B.320 - Conduct of examinations

Current through June 11, 2024
Each examination of a nonprofit corporation which establishes,
				maintains or operates a hospital, medical or dental service plan, including,
				without limitation, an examination conducted pursuant to
				NRS
				695B.160, 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 by R247-03, eff. 11-12-2004
NRS
				  679B.130,
				  695B.160
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › GENERAL PROVISIONS › Section 695C.010 - Definitions

Current through June 11, 2024
As used in this chapter, unless the context otherwise requires,
				the words and terms defined in:
1. NAC
			 695C.019 to 695C.090, inclusive, have the meanings ascribed to them in those
			 sections; and
2.NRS
			 695C.030 have the meanings ascribed to them
			 in that section.
Supplied in
				codification; A by Comm'r of Insurance, 6-11-86; R129-96, 10-29-97; R132-98,
				3-30-99; R148-99, 1-27-2000
NRS
				  679B.130
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › GENERAL PROVISIONS › Section 695C.025 - "Delivery system intermediary" defined

Current through June 11, 2024
1. "Delivery system
			 intermediary" means a partnership, association, corporation or other legal
			 entity which enters into a contract with an organization to provide health care
			 services. The term includes:
(a) An entity
			 jointly owned and controlled by a hospital and a physician; and
(b) An entity primarily owned and controlled
			 by physicians.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › GENERAL PROVISIONS › Section 695C.040 - "Division" defined

Current through June 11, 2024
"Division" means the Division of Insurance of the Department of
				Business and Industry.
Comm'r of Insurance,
				LH-4 part § II, eff. 7-1-74-NAC A 5-27-92
NRS
				  679B.130
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › GENERAL PROVISIONS › Section 695C.041 - "Division of Public and Behavioral Health" defined

Current through June 11, 2024
"Division of Public and Behavioral Health" means the Division
				of Public and Behavioral Health of the Department of Health and Human
				Services.
Added to NAC by Bd. of
				Health, eff. 11-1-95
NRS
				  439.200
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › GENERAL PROVISIONS › Section 695C.042 - "Group practice" defined

Current through June 11, 2024
"Group practice" has the meaning ascribed to it in
				NRS
				439B.425.
Added to NAC by Comm'r
				of Insurance by R129-96, eff. 10-29-97
NRS
				  679B.130
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › GENERAL PROVISIONS › Section 695C.043 - "Health care services" defined

Current through June 11, 2024
"Health care services" has the meaning ascribed to it in
				NRS 695C.030.
Added to NAC by Comm'r
				of Insurance by R129-96, eff. 10-29-97
NRS
				  679B.130
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › GENERAL PROVISIONS › Section 695C.047 - "Health service contract" defined

Current through June 11, 2024
"Health service contract" means an agreement between an
				organization and a delivery system intermediary in which the delivery system
				intermediary:
1. Accepts risk from the
			 organization in any form, including, without limitation, per capita payments
			 and payments of a percentage of premiums, for one or more health care services
			 which will be furnished to enrollees, members, policyholders or subscribers of
			 the organization by a provider chosen by the delivery system intermediary and
			 the delivery system intermediary assumes financial liability for the covered
			 services; and
2. Contracts with a
			 provider to furnish one or more health care services to enrollees, members,
			 policyholders or subscribers of the organization.
Added to NAC by Comm'r
				of Insurance by R129-96, eff. 10-29-97
NRS
				  679B.130
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › GENERAL PROVISIONS › Section 695C.057 - "Medicare + Choice plan" defined

Current through June 11, 2024
"Medicare + Choice plan" means a plan of health insurance
				established pursuant to the program set forth in sections 1851 to 1859,
				inclusive, of the Social Security Act,
				42 U.S.C. §§
									1395w-21 to - 28, inclusive.
Added to NAC by Comm'r
				of Insurance by R148-99, eff. 1-27-2000
NRS
				  679B.130
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › GENERAL PROVISIONS › Section 695C.060 - "Organization" defined

Current through June 11, 2024
"Organization" means a health maintenance organization or a
				provider-sponsored organization.
Comm'r of Insurance,
				LH-4 part § II, eff. 7-1-74-NAC A by R148-99,
				1-27-2000
NRS
				  679B.130
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › GENERAL PROVISIONS › Section 695C.065 - "Preexisting condition" defined

