[Rev. 11/22/2013 10:32:28 AM--2013]

[NAC-695F Revised Date: 2-12]

CHAPTER 695F - PREPAID LIMITED HEALTH SERVICES

GENERAL PROVISIONS

695F.010          Definitions.

695F.020          “Commissioner” defined.

695F.030          “Division” defined.

695F.040          “Limited health service plan” defined.

695F.050          “Organization” defined.

CERTIFICATE OF AUTHORITY

695F.100          Application: Contents; certification of financial statements.

695F.110          Application: Proposed plan of operation.

695F.120          Application: Submission; incomplete application deemed withdrawn.

695F.130          Application: Public inspection; notice of pending application or hearing.

695F.140          Licensure in another state: Application for this State; copy of license; notice of disciplinary action.

695F.150          Licensure in another state: Contract with providers in contiguous state; approval of plan of operation.

695F.160          Surety bond.

695F.170          Hearings and administrative proceedings.

FINANCIAL REQUIREMENTS; INSURANCE; ADVERTISING

695F.200          Reserves.

695F.205          Capital account.

695F.210          Requirements for insurance.

695F.220          Advertising and solicitation.

SERVICES AND BENEFITS

695F.250          Geographic area of service: Definition.

695F.260          Geographic area of service: Expansion.

PROVIDERS OF LIMITED HEALTH SERVICE

695F.300          Requirements for agreement between provider and organization.

695F.310          Per capita payments.

695F.320          List of providers: Submission; changes; excessive reduction.

695F.330          Restriction of choice of provider.

695F.340          Copayments.

ADMINISTRATION OF ORGANIZATION

695F.400          Approval of contract for marketing, enrollment, administration or health care; effect of agreement; licensing of third party.

695F.430          Segregation and separate treatment of records.

695F.440          Retention of minutes and of materials used for marketing or advertising.

695F.450          Annual report.

695F.455          Filing of reports and financial statements.

695F.460          Filing of notice for modification of rates, charges, benefits, organization, operations, documents or services.

695F.470          Summary of coverage: Filing, contents and delivery of disclosure.

695F.480          Evidence of coverage: Requirements.

695F.490          Evidence of coverage: Submission of actuarial memorandum.

EMPLOYEE ASSISTANCE PROGRAM

695F.500          Exemption under certain circumstances of program for abuse of alcohol or other substances.

695F.510          Burden of proof to claim exemption.

SYSTEM FOR RESOLVING COMPLAINTS OF ENROLLEES

695F.600          Establishment; scope; examination of system.

695F.610          Requirements for approval.

695F.620          Notices: Right of member to file complaint; denial of coverage; clear and comprehensive language.

695F.630          Annual report: Content; maintenance of records.

695F.640          Annual report: Submission; resolution of oral inquiry.

695F.650          Records of complaints: Maintenance; submission of summary; copies.

 

 

 

GENERAL PROVISIONS

      NAC 695F.010  Definitions. (NRS 679B.130, 695F.300)  As used in this chapter, unless the context otherwise requires, the words and terms defined in NRS 695F.020 to 695F.070, inclusive, and NAC 695F.020 to 695F.050, inclusive, have the meanings ascribed to them in those sections.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

      NAC 695F.020  “Commissioner” defined. (NRS 679B.130, 695F.300)  “Commissioner” means the Commissioner of Insurance.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

      NAC 695F.030  “Division” defined. (NRS 679B.130, 695F.300)  “Division” means the Division of Insurance of the Department of Business and Industry.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

      NAC 695F.040  “Limited health service plan” defined. (NRS 679B.130, 695F.300)  “Limited health service plan” means any arrangement whereby an organization agrees to provide or arrange for the provision of one or more limited health services to enrollees.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

      NAC 695F.050  “Organization” defined. (NRS 679B.130, 695F.300)  “Organization” means a prepaid limited health service organization.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

CERTIFICATE OF AUTHORITY

      NAC 695F.100  Application: Contents; certification of financial statements. (NRS 679B.130, 695F.110, 695F.300)

     1.  In addition to the documents required by NRS 695F.110, an application for a certificate of authority to operate an organization must include:

     (a) All documents describing the financing and ownership of the organization, including financial statements and copies of any contracts made or to be made between the organization and any:

          (1) Member of the governing board or committee of the organization;

          (2) Corporate officers of the organization, if the organization is a corporation;

          (3) Partners of the organization, if the organization is a partnership; and

          (4) Providers associated or to be associated with the organization, regarding the provision of a limited health service to enrollees.

     (b) A description of the proposed geographic area of service for the organization.

