[Rev. 11/21/2013 1:18:22 PM--2013]

CHAPTER 695C - HEALTH MAINTENANCE ORGANIZATIONS

GENERAL PROVISIONS

NRS 695C.010        Short title.

NRS 695C.020        Legislative declaration.

NRS 695C.030        Definitions.

NRS 695C.050        Applicability of certain provisions. [Effective through December 31, 2013.]

NRS 695C.050        Applicability of certain provisions. [Effective January 1, 2014.]

NRS 695C.055        Applicability of certain other provisions. [Effective through December 31, 2013.]

NRS 695C.055        Applicability of certain other provisions. [Effective January 1, 2014.]

NRS 695C.057        Applicability of certain provisions concerning portability and availability of health insurance. [Effective through December 31, 2013.]

NRS 695C.057        Applicability of certain provisions concerning portability and availability of health insurance. [Effective January 1, 2014.]

NRS 695C.060        Establishment of organization.

NRS 695C.070        Certificate of authority: Application.

NRS 695C.080        Certificate of authority: Evaluation of application. [Effective through December 31, 2013.]

NRS 695C.080        Certificate of authority: Evaluation of application. [Effective January 1, 2014.]

NRS 695C.090        Certificate of authority: Issuance. [Effective through December 31, 2013.]

NRS 695C.090        Certificate of authority: Issuance. [Effective January 1, 2014.]

NRS 695C.100        Certificate of authority: Denial.

NRS 695C.110        Governing body: Composition; participation by enrollees.

NRS 695C.120        Powers of organization.

NRS 695C.123        Contracts with certain federally qualified health centers.

NRS 695C.125        Contract between health maintenance organization and provider of health care: Form to obtain information on provider of health care; modification; provision of schedule of fees.

NRS 695C.128        Contracts to provide services pursuant to certain state programs: Payment of interest on claims.

NRS 695C.130        Notice and approval required for exercise of powers; rules or regulations.

NRS 695C.140        Notice and approval required for modification of operations; regulations. [Effective through December 31, 2013.]

NRS 695C.140        Notice and approval required for modification of operations; regulations. [Effective January 1, 2014.]

NRS 695C.145        Accounting principles required for certain reports and transactions; health maintenance organization subject to requirements for certain insurers.

NRS 695C.150        Fiduciary responsibilities.

NRS 695C.160        Investments.

ELIGIBILITY FOR COVERAGE

NRS 695C.161        Eligibility for coverage: Definitions.

NRS 695C.163        Eligibility for coverage: Effect of eligibility for medical assistance under Medicaid; assignment of rights to state agency.

NRS 695C.165        Eligibility for coverage: Organization prohibited from asserting certain grounds to deny enrollment of child pursuant to order if parent is enrolled in health care plan.

NRS 695C.167        Eligibility for coverage: Certain accommodations to be made when child is covered under health care plan of noncustodial parent.

NRS 695C.169        Eligibility for coverage: Organization to authorize enrollment of child of parent who is required by order to provide medical coverage under certain circumstances; termination of coverage of child.

COVERAGE GENERALLY

NRS 695C.1691      Required provision concerning coverage for continued medical care.

NRS 695C.1693      Required provision concerning coverage for treatment received as part of clinical trial or study. [Effective through December 31, 2013.]

NRS 695C.1693      Required provision concerning coverage for treatment received as part of clinical trial or study. [Effective January 1, 2014.]

NRS 695C.1694      Required provision concerning coverage of drug or device for contraception and of hormone replacement therapy in certain circumstances; prohibited actions by health maintenance organization; exceptions.

NRS 695C.1695      Required provision concerning coverage of health care services related to contraceptives and hormone replacement therapy in certain circumstances; prohibited actions by health maintenance organization; exceptions.

NRS 695C.170        Evidence of coverage: Issuance; form and contents.

NRS 695C.1703      Coverage for prescription drugs: Provision of notice and information regarding use of formulary.

NRS 695C.1705      Group health care plan issued to replace discontinued policy or coverage: Requirements; notice of reduction of benefits; statement of benefits; applicability to self-insured employer. [Effective through December 31, 2013.]

NRS 695C.1705      Group health care plan issued to replace discontinued policy or coverage: Requirements; notice of reduction of benefits; statement of benefits; applicability to self-insured employer. [Effective January 1, 2014.]

NRS 695C.1707      Required provision for continuation of coverage. [Effective through December 31, 2013.]

NRS 695C.1709      Required provision concerning coverage for enrollee on leave without pay as result of total disability.

NRS 695C.171        Required provision concerning coverage relating to mastectomy.

NRS 695C.1713      Required provision concerning coverage of certain gynecological and obstetrical services without authorization or referral from primary care physician.

NRS 695C.1717      Required provision concerning coverage for autism spectrum disorders.

NRS 695C.172        Required provision concerning coverage relating to complications of pregnancy. [Effective through December 31, 2013.]

NRS 695C.172        Required provision concerning coverage relating to complications of pregnancy. [Effective January 1, 2014.]

NRS 695C.1723      Required provision concerning coverage for treatment of certain inherited metabolic diseases.

NRS 695C.1727      Required provision concerning coverage for management and treatment of diabetes. [Effective through December 31, 2013.]

NRS 695C.1727      Required provision concerning coverage for management and treatment of diabetes. [Effective January 1, 2014.]

NRS 695C.173        Required provision concerning coverage for newly born and adopted children and children placed for adoption.

NRS 695C.1731      Required provision concerning coverage for screening for colorectal cancer.

NRS 695C.1733      Required provision concerning coverage for certain drugs for treatment of cancer.

NRS 695C.17335    Required provision concerning coverage for orally administered chemotherapy.

NRS 695C.1734      Required provision concerning coverage for prescription drug previously approved for medical condition of enrollee.

NRS 695C.1735      Required provision concerning coverage for cytologic screening tests and mammograms for certain women.

NRS 695C.1745      Required provision concerning coverage for human papillomavirus vaccine. [Effective through December 31, 2013.]

NRS 695C.1745      Required provision concerning coverage for human papillomavirus vaccine. [Effective January 1, 2014.]

NRS 695C.1751      Required provision concerning coverage for prostate cancer screening.

NRS 695C.1755      Required provision concerning coverage for treatment of temporomandibular joint.

NRS 695C.176        Required provision concerning coverage for hospice care.

REIMBURSEMENT

NRS 695C.1765      Reimbursement for acupuncture.

NRS 695C.177        Reimbursement for treatments by licensed psychologist.

NRS 695C.1773      Reimbursement for treatment by licensed marriage and family therapist or licensed clinical professional counselor.

NRS 695C.1775      Reimbursement for treatment by licensed associate in social work, social worker, independent social worker or clinical social worker.

NRS 695C.178        Reimbursement for treatment by chiropractor.

NRS 695C.1783      Reimbursement for treatment by podiatrist.

NRS 695C.1789      Reimbursement for treatment by licensed clinical alcohol and drug abuse counselor.

NRS 695C.179        Reimbursement for services provided by certain nurses; prohibited limitations; exceptions.

NRS 695C.1795      Reimbursement to provider of medical transportation.

MISCELLANEOUS PROVISIONS

NRS 695C.180        Schedule of charges. [Effective through December 31, 2013.]