Current through June 11, 2024
"Preexisting condition" means a medical condition of an
				enrollee for which he or she has received treatment during the 6 months
				preceding enrollment in the organization.
Added to NAC by Comm'r
				of Insurance, eff. 6-11-86
NRS
				  679B.130
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › GENERAL PROVISIONS › Section 695C.070 - "Primary physician" defined

Current through June 11, 2024
"Primary physician" means the physician who or group of
				physicians which:
1. Is responsible
			 for the initial and primary care given to an enrollee;
2. Is responsible for maintaining the
			 continuity of care to an enrollee; and
3. Initiates referrals to a specialist or
			 other person who provides specialized care to an enrollee pursuant to an
			 evidence of coverage.
Added to NAC by Comm'r
				of Insurance, eff. 6-11-86
NRS
				  679B.130
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › GENERAL PROVISIONS › Section 695C.075 - "Provider-sponsored organization" defined

Current through June 11, 2024
"Provider-sponsored organization" means an entity that
				satisfies all the requirements set forth in
				42
				U.S.C. §
									1395w - 25(d) and the federal
				regulations adopted pursuant thereto.
Added to NAC by Comm'r
				of Insurance by R148-99, eff. 1-27-2000
NRS
				  679B.130
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › GENERAL PROVISIONS › Section 695C.080 - "Subscriber" defined

Current through June 11, 2024
"Subscriber" means an employer or other person purchasing a
				health care plan for himself or herself or others pursuant to a written
				contract with an organization.
Added to NAC by Comm'r
				of Insurance, eff. 6-11-86
NRS
				  679B.130
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › GENERAL PROVISIONS › Section 695C.090 - "Uncovered expenditures" defined

Current through June 11, 2024
"Uncovered expenditures" means the cost of those services,
				including services provided during an emergency, rendered by a provider and
				paid for by an organization during its operation for which:
1. There is no agreement between the provider
			 and organization to release the enrollee from liability for the cost of those
			 services; and
2. The enrollee may
			 be liable for payment should the organization become insolvent.
Added to NAC by Comm'r
				of Insurance, eff. 6-11-86
NRS
				  679B.130
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › GENERAL PROVISIONS › Section 695C.095 - Certain provisions of NRS not applicable to provider-sponsored organizations

Current through June 11, 2024
1. Except as
			 otherwise provided in this chapter or in specific provisions of title 57 of
			 NRS, the provisions of title 57 of NRS are not applicable to any
			 provider-sponsored organization issued a certificate of authority under this
			 chapter. This provision does not apply to an insurer licensed and regulated
			 pursuant to title 57 of NRS except with respect to its activities as a
			 provider-sponsored organization authorized and regulated pursuant to this
			 chapter.
2. Solicitation of
			 enrollees by a provider-sponsored organization issued a certificate of
			 authority, or its representatives, must not be construed to violate any
			 provision of law relating to solicitation or advertising by practitioners of a
			 healing art.
3. A
			 provider-sponsored organization authorized under this chapter shall not be
			 deemed to be practicing medicine and is exempt from the provisions of chapter
			 630 of NRS.
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 › GENERAL PROVISIONS › Section 695C.100 - Applicability of certain provisions of NRS to provider-sponsored organizations

Current through June 11, 2024
1. The provisions
			 of
			 NRS
			 449.465,
			 679B.159,
			 subsections 2, 4, 17, 18 and 31 of
			 NRS
			 680B.010,
			 NRS
			 680B.025 to
			 680B.060,
			 inclusive, chapter 685B of NRS and
			 NRS 695G.010 to
			 695G.260, inclusive, apply to a provider-sponsored organization.
2. For the purposes of subsection 1, unless
			 the context requires that a provision apply only to insurers, any reference in
			 those sections to "insurer" must be replaced by "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 › GENERAL PROVISIONS › Section 695C.105 - Treatment of applications, filings and reports as public documents