     (c) A proposed plan of operation for the first 3 years of operation based on projected total income and projected total expenses. The amounts set forth for the costs of a limited health service and the use of that service in the proposed plan must be certified by a qualified actuary.

     (d) Pro forma balance sheets and statements of earnings, retained earnings and cash flow for each of the 3 years of the proposed plan of operation.

     (e) A separate schedule setting forth all factors and underlying assumptions regarding the proposed plan of operation.

     (f) If the organization has 3 years or more of operational experience, financial statements demonstrating that the organization has realized a net financial gain, after taxes, from its underwriting activities and the investment of its income, during 3 or more recent years. The Commissioner may waive this requirement if the organization is a subsidiary of an insurer licensed in this State.

     2.  All financial statements required by this section must be certified by an independent certified public accountant.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

      NAC 695F.110  Application: Proposed plan of operation. (NRS 679B.130, 695F.110, 695F.300)  The proposed plan of operation required by NAC 695F.100 must include:

     1.  A projection of income and expected costs allocated to:

     (a) Services rendered outside of the organization’s specified geographic area of service;

     (b) Per capita payments to providers pursuant to NAC 695F.310;

     (c) Other fees to providers;

     (d) A contract of stop loss insurance pursuant to NAC 695F.210;

     (e) Expenses of administration; and

     (f) Amortization of necessary costs for the establishment of the organization.

     2.  Procedures to be used by administrators and other agents of the organization for:

     (a) The handling of underwriting claims; and

     (b) The servicing of clients and claims.

     3.  The organization’s plans for the recruitment, training, licensing and supervision of agents.

     4.  An evaluation of the demand for the organization’s products and services in this State.

     5.  The number of persons expected to be employed by the organization in this State.

     6.  Any other information the Commissioner deems necessary.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97; A by R250-03, 11-12-2004)

      NAC 695F.120  Application: Submission; incomplete application deemed withdrawn. (NRS 679B.130, 695F.110, 695F.300)

     1.  A person applying for a certificate of authority to operate an organization must file an application as follows:

     (a) An original and two 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 documents.

     2.  Any incomplete application on which there has been no activity by the applicant for 60 days shall be deemed withdrawn by the applicant. A new application accompanied by all applicable fees must be submitted before the Commissioner takes any further action. Written notice that the application is considered as withdrawn will be provided to the applicant by the Commissioner.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97; A by R103-09, 1-28-2010)

      NAC 695F.130  Application: Public inspection; notice of pending application or hearing. (NRS 679B.130, 695F.300)

     1.  Any person wishing to review an application for issuance of a certificate of authority for an organization shall submit a request to the Commissioner in writing. A copy of the application may be reviewed at or, at the expense of the person making the request, obtained from the offices of the Commissioner at 1818 East College Parkway, Suite 103, Carson City, Nevada 89706.

     2.  If any person wishes to be notified of a pending application or hearing concerning the denial of such a certificate of authority, the person must request in writing that he or she be placed on a list maintained by the Division for that purpose.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97; A by R250-03, 11-12-2004)

      NAC 695F.140  Licensure in another state: Application for this State; copy of license; notice of disciplinary action. (NRS 679B.130, 695F.110, 695F.300)

     1.  Any applicant for a certificate of authority to operate an organization in this State who is licensed to operate an organization in another state or whose affiliate or subsidiary is so licensed must 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.  An organization authorized to operate in this State which 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 on the first day of each quarter of each calendar year or at such other times as the Commissioner requests.

     3.  An organization also licensed in another state shall notify the Commissioner of any disciplinary action taken by that state against the organization and file copies of all documents relating to that action with the Commissioner within 30 days after receipt of the documents by the organization.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

      NAC 695F.150  Licensure in another state: Contract with providers in contiguous state; approval of plan of operation. (NRS 679B.130, 695F.300)

     1.  An organization holding a certificate of authority in this State which is licensed in a contiguous state shall, before the organization contracts with providers in the contiguous state for services for enrollees in this State, submit to the Commissioner and obtain his or her approval of two copies of:

     (a) The organization’s plan for operation in that state;

     (b) A copy of the evidence of coverage to be issued, if it has not been previously filed with the Commissioner;

     (c) Its lists of providers and agreements with the providers; and

     (d) Any other materials concerning the administration of the plan necessary for the Commissioner’s decision concerning it.

     2.  The Commissioner, before approving such a plan, will consider whether the other state will approve the plan.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

      NAC 695F.160  Surety bond. (NRS 679B.130, 695F.200, 695F.300)  The surety bond required by NRS 695F.200 must contain a provision which prohibits cancellation of the bond unless the Commissioner receives at least 90 days’ prior written notice of the cancellation.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

      NAC 695F.170  Hearings and administrative proceedings. (NRS 679B.130, 695F.300)

     1.  Any person not entitled to a hearing pursuant to NRS 695F.140 or 695F.350 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.  Except as otherwise provided in subsection 3, any administrative proceeding held under this chapter or chapter 695F of NRS must be held as provided in chapter 233B of NRS and NAC 679B.161 to 679B.480, inclusive.