NRS 695C.185        Approval or denial of claims; payment of claims and interest; requests for additional information; award of costs and attorney’s fees; compliance with requirements.

NRS 695C.187        Schedule for payment of claims: Mandatory inclusion in arrangements for provision of health care.

NRS 695C.190        Commissioner may require submission of information.

NRS 695C.193        Summary of coverage: Contents of disclosure; approval by Commissioner; regulations. [Effective through December 31, 2013.]

NRS 695C.195        Summary of coverage: Copy to be provided before policy issued; policy not to be offered unless summary approved by Commissioner. [Effective through December 31, 2013.]

NRS 695C.200        Approval of forms and schedules. [Effective through December 31, 2013.]

NRS 695C.200        Approval of forms and schedules. [Effective January 1, 2014.]

NRS 695C.201        Offering policy of health insurance for purposes of establishing health savings account.

NRS 695C.203        Denying coverage solely because person was victim of domestic violence prohibited.

NRS 695C.205        Denying coverage solely because insured was intoxicated or under the influence of controlled substance prohibited; exceptions.

NRS 695C.207        Requiring or using information concerning genetic testing.

NRS 695C.210        Annual report and financial statement required; administrative penalty for failure to file report or statement. [Effective through December 31, 2013.]

NRS 695C.210        Annual report and financial statement required; administrative penalty for failure to file report or statement. [Effective January 1, 2014.]

NRS 695C.220        Applications, filings and reports open to public inspection.

NRS 695C.230        Fees.

NRS 695C.240        Information required to be available for inspection.

NRS 695C.250        Open enrollment. [Effective through December 31, 2013.]

NRS 695C.260        Complaint system.

NRS 695C.265        Required procedure for arbitration of disputes concerning independent medical evaluations.

NRS 695C.267        Provision requiring binding arbitration authorized; procedures for arbitration; declaratory relief.

NRS 695C.270        Bond required; waiver.

NRS 695C.275        Commissioner to adopt regulations for licensing of provider-sponsored organizations.

NRS 695C.280        Commissioner authorized to adopt regulations for licensing of agents or brokers.

NRS 695C.290        Insurance company may establish or contract with health maintenance organization.

NRS 695C.300        Prohibited practices.

NRS 695C.310        Examinations. [Effective through December 31, 2013.]

NRS 695C.310        Examinations. [Effective January 1, 2014.]

NRS 695C.311        Periodic examination by Commissioner to determine financial condition of health maintenance organization.

NRS 695C.313        Financial examination: Procedure; appointment of examiner; maintenance and use of records; penalty for obstruction or interference.

NRS 695C.315        Financial examination: Payment of expense.

NRS 695C.317        Statutory procedures required for examination and hearing.

NRS 695C.320        Rehabilitation, liquidation or conservation.

NRS 695C.325        Authorization to offer health care plan to small employer for purpose of establishing medical savings accounts.

NRS 695C.330        Disciplinary proceedings: Grounds; effect of suspension or revocation. [Effective through December 31, 2013.]

NRS 695C.330        Disciplinary proceedings: Grounds; effect of suspension or revocation. [Effective January 1, 2014.]

NRS 695C.340        Disciplinary proceedings: Notice; hearing; judicial review. [Effective through December 31, 2013.]

NRS 695C.340        Disciplinary proceedings: Notice; hearing; judicial review. [Effective January 1, 2014.]

NRS 695C.350        Violations: Remedies; penalties. [Effective through December 31, 2013.]

NRS 695C.350        Violations: Remedies; penalties. [Effective January 1, 2014.]

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GENERAL PROVISIONS

      NRS 695C.010  Short title.  This chapter may be cited as the Nevada Health Maintenance Organization Act.

      (Added to NRS by 1973, 1246)

      NRS 695C.020  Legislative declaration.  The Legislature hereby declares that the rising cost of health services in recent years has led government agencies, private organizations, and legislative bodies to seek alternatives to the traditional medical delivery system which would provide improved health care and would provide such health care at a lower cost. The health maintenance organization is a concept which has received much attention as one means through which an improvement in delivery might be achieved. The Legislature therefore enacts this chapter to carry out this objective.

      (Added to NRS by 1973, 1246)

      NRS 695C.030  Definitions.  As used in this chapter, unless the context otherwise requires:

      1.  “Comprehensive health care services” means medical services, dentistry, drugs, psychiatric and optometric and all other care necessary for the delivery of services to the consumer.

      2.  “Enrollee” means a natural person who has been voluntarily enrolled in a health care plan.

      3.  “Evidence of coverage” means any certificate, agreement or contract issued to an enrollee setting forth the coverage to which the enrollee is entitled.

      4.  “Health care plan” means any arrangement whereby any person undertakes to provide, arrange for, pay for or reimburse any part of the cost of any health care services and at least part of the arrangement consists of arranging for or the provision of health care services paid for by or on behalf of the enrollee on a periodic prepaid basis.

      5.  “Health care services” means any services included in the furnishing to any natural person of medical or dental care or hospitalization or incident to the furnishing of such care or hospitalization, as well as the furnishing to any person of any other services for the purpose of preventing, alleviating, curing or healing human illness or injury.

      6.  “Health maintenance organization” means any person which provides or arranges for provision of a health care service or services and is responsible for the availability and accessibility of such service or services to its enrollees, which services are paid for or on behalf of the enrollees on a periodic prepaid basis without regard to the dates health services are rendered and without regard to the extent of services actually furnished to the enrollees, except that supplementing the fixed prepayments by nominal additional payments for services in accordance with regulations adopted by the Commissioner shall not be deemed to render the arrangement not to be on a prepaid basis. A health maintenance organization, in addition to offering health care services, may offer indemnity or service benefits provided through insurers or otherwise.

      7.  “Provider” means any physician, hospital or other person who is licensed or otherwise authorized in this state to furnish health care services.

      (Added to NRS by 1973, 1246; A 1985, 538; 1997, 1629)

      NRS 695C.050  Applicability of certain provisions. [Effective through December 31, 2013.]

      1.  Except as otherwise provided in this chapter or in specific provisions of this title, the provisions of this title are not applicable to any health maintenance organization granted a certificate of authority under this chapter. This provision does not apply to an insurer licensed and regulated pursuant to this title except with respect to its activities as a health maintenance organization authorized and regulated pursuant to this chapter.

      2.  Solicitation of enrollees by a health maintenance organization granted 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.  Any health maintenance organization authorized under this chapter shall not be deemed to be practicing medicine and is exempt from the provisions of chapter 630 of NRS.

      4.  The provisions of NRS 695C.110, 695C.125, 695C.1691, 695C.1693, 695C.170 to 695C.173, inclusive, 695C.1733 to 695C.200, inclusive, 695C.250 and 695C.265 do not apply to a health maintenance organization that provides health care services through managed care to recipients of Medicaid under the State Plan for Medicaid or insurance pursuant to the Children’s Health Insurance Program pursuant to a contract with the Division of Health Care Financing and Policy of the Department of Health and Human Services. This subsection does not exempt a health maintenance organization from any provision of this chapter for services provided pursuant to any other contract.