Current through June 11, 2024
All applications, filings and reports required under this
				chapter must be treated as public documents except as otherwise provided in
				this chapter.
Added to NAC by Comm'r
				of Insurance by R148-99, eff. 1-27-2000
NRS
				  679B.130
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › GENERAL PROVISIONS › Section 695C.Sec. 6 - NEW

Current through June 11, 2024
1. A health maintenance
			 organization that issues a health care plan shall not require an
			 enrollee to pay a higher deductible or any copayment, coinsurance or
			 other form of cost-sharing for or use any medical management
			 technique to restrict access by an enrollee to:
(a) A visit to the office of a
			 provider of health care, an urgent care center, an independent center
			 for emergency medical care, the emergency room of a hospital or a
			 COVID-19 screening or testing site, if the purpose of the visit is to
			 determine whether the enrollee has COVID-19;
(b) A test to determine whether the
			 enrollee has COVID-19 if the attending provider of health care
			 determines, in accordance with generally accepted medical standards,
			 that the test is appropriate; or
(c) A vaccine to prevent the
			 enrollee from contracting COVID-19.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › CERTIFICATES OF AUTHORITY › Section 695C.111 - Provider-sponsored organization: Certificate required to offer Medicare + Choice plan

Current through June 11, 2024
1. To offer a Medicare + Choice plan in this
			 State, a provider-sponsored organization must file an application with the
			 Commissioner and obtain a certificate of authority to operate as an
			 organization pursuant to chapter 695C of NRS and the regulations adopted
			 pursuant thereto.
2. A
			 provider-sponsored organization shall not offer health insurance or other
			 benefits for health care services in this State except through a Medicare +
			 Choice plan, unless the provider-sponsored organization is licensed to provide
			 other services in this 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 › CERTIFICATES OF AUTHORITY › Section 695C.115 - Application of provider-sponsored organization

Current through June 11, 2024
For a provider-sponsored organization, an application for a
				certificate of authority must be verified by an officer or authorized
				representative of the applicant, must be in a form prescribed by the
				Commissioner and must set forth or be accompanied by the following:
1. A copy of the basic organizational
			 document, if any, of the applicant, and all amendments thereto;
2. A copy of the bylaws, rules or
			 regulations, or similar documents, if any, regulating the conduct of the
			 internal affairs of the applicant;
3. A list of the names, addresses and
			 official positions of the persons who are to be responsible for the conduct of
			 the affairs of the applicant, including all members of the board of directors,
			 board of trustees, executive committee, or other governing board or committee,
			 the officers in the case of a corporation, and the partners or members in the
			 case of a partnership or association;
4. A copy of any contract made or to be made
			 between any providers or persons listed in subsection 3 and the
			 applicant;
5. A statement generally
			 describing the provider-sponsored organization, the location of facilities at
			 which health care services will be regularly available to enrollees and the
			 type of health care personnel who will provide the health care
			 services;
6. Certified financial
			 statements showing the assets, liabilities and sources of financial support of
			 the applicant;
7. A financial plan
			 that includes a 3-year projection of the initial operating results anticipated
			 and the sources of working capital as well as any other sources of
			 funding;
8. A description of the
			 proposed method of marketing;
9. A
			 power of attorney duly executed by the applicant appointing the Commissioner
			 and his or her duly authorized deputies as the true and lawful attorney of such
			 applicant in and for this State upon whom all lawful process in any legal
			 action or proceeding against the provider-sponsored organization on a cause of
			 action arising in this State may be served;
10. A statement reasonably describing the
			 geographic area to be served; and
11. A description of the procedures for the
			 resolution of 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 › CERTIFICATES OF AUTHORITY › Section 695C.120 - Application: Required documents