     3.  Any administrative proceeding held under NRS 695F.140 must be held as provided in chapter 233B of NRS and NAC 679B.161 to 679B.480, inclusive, to the extent that those provisions are consistent with NRS 679B.310 to 679B.370, inclusive.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

FINANCIAL REQUIREMENTS; INSURANCE; ADVERTISING

      NAC 695F.200  Reserves. (NRS 679B.130, 695F.190, 695F.300)

     1.  An organization shall:

     (a) Maintain the reserve required to be set aside pursuant to subsection 1 of NRS 695F.190. The reserve must be:

          (1) Based on the premiums collected for the immediately preceding calendar year, as reported on the annual report of the organization filed with the Commissioner; and

          (2) Designated as a “write-in liability” on each report of the organization filed with the Commissioner.

     (b) After the first year of operation, set aside a reserve for incurred but unreported claims in an amount equal to at least 5 percent of its earned premiums for the immediately preceding calendar year, as reported on the annual report of the organization filed with the Commissioner, or $250,000, whichever is greater. The reserve for incurred but unreported claims must be included with the claims unpaid and the unpaid claims adjustment expenses.

     2.  No organization may reduce the reserve for incurred but unreported claims unless it notifies the Commissioner in writing and receives his or her written approval of the reduction. Any unauthorized reduction in this reserve creates a presumption that the organization is in an unsound financial condition.

     3.  The reserve for incurred but unreported claims must be deposited in a trust account in a federally insured financial institution located in this State. The income earned on money in the account must be paid to the organization and used for its operations.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97; A by R250-03, 11-12-2004)

      NAC 695F.205  Capital account. (NRS 679B.130, 695F.200, 695F.300)  Each organization shall maintain a capital account with a net worth in an amount which is the greater of:

     1.  The amount required pursuant to NRS 695F.200; or

     2.  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 R005-03, eff. 2-12-2004)

      NAC 695F.210  Requirements for insurance. (NRS 679B.130, 695F.215, 695F.300)

     1.  Except as otherwise provided in subsections 2 and 5, each organization shall obtain a contract of insurance for the cost of providing limited health services which exceed in the aggregate, for an organization that has a free surplus of:

     (a) Not more than $1,000,000, $30,000 per enrollee per year.

     (b) More than $1,000,000 but not more than $2,000,000, $50,000 per enrollee per year.

     (c) More than $2,000,000, $100,000 per enrollee per year.

     2.  Upon written application by the organization, the Commissioner may authorize an organization to obtain a contract of insurance for the cost of providing limited health services which exceed in the aggregate per enrollee an amount which is less than the amount required pursuant to subsection 1 if the maximum benefit payable per enrollee is less than the amount required pursuant to subsection 1. An organization may not reduce the amount of the aggregate per enrollee unless it has requested the reduction of the amount from the Commissioner in writing and the Commissioner has given written approval of the reduction. Any unauthorized reduction in the amount of the aggregate creates a presumption that the organization is in an unsound financial condition.

     3.  The contract of insurance may have an aggregate limit of $5,000,000. Subject to that limit, the contract must:

     (a) Include a provision that, in case of the insolvency of the organization, the insurer will pay all claims made by an enrollee for the period for which a premium has been paid to the organization.

     (b) Specifically provide for:

          (1) The continuation of benefits to enrollees for the period for which the subscribers have made prepayments to the 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 organization until the enrollee is discharged from the facility; and

          (3) The payment of a provider who is not affiliated with the organization and who provided medically necessary services, as described in the evidence of coverage, to an enrollee for the time the subscriber made payments to the organization.

     4.  A contract of insurance obtained by an organization pursuant to this section may not be cancelled unless the organization and insurer provide the Commissioner with 90 days’ prior written notice of the cancellation.

     5.  Upon written application from an organization pursuant to this section, the Commissioner may find that good cause exists for an exemption of the amounts listed in subsection 1 for the year if, at the end of the immediately preceding calendar year:

     (a) The organization fully capitated all the services provided by the organization pursuant to this chapter; and

     (b) The capitation agreement contains provisions similar to the provisions set forth in subsections 3 and 4 in which the provider would take the place of the insurer.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97; A by R250-03, 11-12-2004)

      NAC 695F.220  Advertising and solicitation. (NRS 679B.130, 695F.300)

     1.  An organization which advertises its benefits must, in that same advertisement, plainly state the exclusions or limitations of its limited health service plan.