      5.  The provisions of NRS 695C.1694, 695C.1695 and 695C.1731 apply to a health maintenance organization that provides health care services through managed care to recipients of Medicaid under the State Plan for Medicaid.

      (Added to NRS by 1973, 1258; A 1983, 2030; 1995, 2720; 1997, 311, 1528; 1999, 418, 420, 1945, 2004, 2241; 2001, 141, 144, 864, 2734; 2003, 1335, 3366, 3531; 2007, 3240; 2009, 1473; 2013, 1999)

      NRS 695C.050  Applicability of certain provisions. [Effective January 1, 2014.]

      1.  Except as otherwise provided in this chapter or in specific provisions of this title, the provisions of this title are not applicable to any health maintenance organization granted a certificate of authority under this chapter. This provision does not apply to an insurer licensed and regulated pursuant to this title except with respect to its activities as a health maintenance organization authorized and regulated pursuant to this chapter.

      2.  Solicitation of enrollees by a health maintenance organization granted 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.  Any health maintenance organization authorized under this chapter shall not be deemed to be practicing medicine and is exempt from the provisions of chapter 630 of NRS.

      4.  The provisions of NRS 695C.110, 695C.125, 695C.1691, 695C.1693, 695C.170 to 695C.173, inclusive, 695C.1733 to 695C.200, inclusive, and 695C.265 do not apply to a health maintenance organization that provides health care services through managed care to recipients of Medicaid under the State Plan for Medicaid or insurance pursuant to the Children’s Health Insurance Program pursuant to a contract with the Division of Health Care Financing and Policy of the Department of Health and Human Services. This subsection does not exempt a health maintenance organization from any provision of this chapter for services provided pursuant to any other contract.

      5.  The provisions of NRS 695C.1694, 695C.1695 and 695C.1731 apply to a health maintenance organization that provides health care services through managed care to recipients of Medicaid under the State Plan for Medicaid.

      (Added to NRS by 1973, 1258; A 1983, 2030; 1995, 2720; 1997, 311, 1528; 1999, 418, 420, 1945, 2004, 2241; 2001, 141, 144, 864, 2734; 2003, 1335, 3366, 3531; 2007, 3240; 2009, 1473; 2013, 1999, 3638, effective January 1, 2014)

      NRS 695C.055  Applicability of certain other provisions. [Effective through December 31, 2013.]

      1.  The provisions of NRS 449.465, 679A.200, 679B.700, subsections 2, 4, 18, 19 and 32 of NRS 680B.010, NRS 680B.020 to 680B.060, inclusive, and chapters 686A and 695G of NRS apply to a health maintenance 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 “health maintenance organization.”

      (Added to NRS by 1987, 469; A 1995, 472, 988; 1997, 299, 311, 2958, 2962; 2001, 2735; 2003, 3333, 3367; 2013, 3458)

      NRS 695C.055  Applicability of certain other provisions. [Effective January 1, 2014.]

      1.  The provisions of NRS 449.465, 679A.200, 679B.700, subsections 2, 4, 18, 19 and 32 of NRS 680B.010, NRS 680B.020 to 680B.060, inclusive, chapter 686A of NRS, NRS 687B.500 and chapter 695G of NRS apply to a health maintenance 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 “health maintenance organization.”

      (Added to NRS by 1987, 469; A 1995, 472, 988; 1997, 299, 311, 2958, 2962; 2001, 2735; 2003, 3333, 3367; 2013, 3458, 3639, effective January 1, 2014)

      NRS 695C.057  Applicability of certain provisions concerning portability and availability of health insurance. [Effective through December 31, 2013.]

      1.  A health maintenance organization is subject to the provisions of NRS 689B.340 to 689B.590, inclusive, and chapter 689C of NRS relating to the portability and availability of health insurance offered by such organizations. If there is a conflict between the provisions of this chapter and the provisions of NRS 689B.340 to 689B.590, inclusive, and chapter 689C of NRS, the provisions of NRS 689B.340 to 689B.590, inclusive, and chapter 689C of NRS control.

      2.  For the purposes of subsection 1, unless the context requires that a provision apply only to a group health plan or a carrier that provides coverage under a group health plan, any reference in those sections to “group health plan” or “carrier” must be replaced by “health maintenance organization.”

      (Added to NRS by 1997, 2957)

      NRS 695C.057  Applicability of certain provisions concerning portability and availability of health insurance. [Effective January 1, 2014.]

      1.  A health maintenance organization is subject to the provisions of NRS 689B.340 to 689B.580, inclusive, and chapter 689C of NRS relating to the portability and availability of health insurance offered by such organizations. If there is a conflict between the provisions of this chapter and the provisions of NRS 689B.340 to 689B.580, inclusive, and chapter 689C of NRS, the provisions of NRS 689B.340 to 689B.580, inclusive, and chapter 689C of NRS control.

      2.  For the purposes of subsection 1, unless the context requires that a provision apply only to a group health plan or a carrier that provides coverage under a group health plan, any reference in those sections to “group health plan” or “carrier” must be replaced by “health maintenance organization.”

      (Added to NRS by 1997, 2957; A 2013, 3639, effective January 1, 2014)

      NRS 695C.060  Establishment of organization.

      1.  Any person may apply to the Commissioner for and obtain a certificate of authority to establish and operate a health maintenance organization in compliance with this chapter. No person shall operate a health maintenance organization without obtaining a certificate of authority under this chapter. A foreign corporation may qualify under this chapter, subject to its qualification to do business in this state as a foreign corporation.

      2.  No person shall be certified to establish or operate a health maintenance organization in this state, nor sell or offer to sell, or solicit offers to purchase or receive advance or periodic consideration in conjunction with health care plans unless such health maintenance organization provides or arranges for the provision of comprehensive health care services.

      3.  Every health maintenance organization or person operating a health maintenance organization shall submit an application for a certificate of authority under NRS 695C.070 within 30 days after July 1, 1973. Each such applicant may continue to operate until the Commissioner acts upon the application. In the event that an application is denied under NRS 695C.090 and 695C.100, the applicant shall thereafter be treated as a health maintenance organization whose certificate of authority has been revoked. For purposes of this subsection, a health maintenance organization shall be deemed to be in operation only if health care services are being provided to the public generally or to some group or groups thereof.

      (Added to NRS by 1973, 1247)

      NRS 695C.070  Certificate of authority: Application.  Each 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 a similar document, 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 will 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 health maintenance organization, its health care plan or plans, 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.  A copy of the form of evidence of coverage to be issued to the enrollees;

      7.  A copy of the form of the group contract, if any, which is to be issued to employers, unions, trustees or other organizations;

      8.  Certified financial statements showing the applicant’s assets, liabilities and sources of financial support;

      9.  The proposed method of marketing the plan, a financial plan which includes a 3-year projection of the initial operating results anticipated and the sources of working capital and any other sources of funding;

      10.  A power of attorney, executed by the applicant, appointing the Commissioner and the authorized deputies of the Commissioner 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 health maintenance organization on a cause of action arising in this State may be served;

      11.  A statement reasonably describing the geographic area to be served;

      12.  A description of the procedures for resolving complaints and procedures for external reviews to be used as required under NRS 695C.260;

      13.  A description of the procedures and programs to be implemented to meet the quality of health care requirements in NRS 695C.080;

      14.  A description of the mechanism by which enrollees will be afforded an opportunity to participate in matters of program content under subsection 2 of NRS 695C.110; and

      15.  Such other information as the Commissioner may require to make the determinations required in NRS 695C.080.

      (Added to NRS by 1973, 1247; A 2003, 777)

      NRS 695C.080  Certificate of authority: Evaluation of application. [Effective through December 31, 2013.]