Current through June 11, 2024
An application for a certificate of authority must be
				accompanied by all forms specifically required by chapter 695C of NRS and
				provided by the Division and by:
1.
			 All documents describing the financing and ownership of the organization,
			 including financial statements and copies of any contracts made or to be made
			 between any member of the governing board or committee, the officers of the
			 corporation or partners of a partnership or association, or providers, and the
			 proposed organization. The financial statements must depict a net worth of not
			 less than $1,500,000 for a health maintenance organization. All financial
			 statements must be certified by an independent certified public
			 accountant.
2. For a health
			 maintenance organization, a surety bond or deposit of cash or securities to
			 secure the debts of the health maintenance organization and for the protection
			 of the enrollees in the amount of $250,000 or more which is deposited with the
			 Commissioner. The bond must include a provision preventing cancellation except
			 after written notice to the Commissioner of not less than 90 days. A health
			 maintenance organization which has made a deposit of securities pursuant to
			 this subsection may withdraw them if it makes an equivalent deposit of cash,
			 securities or a combination of cash and securities acceptable to the
			 Commissioner.
3. For a health
			 maintenance organization, blanket fidelity coverage issued by an authorized
			 insurer in an amount of not less than $1,000,000 in the aggregate to cover
			 every director, officer, partner and employee of the health maintenance
			 organization who may receive, collect, disburse or invest funds in connection
			 with the activities of the health maintenance organization.
4. A proposed plan of operation for the first
			 3 years of operation based on projected total income and projected total
			 expenses. The amounts stated for the cost of medical services and the use of
			 them in the proposed plan must be certified by a qualified actuary. The plan
			 must project income and expected costs allocated to:
(a) Coverage for emergencies or medically
			 necessary services rendered outside of the specified geographic area of service
			 of the organization;
(b) Per capita
			 payments to primary physicians;
(c)
			 Fees to other providers of health care;
(d) Supplemental benefits;
(e) A contract of stop-loss
			 insurance;
(f) Expenses of
			 administration; and
(g)
			 Amortization of necessary costs for the establishment of the
			 organization.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › CERTIFICATES OF AUTHORITY › Section 695C.121 - Application: Submission; incomplete application deemed withdrawn; notice of review; deadline

Current through June 11, 2024
1. Any person
			 applying for a certificate of authority as an organization shall file an
			 application as follows:
(a) An original and
			 three copies of the application must be submitted in binders having three
			 rings.
(b) If a new page is
			 submitted to supplement or amend the application, the date of submission must
			 be noted on the bottom of the page, and the page must be prepared so it can be
			 placed in the binder with the other materials.
(c) Each binder must contain a table of
			 contents and include dividers which separate the various sections of the
			 application and indicate the subject in each section.
(d) One binder must contain the original
			 application, the original of the completed forms supplied by the Division and
			 the original or a certified copy of any supporting document.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › CERTIFICATES OF AUTHORITY › Section 695C.122 - Application: Member of insurance holding company system

Current through June 11, 2024
1.
			 Any organization which is wholly or partially owned by an insurance company or
			 other entity defined in
			 NRS
			 692C.060 shall describe that relationship in
			 its application for a certificate of authority. The organization shall provide
			 the Division with the information described in chapter 692C of NRS concerning
			 filings by an insurance holding company.
2. Any filing required of an insurance
			 holding company by chapter 692C of NRS applies at the time of the application
			 by an organization and continues after the issuance of a certificate of
			 authority to the organization.
3.
			 For the purposes of this section and
			 NRS
			 692C.060, the term "organization" is included
			 in the meaning of the term "insurer." As such, any organization affiliated with
			 any other person is a member of an insurance holding company system.
Added to NAC by Comm'r
				of Insurance, eff. 6-11-86; A 12-9-91
NRS
				  679B.130,
				  695C.070,
				  695C.275
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › CERTIFICATES OF AUTHORITY › Section 695C.1225 - Provider-sponsored organization: Transmittal of information to State Board of Health; conditions for issuance of certificate

Current through June 11, 2024
Upon the receipt of an application for a certificate of
				authority, the Commissioner will transmit a copy of the application and any
				accompanying documents to the State Board of Health for informational purposes.
				The Commissioner will issue or deny a certificate of authority to any person
				filing an application pursuant to NAC 695C.111 within 90 days after the date
				that the Commissioner receives the application for a certificate of authority
				to operate as a provider-sponsored organization. A certificate of authority
				must be issued upon payment of the fees prescribed in NAC 695C.365 if the
				Commissioner is satisfied that the following conditions are met:
1. The persons responsible for the conduct of
			 the affairs of the applicant are competent, trustworthy and possess good
			 reputations.
2. The
			 provider-sponsored organization is financially responsible and may reasonably
			 be expected to meet its obligations to enrollees and prospective enrollees. In
			 making this determination, the Commissioner may consider:
(a) The financial soundness of the
			 arrangements of the health care plan for health care services and the schedule
			 of charges used in connection therewith;
(b) The adequacy of working
			 capital;
(c) Any agreement with an
			 insurer, a government or any other organization for insuring the payment of the
			 cost of health care services;
(d)
			 Any agreement with providers for the provision of health care services;
			 and
(e) Any surety bond or deposit
			 of cash or securities to guarantee that the obligations will be duly
			 performed.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › CERTIFICATES OF AUTHORITY › Section 695C.123 - Federal qualification: Information required