     2.  Any period of waiting required before an enrollee is eligible to receive benefits under a limited health service 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 limited health service plan being sold by the number used to file that plan with the Commissioner.

     5.  Advertisements by organizations must comply with the provisions of NAC 689A.010 to 689A.270, inclusive.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

SERVICES AND BENEFITS

      NAC 695F.250  Geographic area of service: Definition. (NRS 679B.130, 695F.300)  An organization shall clearly define the geographic area it intends to serve, which:

     1.  In a county having a population of 30,000 or more, must have a radius of not more than 25 miles between the subscriber or individual enrollee and the providers used by the organization, unless the organization demonstrates to the satisfaction of the Commissioner that the standards of that community differ from the requirements of this subsection.

     2.  In any other county, must be defined by the organization under a plan of operation for the provision of limited health service which is approved in writing by the Commissioner. The plan of operation must:

     (a) Demonstrate the availability and accessibility of services to the organization’s enrollees, including reasonable access to providers and to medically necessary services or services in an emergency;

     (b) Include a statement concerning the standards within that community regarding the availability and accessibility of other limited health services; and

     (c) Demonstrate that the organization will meet the standards of that community for limited health services.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

      NAC 695F.260  Geographic area of service: Expansion. (NRS 679B.130, 695F.300)

     1.  An organization that wishes to expand its geographic area of service from that stated in its application for a certificate of authority must submit to the Commissioner:

     (a) A copy of a written description of the area it proposes to serve;

     (b) A list of the providers who will offer a limited health service to the organization’s enrollees in that area;

     (c) A copy of the contract with those providers;

     (d) A statement describing the effect of the expansion on the operation of the organization;

     (e) Certification that the organization is financially able to expand;

     (f) A statement describing the method of marketing and the projected number of enrollees from the new area;

     (g) Proof that the organization has notified its insurers for its contracts of surety, fidelity and stop loss insurance of the proposed changes;

     (h) Any other information requested by the Commissioner; and

     (i) The fee for filing a material change or addition of a limited health service.

     2.  Any request by an organization to expand the area of its service will be treated by the Commissioner as a material modification of the organization’s operation pursuant to NRS 695F.170. If the organization subsequently submits information amending the request for expansion, the original request shall be deemed withdrawn and the period for approval or disapproval must be computed from the date of receipt of the amended request.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

PROVIDERS OF LIMITED HEALTH SERVICE

      NAC 695F.300  Requirements for agreement between provider and organization. (NRS 679B.130, 695F.220, 695F.300)  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 limited health service 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 a program to ensure the quality of health care provided to enrollees by the organization through its providers.

     5.  Require the provider to provide all medically necessary services within the scope of his or her license 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 limited health services rendered by the provider.

     7.  Require a provider 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 providers associated with the organization.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

      NAC 695F.310  Per capita payments. (NRS 679B.130, 695F.300)

     1.  An agreement between a provider and an organization for the provision of a limited health service to enrollees on a prepayment basis may provide for per capita payments if the payments are:

     (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.

     2.  The per capita payment:

     (a) May be reduced by an amount withheld pursuant to the agreement between the provider and organization as an incentive for the effective use of health care services.

     (b) May not reflect any payment made by an enrollee to a provider in accordance with a schedule of copayments filed with and approved by the Commissioner.

     3.  This section does not prohibit the organization and provider from agreeing to prospective or retroactive adjustments of the per capita payment which reflect an increase in the number of enrollees or additional services tendered by the provider.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

      NAC 695F.320  List of providers: Submission; changes; excessive reduction. (NRS 679B.130, 695F.300)

     1.  An applicant for a certificate of authority to operate an organization shall:

     (a) Submit a list of the providers in its limited health service plan and a description of the type of providers based upon a projected number of enrollees;

     (b) Sufficiently describe its list of providers to demonstrate the accessibility and availability of a limited health service to its enrollees; and

     (c) Describe a plan for increasing the number of providers based upon increased enrollment.

     2.  An organization shall notify the Commissioner in writing at the end of each quarter of each calendar year of any changes in its list of providers.

     3.  Based upon the current list of providers of an organization, an overall reduction in the number of providers in a geographic area of service to a number which reduces the ratio of providers to members below the ratio approved by the Commissioner shall be deemed by the Commissioner to jeopardize the ability of the organization to meet its obligations to its enrollees, unless the organization rebuts this presumption by providing appropriate written information to the Commissioner.