      1.  Upon receipt of an application for issuance of a certificate of authority, the Commissioner shall forthwith transmit copies of such application and accompanying documents to the State Board of Health.

      2.  The State Board of Health shall determine whether the applicant for a certificate of authority, with respect to health care services to be furnished:

      (a) Has demonstrated the willingness and ability to ensure that such health care services will be provided in a manner to ensure both availability and accessibility of adequate personnel and facilities and in a manner enhancing availability, accessibility and continuity of service;

      (b) Has organizational arrangements, established in accordance with regulations promulgated by the State Board of Health; and

      (c) Has a procedure established in accordance with regulations of the State Board of Health to develop, compile, evaluate and report statistics relating to the cost of its operations, the pattern of utilization of its services, the availability and accessibility of its services and such other matters as may be reasonably required by the State Board of Health.

      3.  Within 90 days of receipt of the application for issuance of a certificate of authority, the State Board of Health shall certify to the Commissioner whether the proposed health maintenance organization meets the requirements of subsection 2. If the State Board of Health certifies that the health maintenance organization does not meet such requirements, it shall specify in what respects it is deficient.

      (Added to NRS by 1973, 1249)

      NRS 695C.080  Certificate of authority: Evaluation of application. [Effective January 1, 2014.]

      1.  The Commissioner shall determine whether the applicant for a certificate of authority, with respect to health care services to be furnished:

      (a) Has demonstrated the willingness and ability to ensure that such health care services will be provided in a manner to ensure both availability and accessibility of adequate personnel and facilities and in a manner enhancing availability, accessibility and continuity of service;

      (b) Has organizational arrangements, established in accordance with regulations promulgated by the Commissioner and in consultation with the State Board of Health; and

      (c) Has a procedure established in accordance with regulations of the Commissioner to develop, compile, evaluate and report statistics relating to the cost of its operations, the pattern of utilization of its services, the availability and accessibility of its services and such other matters as may be reasonably required by the Commissioner.

      2.  Within 90 days of receipt of the application for issuance of a certificate of authority, the Commissioner shall certify whether the proposed health maintenance organization meets the requirements of subsection 1. If the Commissioner certifies that the health maintenance organization does not meet such requirements, it shall specify in what respects it is deficient.

      (Added to NRS by 1973, 1249; A 2013, 3639, effective January 1, 2014)

      NRS 695C.090  Certificate of authority: Issuance. [Effective through December 31, 2013.]  The Commissioner shall issue or deny a certificate of authority to any person filing an application pursuant to NRS 695C.060 within 90 days of receipt of the certification from the State Board of Health. Issuance of a certificate of authority must be granted upon payment of the fees prescribed in NRS 695C.230 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 State Board of Health certifies, in accordance with NRS 695C.080, that the health maintenance organization’s proposed plan of operation meets the requirements of subsection 2 of NRS 695C.080.

      3.  The health care plan furnishes comprehensive health care services.

      4.  The health maintenance 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 health care plan’s arrangements 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 submitted in accordance with NRS 695C.270 as a guarantee that the obligations will be duly performed.

      5.  The enrollees will be afforded an opportunity to participate in matters of program content pursuant to NRS 695C.110.

      6.  Nothing in the proposed method of operation, as shown by the information submitted pursuant to NRS 695C.060, 695C.070 and 695C.140, or by independent investigation is contrary to the public interest.

      (Added to NRS by 1973, 1249; A 1987, 469; 1993, 2400)

      NRS 695C.090  Certificate of authority: Issuance. [Effective January 1, 2014.]  The Commissioner shall issue or deny a certificate of authority to any person filing an application pursuant to NRS 695C.060 within 90 days after certification. Issuance of a certificate of authority must be granted upon payment of the fees prescribed in NRS 695C.230 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 Commissioner certifies, in accordance with NRS 695C.080, that the health maintenance organization’s proposed plan of operation meets the requirements of subsection 1 of NRS 695C.080.

      3.  The health care plan furnishes comprehensive health care services.

      4.  The health maintenance 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 health care plan’s arrangements 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 submitted in accordance with NRS 695C.270 as a guarantee that the obligations will be duly performed.

      5.  The enrollees will be afforded an opportunity to participate in matters of program content pursuant to NRS 695C.110.

      6.  Nothing in the proposed method of operation, as shown by the information submitted pursuant to NRS 695C.060, 695C.070 and 695C.140, or by independent investigation is contrary to the public interest.

      (Added to NRS by 1973, 1249; A 1987, 469; 1993, 2400; 2013, 3640, effective January 1, 2014)

      NRS 695C.100  Certificate of authority: Denial.  A certificate of authority shall be denied only after compliance with the requirements of NRS 695C.340.

      (Added to NRS by 1973, 1250)

      NRS 695C.110  Governing body: Composition; participation by enrollees.

      1.  The governing body of any health maintenance organization may include providers, other individuals or both.

      2.  Such governing body shall establish a mechanism to afford the enrollees an opportunity to participate in matters of program content through the establishment of advisory panels, by the use of advisory referenda on major policy decisions or through the use of other mechanisms. In addition there shall be a provider advisory board to advise the health plan in the matter of quality of care. There shall be a joint board of consumers and providers to advise on consumer satisfaction.

      (Added to NRS by 1973, 1250)

      NRS 695C.120  Powers of organization.  The powers of a health maintenance organization include, but are not limited to, the following:

      1.  The purchase, lease, construction, renovation, operation or maintenance of hospitals, medical facilities, or both, and their ancillary equipment, and such property as may reasonably be required for its principal office or for such other purposes as may be necessary in the transaction of the business of the organization;

      2.  The making of loans to a medical group under contract with it in furtherance of its program or the making of loans to a corporation under its control for the purpose of acquiring or constructing medical facilities and hospitals or in furtherance of a program providing health care services to enrollees;

      3.  The furnishing of health care service through providers which are under contract with or employed by the health maintenance organization;

      4.  The contracting with any person for the performance on its behalf of certain functions such as marketing, enrollment and administration; and

      5.  The contracting with an insurance company licensed in this state or authorized to do business in this state for the provision of such insurance, indemnity, or reimbursement against the cost of health care services provided by the health maintenance organization.

      (Added to NRS by 1973, 1250; A 1995, 2166; 1999, 1834)

      NRS 695C.123  Contracts with certain federally qualified health centers.

      1.  Except as otherwise provided in NRS 422.273, a health maintenance organization that furnishes health care services through providers which are under contract with the organization shall use its best efforts to contract with at least one health center in each geographic area served by the organization to provide such services to enrollees if the health center:

      (a) Meets all conditions imposed by the organization on similarly situated providers of health care that are under contract with the organization, including, without limitation:

             (1) Certification for participation in the Medicaid or Medicare program; and

             (2) Requirements relating to the appropriate credentials for providers of health care; and

      (b) Agrees to reasonable reimbursement rates that are generally consistent with those offered by the organization to similarly situated providers of health care that are under contract with the organization.