Current through June 11, 2024
1. Any
			 organization which holds a certificate of authority issued by the Commissioner
			 and is seeking qualification as a health maintenance organization pursuant to
			 42 U.S.C. §
									300e - 9(c) or qualifies as a
			 provider-sponsored organization by satisfying all the requirements set forth in
			 42
			 U.S.C. §
									1395w - 25(d) and the federal
			 regulations adopted pursuant thereto shall submit to the Division information
			 concerning that qualification, including:
(a)
			 The date and time of the inspection to be conducted by the Federal
			 Government;
(b) The name and
			 address of the federal officer responsible for investigating the organization;
			 and
(c) A copy of any report by the
			 Federal Government qualifying or denying the qualification of the
			 organization.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › CERTIFICATES OF AUTHORITY › Section 695C.124 - Application: Public inspection; notice of hearing

Current through June 11, 2024
1. Any
			 person wishing to review an application for issuance of a certificate of
			 authority for an organization shall submit a request to the Division in
			 writing. The application may be reviewed at the offices of the Division at 1818
			 East College Parkway, Suite 103, Carson City, Nevada 89706, or a copy of the
			 application may be requested. If a copy of the application is requested, money
			 to reimburse the Division for the cost of postage and of preparing the copy
			 must be submitted with the request.
2. If any person wishes to be notified of a
			 pending application or hearing concerning the denial of a certificate of
			 authority, the person must request in writing that he or she be placed on a
			 list maintained by the Division for this purpose.
Added to NAC by Comm'r
				of Insurance, eff. 6-11-86; A 5-27-92; R148-99, 1-27-2000; R248-03,
				11-12-2004
NRS
				  679B.130,
				  695C.275
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › CERTIFICATES OF AUTHORITY › Section 695C.125 - Application of health maintenance organization: Evaluation by Division of Public and Behavioral Health (Repealed)

Current through June 11, 2024
Bd. of Health, Health
				Maintenance Plans Art. 2, eff. 4-11-80-NAC A 11-1-95; A by Comm'r of Insurance
				by R148-99, 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 › CERTIFICATES OF AUTHORITY › Section 695C.1255 - Application: Organization to establish that it has met requirements

Current through June 11, 2024
1. An organization applying for a certificate
			 of authority must establish that:
(a) The
			 organization has an adequate number of providers in each category of provider
			 of health care necessary to serve its members in each geographic location in
			 its service area;
(b) The providers
			 of health care with whom the organization has contracted to provide services
			 are located so that the members may obtain health care without unreasonable
			 travel;
(c) Nonemergency services
			 are available and accessible during normal business hours and emergency
			 services are available at any time;
(d) For a health maintenance organization,
			 members can schedule appointments within a reasonable time, as determined by
			 the State Board of Health;
(e) For
			 a health maintenance organization, members are not required to wait for an
			 unreasonable period of time in the office of a provider for a scheduled
			 appointment, as determined by the State Board of Health;
(f) Members have access to their primary
			 physician through on-call procedures after normal business hours;
(g) It requires the providers of health care
			 with whom the organization has contracted to provide service to maintain
			 records of the health care of its members which are accessible to other
			 professionals within the organization;
(h) It provides a health care professional
			 who is primarily responsible for coordinating the overall health care services
			 offered to members;
(i) It has
			 established a quality assurance program as required pursuant to NAC 695C.400;
			 and
(j) The organization has
			 established a system to collect data related to the health care services
			 provided to members.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › CERTIFICATES OF AUTHORITY › Section 695C.126 - Application of health maintenance organization: Effect of change after review