     4.  The provisions of subsection 3 do not apply if the organization:

     (a) Notifies the Commissioner in writing;

     (b) Submits information concerning the number of persons enrolled in the organization and the reasons for any reductions; and

     (c) Obtains the approval of the Commissioner for the reduction.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

      NAC 695F.330  Restriction of choice of provider. (NRS 679B.130, 695F.300)  An organization may restrict the enrollee’s or subscriber’s choice of a provider to those providers 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. 2-3-97)

      NAC 695F.340  Copayments. (NRS 679B.130, 695F.300)

     1.  An organization may establish schedules for nominal copayments to be made by an enrollee to a provider. Each schedule of copayments must be given to the enrollee and submitted to the Commissioner for approval.

     2.  A copayment may be not more than 20 percent of the total cost of providing the limited health service described in the evidence of coverage, unless the Commissioner approves a greater amount based upon the type of limited health service offered by the organization and the dollar amount of the benefits provided. The amount of each copayment must be stated in dollars and must not be expressed as a percentage of the cost of the service or item supplied.

     3.  With each filing of a schedule of copayments, the organization shall submit a:

     (a) Certificate, signed by an officer of the organization, stating that the schedule meets the requirements of this section; and

     (b) Copy of the calculations demonstrating that the schedule meets those requirements.

     4.  If the Commissioner fails to notify the organization of the denial of the schedule within 30 days after it has been filed, the schedule shall be deemed to be approved as submitted by the organization.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

ADMINISTRATION OF ORGANIZATION

      NAC 695F.400  Approval of contract for marketing, enrollment, administration or health care; effect of agreement; licensing of third party. (NRS 679B.130, 695F.300)

     1.  An organization that enters into a contract with a third party to provide services for marketing, enrollment, administration or health care shall submit a copy of the contract to the Commissioner for his or her review and approval.

     2.  The Commissioner will consider such a contract to be an agreement by the third party contracting with the organization to:

     (a) Submit to the jurisdiction of the Commissioner for his or her review of the contract; and

     (b) Authorize the Commissioner 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.

     3.  The third party must hold an appropriate license issued pursuant to chapter 683A of NRS.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

      NAC 695F.430  Segregation and separate treatment of records. (NRS 679B.130, 695F.300)  The records of an organization holding a certificate of authority in this State 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. 2-3-97)

      NAC 695F.440  Retention of minutes and of materials used for marketing or advertising. (NRS 679B.130, 695F.300)  An organization shall retain:

     1.  Indefinitely, by microfilm or any other means, the minutes of the meetings of its governing body and any advisory panel on enrollees’ satisfaction.

     2.  For 3 years or until the next examination of the organization conducted by the Commissioner, a copy of all:

     (a) Published material used to market the organization; and

     (b) Scripts used for advertising on radio or television.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

      NAC 695F.450  Annual report. (NRS 679B.130, 695F.300, 695F.320)  An organization shall:

     1.  File its annual report on the form designated as form number HRSA-905 and approved by the Office of Health Maintenance Organizations on January 1, 1985. That form, which is hereby adopted by reference, may be obtained at a cost of $6.15 plus the cost of mailing from Brandon Insurance Service Company, P.O. Box 22238, Nashville, Tennessee 37202-2238.

     2.  Include in its annual report the number and amount of claims of malpractice initiated against it during that year. The report must include claims made with or without legal process and the disposition, if any, of each claim.

     3.  Furnish a copy of any annual report it distributes to its enrollees to the Commissioner 30 days before that distribution with a notice of its intent to distribute it.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

      NAC 695F.455  Filing of reports and financial statements. (NRS 679B.130, 695F.300, 695F.320)

     1.  As a condition of doing business in this State, each organization must file with the Commissioner an annual report required by NRS 695F.320 that:

     (a) Conforms to the format prescribed by the National Association of Insurance Commissioners in the Annual 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.

     2.  Information from the annual report of the organization must be filed:

     (a) Pursuant to the specifications adopted by the National Association of Insurance Commissioners for filing information in an electronic format;

     (b) At the central office of the National Association of Insurance Commissioners, 2301 McGee Street, Suite 800, Kansas City, Missouri 64108-2662; and

     (c) On or before March 1 of each year.

     3.  If a foreign or alien organization files a report in an electronic format with the National Association of Insurance Commissioners, that report will be deemed to have been filed with the Commissioner if:

     (a) The foreign or alien organization submits an affidavit, a jurat page or a copy of the jurat page to the Commissioner indicating that the report has been so filed. If the organization submits a jurat page, the jurat page must:

          (1) Conform to the format prescribed by the National Association of Insurance Commissioners in the Annual Statement Instructions for Health, which has been adopted by reference in NAC 679B.033; and

          (2) Be executed by a notarial officer pursuant to NRS 240.1655 and 240.167.