      2.  As used in this section, “health center” has the meaning ascribed to it in 42 U.S.C. § 254b.

      (Added to NRS by 2001, 1924)

      NRS 695C.125  Contract between health maintenance organization and provider of health care: Form to obtain information on provider of health care; modification; provision of schedule of fees.

      1.  A health maintenance organization shall not contract with a provider of health care to provide health care to an insured unless the health maintenance organization uses the form prescribed by the Commissioner pursuant to NRS 629.095 to obtain any information related to the credentials of the provider of health care.

      2.  A contract between a health maintenance organization and a provider of health care may be modified:

      (a) At any time pursuant to a written agreement executed by both parties.

      (b) Except as otherwise provided in this paragraph, by the health maintenance organization upon giving to the provider 45 days’ written notice of the modification of the health maintenance organization’s schedule of payments, including any changes to the fee schedule applicable to the provider’s practice. If the provider fails to object in writing to the modification within the 45-day period, the modification becomes effective at the end of that period. If the provider objects in writing to the modification within the 45-day period, the modification must not become effective unless agreed to by both parties as described in paragraph (a).

      3.  If a health maintenance organization contracts with a provider of health care to provide health care to an enrollee, the health maintenance organization shall:

      (a) If requested by the provider of health care at the time the contract is made, submit to the provider of health care the schedule of payments applicable to the provider of health care; or

      (b) If requested by the provider of health care at any other time, submit to the provider of health care the schedule of payments, including any changes to the fee schedule applicable to the provider’s practice, specified in paragraph (a) within 7 days after receiving the request.

      4.  As used in this section, “provider of health care” means a provider of health care who is licensed pursuant to chapter 630, 631, 632 or 633 of NRS.

      (Added to NRS by 1999, 1651; A 2001, 2735; 2003, 3367; 2011, 2535)

      NRS 695C.128  Contracts to provide services pursuant to certain state programs: Payment of interest on claims.  Any contract or other agreement entered into or renewed by a health maintenance organization on or after October 1, 2001:

      1.  To provide health care services through managed care to recipients of Medicaid under the state plan for Medicaid; or

      2.  With the Division of Health Care Financing and Policy of the Department of Health and Human Services to provide insurance pursuant to the Children’s Health Insurance Program,

Ê must require the health maintenance organization to pay interest to a provider of health care services on a claim that is not paid within the time provided in the contract or agreement at a rate of interest equal to the prime rate at the largest bank in Nevada, as ascertained by the Commissioner of Financial Institutions, on January 1 or July 1, as the case may be, immediately preceding the date on which the payment was due, plus 6 percent. The interest must be calculated from 30 days after the date on which the claim is approved until the date on which the claim is paid.

      (Added to NRS by 2001, 2734)

      NRS 695C.130  Notice and approval required for exercise of powers; rules or regulations.

      1.  A health maintenance organization shall file notice, with adequate supporting information, with the Commissioner prior to the exercise of any power granted in subsections 1 and 2 of NRS 695C.120. The Commissioner shall disapprove such exercise of power if in the opinion of the Commissioner it would substantially and adversely affect the financial soundness of the health maintenance organization and endanger its ability to meet its obligations. If the Commissioner does not disapprove within 60 days of the filing, it is deemed approved.

      2.  The Commissioner may promulgate rules or regulations.

      (Added to NRS by 1973, 1250)

      NRS 695C.140  Notice and approval required for modification of operations; regulations. [Effective through December 31, 2013.]

      1.  A health maintenance organization shall, unless otherwise provided for in this chapter, file notice with the Commissioner and the State Board of Health before any material modification of the operations described in the information required by NRS 695C.070. If the Commissioner does not disapprove within 90 days after filing of the notice, the modification is deemed approved.

      2.  The Commissioner may adopt regulations to carry out the provisions of this section.

      (Added to NRS by 1973, 1248; A 1995, 1632)

      NRS 695C.140  Notice and approval required for modification of operations; regulations. [Effective January 1, 2014.]

      1.  A health maintenance organization shall, unless otherwise provided for in this chapter, file notice with the Commissioner before any material modification of the operations described in the information required by NRS 695C.070. If the Commissioner does not disapprove within 90 days after filing of the notice, the modification is deemed approved.

      2.  The Commissioner may adopt regulations to carry out the provisions of this section.

      (Added to NRS by 1973, 1248; A 1995, 1632; 2013, 3640, effective January 1, 2014)

      NRS 695C.145  Accounting principles required for certain reports and transactions; health maintenance organization subject to requirements for certain insurers.

      1.  A health maintenance organization shall use accounting principles that are recognized by the laws of this state or approved by the Commissioner for:

      (a) All financial reports;

      (b) The accounting of investments and deposits; and

      (c) Transactions between affiliates and holding companies.

      2.  A health maintenance organization is subject to the requirements for insurers for:

      (a) Administrators, agents, brokers and solicitors, pursuant to chapter 683A of NRS;

      (b) Borrowing, pursuant to NRS 693A.180;

      (c) Impairment of capital, surplus or assets, pursuant to NRS 693A.260, 693A.270 and 693A.280;

      (d) Management and agency contracts executed on or after January 1, 1992; and

      (e) Officers, pursuant to NRS 693A.120 and 693A.130.

      3.  A domestic health maintenance organization is subject to the requirements for insurers for corporations pursuant to NRS 693A.040 to 693A.070, inclusive.

      (Added to NRS by 1991, 2036)

      NRS 695C.150  Fiduciary responsibilities.  Any director, officer, partner, member or employee of a health maintenance organization who receives, collects, disburses or invests funds in connection with the activities of such organization shall be responsible for such funds in a fiduciary relationship to the enrollees.

      (Added to NRS by 1973, 1250)

      NRS 695C.160  Investments.  With the exception of investments made in accordance with subsections 1 and 2 of NRS 695C.120 and NRS 695C.130, the investable funds of a health maintenance organization shall be invested only in securities or other investments permitted by the laws of this state for the investment of assets constituting the legal reserves of life insurance companies or such other securities or investments as the Commissioner may permit.

      (Added to NRS by 1973, 1253)

ELIGIBILITY FOR COVERAGE

      NRS 695C.161  Eligibility for coverage: Definitions.  As used in NRS 695C.161 to 695C.169, inclusive, unless the context otherwise requires:

      1.  “Medicaid” means a program established in any state pursuant to Title XIX of the Social Security Act (42 U.S.C. §§ 1396 et seq.) to provide assistance for part or all of the cost of medical care rendered on behalf of indigent persons.

      2.  “Order for medical coverage” means an order of a court or administrative tribunal to provide coverage under a health care plan to a child pursuant to the provisions of 42 U.S.C. § 1396g-1.

      (Added to NRS by 1995, 2435)

      NRS 695C.163  Eligibility for coverage: Effect of eligibility for medical assistance under Medicaid; assignment of rights to state agency.

      1.  A health maintenance organization shall not, when considering eligibility for coverage or making payments under a health care plan, consider the availability of, or eligibility of a person for, medical assistance under Medicaid.