Current through June 11, 2024
If an applicant for a certificate of authority to establish and
				operate a health maintenance organization submits information changing its
				application after review by the State Board of Health, the Division will deny
				the application.
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 › CERTIFICATES OF AUTHORITY › Section 695C.127 - Licensure in another state: Application for this State; copy of license; notice of disciplinary action

Current through June 11, 2024
1. Any applicant
			 for a certificate of authority who is licensed to operate an organization in
			 another state or whose affiliate or subsidiary is so licensed shall include in
			 its application a copy of that license and, if available, a certificate of good
			 standing from that state's agency which regulates organizations.
2. Any organization already authorized in
			 this State who obtains a license as an organization in another state or whose
			 affiliate or subsidiary obtains such a license shall furnish a copy of that
			 license to the Commissioner within 30 days after receipt of the
			 license.
3. An organization also
			 licensed in another state shall notify the Division of any disciplinary action
			 taken by that state and file copies of all documents relating to that action
			 with the Division within 10 days after receipt of the documents by the
			 organization.
Added to NAC by Comm'r
				of Insurance, eff. 6-11-86; A 5-27-92; R148-99,
				1-27-2000
NRS
				  679B.130,
				  695C.275
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › CERTIFICATES OF AUTHORITY › Section 695C.128 - Licensure in another state: Contract with providers of medical care in state contiguous to Nevada; plan for operation

Current through June 11, 2024
1. If an
			 organization holding a certificate of authority in this State is licensed in a
			 state contiguous to this State and wishes to contract with providers in that
			 state for services for enrollees in this State, the organization shall submit
			 to the Division, for its review and approval, two copies of:
(a) The plan of the organization for
			 operation in that other state;
(b)
			 A copy of the evidence of coverage to be issued, if it has not been previously
			 filed with the Division;
(c) Its
			 list of providers and agreements with the providers; and
(d) Any other materials concerning the
			 administration of the plan necessary for the decision of the Division
			 concerning the organization.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › CERTIFICATES OF AUTHORITY › Section 695C.1282 - Provider-sponsored organization: Denial of certificate

Current through June 11, 2024
The Commissioner may deny a certificate of authority only after
				he or she has complied with NAC 695C.1286.
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 › CERTIFICATES OF AUTHORITY › Section 695C.1284 - Provider-sponsored organization: Grounds for suspension or revocation of certificate; effect of revocation

Current through June 11, 2024
1. The Commissioner
			 may suspend or revoke any certificate of authority issued to a
			 provider-sponsored organization pursuant to the provisions of this chapter if
			 he or she finds that any of the following conditions exist:
(a) The provider-sponsored organization is
			 operating significantly in contravention of its basic organizational document,
			 its health care plan or in a manner contrary to that described in and
			 reasonably inferred from any other information submitted pursuant to NAC
			 695C.111, 695C.115 or 695C.350, unless any amendments to those submissions have
			 been filed with and approved by the Commissioner;
(b) The provider-sponsored organization is no
			 longer financially responsible and may reasonably be expected to be unable to
			 meet its obligations to enrollees or prospective enrollees;
(c) The continued operation of the
			 provider-sponsored organization would be hazardous to its enrollees;
			 or
(d) The provider-sponsored
			 organization has otherwise failed to comply substantially with the provisions
			 of this chapter.
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › CERTIFICATES OF AUTHORITY › Section 695C.1286 - Provider-sponsored organization: Notice of hearing; action by Commissioner; judicial review

Current through June 11, 2024
1. When the
			 Commissioner has cause to believe that grounds for the denial of an application
			 for a certificate of authority to operate a provider-sponsored organization
			 exist, or that grounds for the suspension or revocation of a certificate of
			 authority for a provider-sponsored organization exist, he or she will notify
			 the provider-sponsored organization in writing specifically stating the grounds
			 for denial, suspension or revocation and fixing a time at least 30 days
			 thereafter for a hearing on the matter.
2. After the hearing, or upon the failure of
			 the provider-sponsored organization to appear at the hearing, the Commissioner
			 will take action as is deemed advisable on the written findings which must be
			 mailed to the provider-sponsored organization. The actions of the Commissioner
			 are subject to review by the First Judicial District Court of the State of
			 Nevada in and for Carson City. The court may, in disposing of the issue before
			 it, modify, affirm or reverse the order of the Commissioner in whole or in
			 part.
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 › CERTIFICATES OF AUTHORITY › Section 695C.1288 - Provider-sponsored organization: Penalties and remedies for violations; cease and desist order; request for hearing; injunctive relief