     (b) The affidavit, jurat page or copy of the jurat page is accompanied by the applicable fees set forth in NRS 680B.010.

     4.  An annual report required by NRS 695F.320 to be filed with the Commissioner by an organization must be on the current version of the Annual Statement Blanks for Health adopted by the National Association of Insurance Commissioners, which has been adopted by reference in NAC 679B.033. Each organization shall, in preparing the report, follow the Annual Statement Instructions for Health adopted by the National Association of Insurance Commissioners, which accompanies the Annual Statement Blanks for Health.

     5.  If necessary to determine the financial condition of a foreign or alien organization or the fulfillment of contractual obligations or compliance with law by a foreign or alien organization, the Commissioner may require the foreign or alien organization to file a financial report more frequently than annually. Such a report must be:

     (a) Filed on the current form adopted by the National Association of Insurance Commissioners for the type of organization filing;

     (b) Completed in accordance with the instructions accompanying that form; and

     (c) Filed with the National Association of Insurance Commissioners in an electronic format.

     6.  Each domestic organization shall file a quarterly report with the Commissioner. A quarterly report must be:

     (a) Filed on the current form adopted by the National Association of Insurance Commissioners for the type of organization filing;

     (b) Completed in accordance with the instructions accompanying that form; and

     (c) Filed with the National Association of Insurance Commissioners in an electronic format.

     7.  The audited financial statement of the organization filed pursuant to subsection 3 of NRS 695F.320 is a separate document from the annual report required to be filed pursuant to subsection 1 of NRS 695F.320. The audited financial statement must:

     (a) Cover the most recent fiscal year of the organization;

     (b) Be filed with the Commissioner within 120 days after the end of that fiscal year; and

     (c) Be filed pursuant to the specifications and instructions adopted by the National Association of Insurance Commissioners which are included in the Annual Statement Instructions for Health, which have been adopted by reference in NAC 679B.033.

Ê Consolidated statements for organizations that are members of an insurance holding company are not acceptable.

     8.  The Commissioner may grant a reasonable extension of time for filing the annual report or the audited financial statement required by NRS 695F.320 if the request for an extension is submitted in writing and in advance and shows good cause.

     9.  As used in this section, “jurat page” means a written declaration by a notarial officer that the signer of a document signed the document in the presence of the notarial officer and swore to or affirmed that the statements in the document are true.

     (Added to NAC by Comm’r of Insurance by R250-03, eff. 11-12-2004)

      NAC 695F.460  Filing of notice for modification of rates, charges, benefits, organization, operations, documents or services. (NRS 679B.130, 695F.170, 695F.300)  An organization shall file the notice required by NRS 695F.170 at least 30 days before it desires a change in its charges to become effective. The notice must be accompanied by:

     1.  The loss experience or factor for modification, which must be clearly defined and supported by documents maintained as a part of the organization’s records.

     2.  Certification by a qualified actuary, with adequate supporting documentation, that the proposed charges are not excessive, inadequate or unfairly discriminatory.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

      NAC 695F.470  Summary of coverage: Filing, contents and delivery of disclosure. (NRS 679B.130, 695F.300)

     1.  An organization shall file with the Commissioner, for his or her approval, a disclosure summarizing the coverage provided by a limited health service plan offered by the organization.

     2.  The disclosure must:

     (a) Be in at least 10-point type;

     (b) Include the name, address and telephone number of the organization;

     (c) Include the name, address and telephone number of the agent, broker and administrator, if applicable;

     (d) Include a statement describing the principal benefits and the type of coverage being provided;

     (e) Include a description of any provision of the plan which significantly excludes, eliminates, reduces or in any other manner operates to limit the payment of the benefits;

     (f) Include a statement concerning the renewal provisions of the plan; and

     (g) Define the term “usual and customary” or any similar term used in the plan.

     3.  The agent for the organization, the organization after a response to a direct-response solicitation or the broker representing the group policyholder shall deliver the approved disclosure summary to the proposed group policyholder before the limited health service plan is issued.

     (Added to NAC to Comm’r of Insurance, eff. 2-3-97)

      NAC 695F.480  Evidence of coverage: Requirements. (NRS 679B.130, 695F.150, 695F.300)  Any evidence of coverage issued by an organization:

     1.  Must, in addition to the requirements of NRS 695F.150, contain a clear and complete statement of any benefits other than a limited health service to which an enrollee is entitled.