      2.  To the extent that payment has been made by Medicaid for health care, a health maintenance organization:

      (a) Shall treat Medicaid as having a valid and enforceable assignment of benefits due an enrollee or claimant under the enrollee regardless of any exclusion of Medicaid or the absence of a written assignment; and

      (b) May, as otherwise allowed by its plan, evidence of coverage or contract and applicable law or regulation concerning subrogation, seek to enforce any rights of a recipient of Medicaid to reimbursement against any other liable party if:

             (1) It is so authorized pursuant to a contract with Medicaid for managed care; or

             (2) It has reimbursed Medicaid in full for the health care provided by Medicaid to its enrollee.

      3.  If a state agency is assigned any rights of a person who is:

      (a) Eligible for medical assistance under Medicaid; and

      (b) Covered by a health care plan,

Ê the organization responsible for the health care plan shall not impose any requirements upon the state agency except requirements it imposes upon the agents or assignees of other persons covered by the same plan.

      4.  If a state agency is assigned any rights of an enrollee who is eligible for medical assistance under Medicaid, a health maintenance organization shall:

      (a) Upon request of the state agency, provide to the state agency information regarding the enrollee to determine:

             (1) Any period during which the enrollee, the spouse or a dependent of the enrollee may be or may have been covered by the health care plan; and

             (2) The nature of the coverage that is or was provided by the organization, including, without limitation, the name and address of the enrollee and the identifying number of the health care plan;

      (b) Respond to any inquiry by the state agency regarding a claim for payment for the provision of any medical item or service not later than 3 years after the date of the provision of the medical item or service; and

      (c) Agree not to deny a claim submitted by the state agency solely on the basis of the date of submission of the claim, the type or format of the claim form or failure to present proper documentation at the point of sale that is the basis for the claim if:

             (1) The claim is submitted by the state agency not later than 3 years after the date of the provision of the medical item or service; and

             (2) Any action by the state agency to enforce its rights with respect to such claim is commenced not later than 6 years after the submission of the claim.

      (Added to NRS by 1995, 2435; A 2007, 2406)

      NRS 695C.165  Eligibility for coverage: Organization prohibited from asserting certain grounds to deny enrollment of child pursuant to order if parent is enrolled in health care plan.  An organization shall not deny the enrollment of a child pursuant to an order for medical coverage under a health care plan in which a parent of the child is enrolled, on the ground that the child:

      1.  Was born out of wedlock;

      2.  Has not been claimed as a dependent on the parent’s federal income tax return; or

      3.  Does not reside with the parent or within the organization’s geographic area of service.

      (Added to NRS by 1995, 2436)

      NRS 695C.167  Eligibility for coverage: Certain accommodations to be made when child is covered under health care plan of noncustodial parent.  If a child has coverage under a health care plan in which a noncustodial parent of the child is enrolled, the organization responsible for that plan shall:

      1.  Provide to the custodial parent such information as necessary for the child to obtain any benefits under that coverage.

      2.  Allow the custodial parent or, with the approval of the custodial parent, a provider to submit claims for covered services without the approval of the noncustodial parent.

      3.  Make payments on claims submitted pursuant to subsection 2 directly to the custodial parent, the provider or an agency of this or another state responsible for the administration of Medicaid.

      (Added to NRS by 1995, 2436)

      NRS 695C.169  Eligibility for coverage: Organization to authorize enrollment of child of parent who is required by order to provide medical coverage under certain circumstances; termination of coverage of child.  If a parent is required by an order for medical coverage to provide coverage for a child and the parent is eligible for coverage of members of the parent’s family under a health care plan, the organization responsible for that plan:

      1.  Shall, if the child is otherwise eligible for that coverage, allow the parent to enroll the child in that coverage without regard to any restrictions upon periods for enrollment.

      2.  Shall, if:

      (a) The child is otherwise eligible for that coverage; and

      (b) The parent is enrolled in that coverage but fails to apply for enrollment of the child,

Ê enroll the child in that coverage upon application by the other parent of the child, or by an agency of this or another state responsible for the administration of Medicaid or a state program for the enforcement of child support established pursuant to 42 U.S.C. §§ 651 et seq., without regard to any restrictions upon periods for enrollment.

      3.  Shall not terminate the enrollment of the child in that coverage or otherwise eliminate that coverage of the child unless the organization has written proof that:

      (a) The order for medical coverage is no longer in effect; or

      (b) The child is or will be enrolled in comparable coverage through another insurer on or before the effective date of the termination of enrollment or elimination of coverage.

      (Added to NRS by 1995, 2436)

COVERAGE GENERALLY

      NRS 695C.1691  Required provision concerning coverage for continued medical care.

      1.  The provisions of this section apply to a health care plan offered or issued by a health maintenance organization if an insured covered by the health care plan receives health care through a defined set of providers of health care who are under contract with the health maintenance organization.

      2.  Except as otherwise provided in this section, if an insured who is covered by a health care plan described in subsection 1 is receiving medical treatment for a medical condition from a provider of health care whose contract with the health maintenance organization is terminated during the course of the medical treatment, the health care plan must provide that:

      (a) The insured may continue to obtain medical treatment for the medical condition from the provider of health care pursuant to this section, if:

             (1) The insured is actively undergoing a medically necessary course of treatment; and

             (2) The provider of health care and the insured agree that the continuity of care is desirable.

      (b) The provider of health care is entitled to receive reimbursement from the health maintenance organization for the medical treatment the provider of health care provides to the insured pursuant to this section, if the provider of health care agrees:

             (1) To provide medical treatment under the terms of the contract between the provider of health care and the health maintenance organization with regard to the insured, including, without limitation, the rates of payment for providing medical service, as those terms existed before the termination of the contract between the provider of health care and the health maintenance organization; and

             (2) Not to seek payment from the insured for any medical service provided by the provider of health care that the provider of health care could not have received from the insured were the provider of health care still under contract with the health maintenance organization.

      3.  The coverage required by subsection 2 must be provided until the later of:

      (a) The 120th day after the date the contract is terminated; or

      (b) If the medical condition is pregnancy, the 45th day after:

             (1) The date of delivery; or

             (2) If the pregnancy does not end in delivery, the date of the end of the pregnancy.

      4.  The requirements of this section do not apply to a provider of health care if:

      (a) The provider of health care was under contract with the health maintenance organization and the health maintenance organization terminated that contract because of the medical incompetence or professional misconduct of the provider of health care; and

      (b) The health maintenance organization did not enter into another contract with the provider of health care after the contract was terminated pursuant to paragraph (a).

      5.  An evidence of coverage for a health care plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 2003, has the legal effect of including the coverage required by this section, and any provision of the evidence of coverage or renewal thereof that is in conflict with this section is void.

      6.  The Commissioner shall adopt regulations to carry out the provisions of this section.

      (Added to NRS by 2003, 3365)

      NRS 695C.1693  Required provision concerning coverage for treatment received as part of clinical trial or study. [Effective through December 31, 2013.]