Current through June 11, 2024
1. The
			 Commissioner may, in lieu of suspension or revocation of a certificate of
			 authority of a provider-sponsored organization pursuant to NAC 695C.1284, levy
			 an administrative penalty in an amount not more than $2,500 for each act or
			 violation if reasonable notice in writing is given of the intent to levy the
			 penalty.
2. If the Commissioner for
			 any reason has cause to believe that any violation of this chapter has occurred
			 or is threatened, the Commissioner may give notice to the provider-sponsored
			 organization and to the representatives, or other persons who appear to be
			 involved in the suspected violation, to arrange a conference with the alleged
			 violators or their authorized representatives to attempt to determine the facts
			 relating to the suspected violation, and, if it appears that any violation has
			 occurred or is threatened, to arrive at an adequate and effective means of
			 correcting or preventing the violation.
3. The proceedings conducted pursuant to the
			 provisions of subsection 2 will not be governed by any formal procedural
			 requirements and may be conducted in such manner as the Commissioner may deem
			 appropriate under the circumstances.
4. The Commissioner may issue an order
			 directing a provider-sponsored organization or a representative of a
			 provider-sponsored organization to cease and desist from engaging in any act or
			 practice in violation of the provisions of this chapter.
5. Within 30 days after service of the order
			 to cease and desist, the respondent may request a hearing on the question of
			 whether acts or practices in violation of this chapter have occurred. The
			 hearing will be conducted pursuant to the provisions of chapter 233B of NRS,
			 and judicial review will be available as provided therein.
6. In the case of any violation of the
			 provisions of this chapter, if the Commissioner elects not to issue a cease and
			 desist order, or in the event of noncompliance with a cease and desist order
			 issued pursuant to subsection 4, the Commissioner may institute a proceeding to
			 obtain injunctive relief, or seek other appropriate relief in the district
			 court of the judicial district of the county in which the violator
			 resides.
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 › CERTIFICATES OF AUTHORITY › Section 695C.129 - Hearings and proceedings

Current through June 11, 2024
1. Any person not
			 entitled to a hearing pursuant to
			 NRS
			 695C.340 or NAC 695C.1286 who is aggrieved by
			 an action of the Commissioner in his or her approval, denial or revocation of a
			 certificate of authority for an organization may request a hearing as provided
			 in
			 NRS
			 679B.310.
2. Any person who wants to intervene in any
			 proceeding held pursuant to
			 NRS
			 695C.340 or NAC 695C.1286 may request that
			 intervention as provided in NAC 679B.460, 679B.470 and 679B.480.
3. Any administrative proceeding under
			 chapter 695C of NRS and this chapter will be held pursuant to the procedures in
			 NAC 679B.161 to 679B.480, inclusive.
Added to NAC by Comm'r
				of Insurance, eff. 6-11-86; A 12-15-94; R148-99,
				1-27-2000
NRS
				  679B.130,
				  695C.275
Nevada Administrative Code › Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations › FINANCIAL REQUIREMENTS; INSURANCE › Section 695C.130 - Health maintenance organization: Financial requirements; modification to approved plan of operations

Current through June 11, 2024
1. Except as
			 otherwise provided in this section, a health maintenance organization which
			 receives a certificate of authority shall maintain and report on its financial
			 statement filed with the Commissioner pursuant to
			 NRS
			 695C.210 a minimum net worth in an amount
			 which is the greater of:
(a) One million five
			 hundred thousand dollars;
(b) Two
			 percent of the first $150,000,000 earned as revenue from premiums collected in
			 the preceding 12-month period, plus 1 percent of the amount in excess of
			 $150,000,000 earned as revenue from premiums collected in the preceding
			 12-month period; or
(c) The amount
			 of risk-based capital determined in the manner set forth in
			 NRS
			 681B.550 and the regulations adopted pursuant
			 thereto.