     2.  Must not contain any provision authorizing:

     (a) Subrogation; or

     (b) The coordination of payment of any benefits with any other plan of health insurance or plan for the provision of health care offered by an employer to the same subscribers or enrollees as those covered by the organization.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

      NAC 695F.490  Evidence of coverage: Submission of actuarial memorandum. (NRS 679B.130, 695F.300)  An organization shall, when it files with the Commissioner any evidence of coverage or notice of a material change in any evidence of coverage, submit to the Commissioner an actuarial memorandum which demonstrates:

     1.  The development of rates; and

     2.  The reasonableness of benefits in relation to the premiums charged.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

EMPLOYEE ASSISTANCE PROGRAM

      NAC 695F.500  Exemption under certain circumstances of program for abuse of alcohol or other substances. (NRS 679B.130, 695F.040, 695F.300)  For the purposes of NRS 695F.040, “limited health service” does not include a program which, pursuant to a contract with an employer or labor union, provides for consultations with employees or the members of employees’ families to identify problems regarding their physical or mental health or the abuse of alcohol or other substances, and for the referral of those persons to providers of health care or other resources in the community for counseling, therapy or treatment, if:

     1.  The purpose of the contract, as it relates to the provision of those services, is to maintain or improve the efficiency of employees by assisting in the alleviation of personal problems affecting their performance.

     2.  The contract does not authorize the provision of counseling, therapy or treatment for problems regarding physical or mental health or the abuse of alcohol or other substances.

     3.  The contract does not require any employee, member of an employee’s family or other person eligible for services under the contract to pay, directly or indirectly, any prepaid or periodic charge, copayment or other fee for any services under the contract for the alleviation of problems regarding physical or mental health or the abuse of alcohol or other substances, unless such a payment is:

     (a) Part of the regular union dues of an employee; or

     (b) A benefit provided by an employer on behalf of an employee and members of the employee’s family, which does not affect the amount of compensation or other benefits to which the employee is entitled.

     4.  No individual employee or member of an employee’s family consults with a representative of the program to receive services pursuant to the contract on more than three occasions within any period of 6 months.

     5.  The operator of the program, at least once every 24 months, meets the burden of proof set forth in NAC 695F.510.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

      NAC 695F.510  Burden of proof to claim exemption. (NRS 679B.130, 695F.040, 695F.300)  The operator of a program described in NAC 695F.500 has the burden of proving that the program meets the requirements of that section for exemption from chapter 695F of NRS. This burden of proof may be met by providing the Commissioner with a claim of exemption in substantially the following form:

 

COMMISSIONER OF INSURANCE

DEPARTMENT OF BUSINESS AND INDUSTRY

STATE OF NEVADA

 

CLAIM OF EXEMPTION FOR EMPLOYEE ASSISTANCE PROGRAM

 

     (  ) Original claim                          (  ) Amendment to claim dated:............................................

    

     1.  Legal name of the person filing this claim: ...........................................................................

     2.  Address of the principal office of the program and, if different, the mailing address of the program:    

     3.  Fictitious names used in connection with the operation of the program (if none, so state): .

     4.  Name, title, address and telephone number of a representative of the program who may be contacted regarding this claim: ..........................................................................................................................

     The undersigned hereby declares that the employee assistance program specified in this claim meets the requirements of NAC 695F.500 and is exempt from chapter 695F of NRS. The undersigned agrees to amend this claim within 30 calendar days after the occurrence of any material change in the information specified in this claim.

     Date of claim: ...............................................................................................................................

     Name of person filing claim: ........................................................................................................

     Signature of authorized officer of program: ................................................................................

     Printed name and title of authorized officer: ...............................................................................

     Verification:..................................................................................................................................

     I hereby certify or declare under penalty of perjury under the laws of the State of Nevada that I have read this claim and any attachments thereto and know the contents thereof and that the statements therein are true and correct.

     Executed at (city and state) ........................................ on the ......... day of the month of .………….. of the year   .

 

                                                                        ...................................................................................

                                                                                                         (Signature)

 

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)

SYSTEM FOR RESOLVING COMPLAINTS OF ENROLLEES

      NAC 695F.600  Establishment; scope; examination of system. (NRS 679B.130, 695F.230, 695F.300)

     1.  Each organization that issues an evidence of coverage in this State shall establish with the approval of the Commissioner a system for resolving any complaints of an enrollee concerning limited health services covered under the evidence of coverage. In determining whether to approve a system for resolving complaints, the Commissioner will consult with the State Board of Health.

     2.  A system for resolving complaints pursuant to subsection 1 must include an initial investigation, a review of the complaint by a review board and a procedure for appealing a determination regarding the complaint. The majority of the members on a review board must be enrollees who receive limited health services pursuant to an evidence of coverage issued by the organization.

     3.  Each organization shall allow the Commissioner or the State Board of Health to examine the system for resolving complaints established pursuant to this section at such times as either deems necessary or appropriate.