      1.  Except as otherwise provided in NRS 695C.050, a health care plan issued by a health maintenance organization must provide coverage for medical treatment which an enrollee receives as part of a clinical trial or study if:

      (a) The medical treatment is provided in a Phase I, Phase II, Phase III or Phase IV study or clinical trial for the treatment of cancer or in a Phase II, Phase III or Phase IV study or clinical trial for the treatment of chronic fatigue syndrome;

      (b) The clinical trial or study is approved by:

             (1) An agency of the National Institutes of Health as set forth in 42 U.S.C. § 281(b);

             (2) A cooperative group;

             (3) The Food and Drug Administration as an application for a new investigational drug;

             (4) The United States Department of Veterans Affairs; or

             (5) The United States Department of Defense;

      (c) In the case of:

             (1) A Phase I clinical trial or study for the treatment of cancer, the medical treatment is provided at a facility authorized to conduct Phase I clinical trials or studies for the treatment of cancer; or

             (2) A Phase II, Phase III or Phase IV study or clinical trial for the treatment of cancer or chronic fatigue syndrome, the medical treatment is provided by a provider of health care and the facility and personnel for the clinical trial or study have the experience and training to provide the treatment in a capable manner;

      (d) There is no medical treatment available which is considered a more appropriate alternative medical treatment than the medical treatment provided in the clinical trial or study;

      (e) There is a reasonable expectation based on clinical data that the medical treatment provided in the clinical trial or study will be at least as effective as any other medical treatment;

      (f) The clinical trial or study is conducted in this State; and

      (g) The enrollee has signed, before participating in the clinical trial or study, a statement of consent indicating that the enrollee has been informed of, without limitation:

             (1) The procedure to be undertaken;

             (2) Alternative methods of treatment; and

             (3) The risks associated with participation in the clinical trial or study, including, without limitation, the general nature and extent of such risks.

      2.  Except as otherwise provided in subsection 3, the coverage for medical treatment required by this section is limited to:

      (a) Coverage for any drug or device that is approved for sale by the Food and Drug Administration without regard to whether the approved drug or device has been approved for use in the medical treatment of the enrollee.

      (b) The cost of any reasonably necessary health care services that are required as a result of the medical treatment provided in a Phase II, Phase III or Phase IV clinical trial or study or as a result of any complication arising out of the medical treatment provided in a Phase II, Phase III or Phase IV clinical trial or study, to the extent that such health care services would otherwise be covered under the health care plan.

      (c) The cost of any routine health care services that would otherwise be covered under the health care plan for an enrollee in a Phase I clinical trial or study.

      (d) The initial consultation to determine whether the enrollee is eligible to participate in the clinical trial or study.

      (e) Health care services required for the clinically appropriate monitoring of the enrollee during a Phase II, Phase III or Phase IV clinical trial or study.

      (f) Health care services which are required for the clinically appropriate monitoring of the enrollee during a Phase I clinical trial or study and which are not directly related to the clinical trial or study.

Ê Except as otherwise provided in NRS 695C.1691, the services provided pursuant to paragraphs (b), (c), (e) and (f) must be covered only if the services are provided by a provider with whom the health maintenance organization has contracted for such services. If the health maintenance organization has not contracted for the provision of such services, the health maintenance organization shall pay the provider the rate of reimbursement that is paid to other providers with whom the health maintenance organization has contracted for similar services and the provider shall accept that rate of reimbursement as payment in full.

      3.  Particular medical treatment described in subsection 2 and provided to an enrollee is not required to be covered pursuant to this section if that particular medical treatment is provided by the sponsor of the clinical trial or study free of charge to the enrollee.

      4.  The coverage for medical treatment required by this section does not include:

      (a) Any portion of the clinical trial or study that is customarily paid for by a government or a biotechnical, pharmaceutical or medical industry.

      (b) Coverage for a drug or device described in paragraph (a) of subsection 2 which is paid for by the manufacturer, distributor or provider of the drug or device.

      (c) Health care services that are specifically excluded from coverage under the enrollee’s health care plan, regardless of whether such services are provided under the clinical trial or study.

      (d) Health care services that are customarily provided by the sponsors of the clinical trial or study free of charge to the participants in the trial or study.

      (e) Extraneous expenses related to participation in the clinical trial or study including, without limitation, travel, housing and other expenses that a participant may incur.

      (f) Any expenses incurred by a person who accompanies the enrollee during the clinical trial or study.

      (g) Any item or service that is provided solely to satisfy a need or desire for data collection or analysis that is not directly related to the clinical management of the enrollee.

      (h) Any costs for the management of research relating to the clinical trial or study.

      5.  A health maintenance organization that delivers or issues for delivery a health care plan specified in subsection 1 may require copies of the approval or certification issued pursuant to paragraph (b) of subsection 1, the statement of consent signed by the enrollee, protocols for the clinical trial or study and any other materials related to the scope of the clinical trial or study relevant to the coverage of medical treatment pursuant to this section.

      6.  A health maintenance organization that delivers or issues for delivery a health care plan specified in subsection 1 shall:

      (a) Include in the disclosure required pursuant to NRS 695C.193 notice to each enrollee of the availability of the benefits required by this section.

      (b) Provide the coverage required by this section subject to the same deductible, copayment, coinsurance and other such conditions for coverage that are required under the plan.

      7.  A health care plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2006, has the legal effect of including the coverage required by this section, and any provision of the plan that conflicts with this section is void.

      8.  A health maintenance organization that delivers or issues for delivery a health care plan specified in subsection 1 is immune from liability for:

      (a) Any injury to an enrollee caused by:

             (1) Any medical treatment provided to the enrollee in connection with his or her participation in a clinical trial or study described in this section; or

             (2) An act or omission by a provider of health care who provides medical treatment or supervises the provision of medical treatment to the enrollee in connection with his or her participation in a clinical trial or study described in this section.

      (b) Any adverse or unanticipated outcome arising out of an enrollee’s participation in a clinical trial or study described in this section.

      9.  As used in this section:

      (a) “Cooperative group” means a network of facilities that collaborate on research projects and has established a peer review program approved by the National Institutes of Health. The term includes:

             (1) The Clinical Trials Cooperative Group Program; and

             (2) The Community Clinical Oncology Program.

      (b) “Facility authorized to conduct Phase I clinical trials or studies for the treatment of cancer” means a facility or an affiliate of a facility that:

             (1) Has in place a Phase I program which permits only selective participation in the program and which uses clear-cut criteria to determine eligibility for participation in the program;

             (2) Operates a protocol review and monitoring system which conforms to the standards set forth in the Policies and Guidelines Relating to the Cancer-Center Support Grant published by the Cancer Centers Branch of the National Cancer Institute;

             (3) Employs at least two researchers and at least one of those researchers receives funding from a federal grant;

             (4) Employs at least three clinical investigators who have experience working in Phase I clinical trials or studies conducted at a facility designated as a comprehensive cancer center by the National Cancer Institute;

             (5) Possesses specialized resources for use in Phase I clinical trials or studies, including, without limitation, equipment that facilitates research and analysis in proteomics, genomics and pharmacokinetics;

             (6) Is capable of gathering, maintaining and reporting electronic data; and

             (7) Is capable of responding to audits instituted by federal and state agencies.

      (c) “Provider of health care” means:

             (1) A hospital; or

             (2) A person licensed pursuant to chapter 630, 631 or 633 of NRS.

      (Added to NRS by 2003, 3528; A 2005, 2018)

      NRS 695C.1693  Required provision concerning coverage for treatment received as part of clinical trial or study. [Effective January 1, 2014.]