     (Added to NAC by Comm’r of Insurance by R132-98, eff. 3-30-99)

      NAC 695F.610  Requirements for approval. (NRS 679B.130, 695F.230, 695F.300)  To obtain approval of a system for resolving complaints of enrollees concerning limited health services covered by an organization from the Commissioner as required pursuant to NAC 695F.600, an organization must:

     1.  Demonstrate that the system will resolve oral and written complaints concerning:

     (a) Payment or reimbursement for covered limited health services;

     (b) The availability, delivery or quality of covered limited health services, including, without limitation, adverse determinations made pursuant to utilization review; and

     (c) The terms and conditions of the evidences of coverage of enrollees.

     2.  If the organization issues any evidence of coverage that provides, delivers, arranges for, pays for or reimburses any cost of health care services through managed care, demonstrate that the system will include the external review of a final adverse determination.

     3.  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 enrollees pursuant to NAC 695F.620.

     (Added to NAC by Comm’r of Insurance by R132-98, eff. 3-30-99; A by R132-03, 4-16-2004)

      NAC 695F.620  Notices: Right of member to file complaint; denial of coverage; clear and comprehensive language. (NRS 679B.130, 695F.230, 695F.300)

     1.  After approval by the Commissioner, each organization that issues an evidence of coverage in this State shall provide a written notice to an enrollee, in clear and comprehensible language that is understandable to an ordinary layperson, explaining the right of the enrollee to file a written complaint. Such a notice must be provided to an enrollee:

     (a) At the time he or she receives the evidence of coverage;

     (b) Any time that the organization denies coverage of a limited health service or limits coverage of a limited health service to an enrollee; and

     (c) Any other time deemed necessary by the Commissioner.

     2.  If an organization denies coverage of a limited health service to an enrollee, it shall notify the enrollee in writing of:

     (a) The reason for denying coverage of the limited health service;

     (b) The criteria by which the organization determines whether to authorize or deny coverage of the limited health service;

     (c) The right to file a written complaint and the procedure for filing such a complaint;

     (d) If the organization issues any evidence of coverage that provides, delivers, arranges for, pays for or reimburses any cost of health care services through managed care, the right to:

          (1) Appeal a final adverse determination pursuant to NRS 695G.200 to 695G.310, inclusive;

          (2) Receive an expedited external review of a final adverse determination if the managed care organization receives proof from the insured’s provider of health care that failure to proceed in an expedited manner may jeopardize the life or health of the insured, including notification of the procedure for requesting the expedited external review; and

          (3) Receive assistance from any person, including an attorney, for an external review of a final adverse determination; and

     (e) The telephone number of the Office for Consumer Health Assistance.

     3.  A written notice which is approved by the Commissioner shall be deemed to be in clear and comprehensible language that is understandable to an ordinary layperson.

     (Added to NAC by Comm’r of Insurance by R132-98, eff. 3-30-99; A by R132-03, 4-16-2004)

      NAC 695F.630  Annual report: Content; maintenance of records. (NRS 679B.130, 695F.230, 695F.300)

     1.  Each organization that issues an evidence of coverage in this State shall submit to the Commissioner and the State Board of Health an annual report regarding its system for resolving complaints established pursuant to NAC 695F.600 on a form prescribed by the Commissioner in consultation with the State Board of Health which includes, without limitation:

     (a) A description of the procedures used for resolving any complaints of an enrollee;

     (b) The total number of complaints and appeals handled through the system for resolving complaints since the last report and a compilation of the causes underlying the complaints filed;

     (c) The current status of each complaint and appeal filed; and

     (d) The average amount of time that was needed to resolve a complaint and an appeal, if any.

     2.  Each organization shall maintain records of complaints filed with it which concern something other than limited health services and shall submit to the Commissioner a report summarizing such complaints at such times and in such format as the Commissioner may require.

     (Added to NAC by Comm’r of Insurance by R132-98, eff. 3-30-99)

      NAC 695F.640  Annual report: Submission; resolution of oral inquiry. (NRS 679B.130, 695F.230, 695F.300)

     1.  An organization shall submit its annual report regarding its system for resolving complaints as required pursuant to NAC 695F.630 on or before June 1 of each year. The 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 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 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 R008-02, 5-23-2002)

      NAC 695F.650  Records of complaints: Maintenance; submission of summary; copies. (NRS 679B.130, 695F.230, 695F.300)  An organization shall:

     1.  Maintain records of complaints filed with it regarding subjects other than the performance of a limited health service;

     2.  Submit to the Commissioner a summary of those records at such times and in such a format as the Commissioner requests; and

     3.  If such a complaint is against a person other than the organization, forward a copy of the complaint to the Commissioner and that person.

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)—(Substituted in revision for NAC 695F.420)