      1.  Except as otherwise provided in NRS 695C.050, a health care plan issued by a health maintenance organization must provide coverage for medical treatment which an enrollee receives as part of a clinical trial or study if:

      (a) The medical treatment is provided in a Phase I, Phase II, Phase III or Phase IV study or clinical trial for the treatment of cancer or in a Phase II, Phase III or Phase IV study or clinical trial for the treatment of chronic fatigue syndrome;

      (b) The clinical trial or study is approved by:

             (1) An agency of the National Institutes of Health as set forth in 42 U.S.C. § 281(b);

             (2) A cooperative group;

             (3) The Food and Drug Administration as an application for a new investigational drug;

             (4) The United States Department of Veterans Affairs; or

             (5) The United States Department of Defense;

      (c) In the case of:

             (1) A Phase I clinical trial or study for the treatment of cancer, the medical treatment is provided at a facility authorized to conduct Phase I clinical trials or studies for the treatment of cancer; or

             (2) A Phase II, Phase III or Phase IV study or clinical trial for the treatment of cancer or chronic fatigue syndrome, the medical treatment is provided by a provider of health care and the facility and personnel for the clinical trial or study have the experience and training to provide the treatment in a capable manner;

      (d) There is no medical treatment available which is considered a more appropriate alternative medical treatment than the medical treatment provided in the clinical trial or study;

      (e) There is a reasonable expectation based on clinical data that the medical treatment provided in the clinical trial or study will be at least as effective as any other medical treatment;

      (f) The clinical trial or study is conducted in this State; and

      (g) The enrollee has signed, before participating in the clinical trial or study, a statement of consent indicating that the enrollee has been informed of, without limitation:

             (1) The procedure to be undertaken;

             (2) Alternative methods of treatment; and

             (3) The risks associated with participation in the clinical trial or study, including, without limitation, the general nature and extent of such risks.

      2.  Except as otherwise provided in subsection 3, the coverage for medical treatment required by this section is limited to:

      (a) Coverage for any drug or device that is approved for sale by the Food and Drug Administration without regard to whether the approved drug or device has been approved for use in the medical treatment of the enrollee.

      (b) The cost of any reasonably necessary health care services that are required as a result of the medical treatment provided in a Phase II, Phase III or Phase IV clinical trial or study or as a result of any complication arising out of the medical treatment provided in a Phase II, Phase III or Phase IV clinical trial or study, to the extent that such health care services would otherwise be covered under the health care plan.

      (c) The cost of any routine health care services that would otherwise be covered under the health care plan for an enrollee in a Phase I clinical trial or study.

      (d) The initial consultation to determine whether the enrollee is eligible to participate in the clinical trial or study.

      (e) Health care services required for the clinically appropriate monitoring of the enrollee during a Phase II, Phase III or Phase IV clinical trial or study.

      (f) Health care services which are required for the clinically appropriate monitoring of the enrollee during a Phase I clinical trial or study and which are not directly related to the clinical trial or study.

Ê Except as otherwise provided in NRS 695C.1691, the services provided pursuant to paragraphs (b), (c), (e) and (f) must be covered only if the services are provided by a provider with whom the health maintenance organization has contracted for such services. If the health maintenance organization has not contracted for the provision of such services, the health maintenance organization shall pay the provider the rate of reimbursement that is paid to other providers with whom the health maintenance organization has contracted for similar services and the provider shall accept that rate of reimbursement as payment in full.

      3.  Particular medical treatment described in subsection 2 and provided to an enrollee is not required to be covered pursuant to this section if that particular medical treatment is provided by the sponsor of the clinical trial or study free of charge to the enrollee.

      4.  The coverage for medical treatment required by this section does not include:

      (a) Any portion of the clinical trial or study that is customarily paid for by a government or a biotechnical, pharmaceutical or medical industry.

      (b) Coverage for a drug or device described in paragraph (a) of subsection 2 which is paid for by the manufacturer, distributor or provider of the drug or device.

      (c) Health care services that are specifically excluded from coverage under the enrollee’s health care plan, regardless of whether such services are provided under the clinical trial or study.

      (d) Health care services that are customarily provided by the sponsors of the clinical trial or study free of charge to the participants in the trial or study.

      (e) Extraneous expenses related to participation in the clinical trial or study including, without limitation, travel, housing and other expenses that a participant may incur.

      (f) Any expenses incurred by a person who accompanies the enrollee during the clinical trial or study.

      (g) Any item or service that is provided solely to satisfy a need or desire for data collection or analysis that is not directly related to the clinical management of the enrollee.

      (h) Any costs for the management of research relating to the clinical trial or study.

      5.  A health maintenance organization that delivers or issues for delivery a health care plan specified in subsection 1 may require copies of the approval or certification issued pursuant to paragraph (b) of subsection 1, the statement of consent signed by the enrollee, protocols for the clinical trial or study and any other materials related to the scope of the clinical trial or study relevant to the coverage of medical treatment pursuant to this section.

      6.  A health maintenance organization that delivers or issues for delivery a health care plan specified in subsection 1 shall provide the coverage required by this section subject to the same deductible, copayment, coinsurance and other such conditions for coverage that are required under the plan.

      7.  A health care plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2006, has the legal effect of including the coverage required by this section, and any provision of the plan that conflicts with this section is void.

      8.  A health maintenance organization that delivers or issues for delivery a health care plan specified in subsection 1 is immune from liability for:

      (a) Any injury to an enrollee caused by:

             (1) Any medical treatment provided to the enrollee in connection with his or her participation in a clinical trial or study described in this section; or

             (2) An act or omission by a provider of health care who provides medical treatment or supervises the provision of medical treatment to the enrollee in connection with his or her participation in a clinical trial or study described in this section.

      (b) Any adverse or unanticipated outcome arising out of an enrollee’s participation in a clinical trial or study described in this section.

      9.  As used in this section:

      (a) “Cooperative group” means a network of facilities that collaborate on research projects and has established a peer review program approved by the National Institutes of Health. The term includes:

             (1) The Clinical Trials Cooperative Group Program; and

             (2) The Community Clinical Oncology Program.

      (b) “Facility authorized to conduct Phase I clinical trials or studies for the treatment of cancer” means a facility or an affiliate of a facility that:

             (1) Has in place a Phase I program which permits only selective participation in the program and which uses clear-cut criteria to determine eligibility for participation in the program;

             (2) Operates a protocol review and monitoring system which conforms to the standards set forth in the Policies and Guidelines Relating to the Cancer-Center Support Grant published by the Cancer Centers Branch of the National Cancer Institute;

             (3) Employs at least two researchers and at least one of those researchers receives funding from a federal grant;

             (4) Employs at least three clinical investigators who have experience working in Phase I clinical trials or studies conducted at a facility designated as a comprehensive cancer center by the National Cancer Institute;

             (5) Possesses specialized resources for use in Phase I clinical trials or studies, including, without limitation, equipment that facilitates research and analysis in proteomics, genomics and pharmacokinetics;

             (6) Is capable of gathering, maintaining and reporting electronic data; and

             (7) Is capable of responding to audits instituted by federal and state agencies.

      (c) “Provider of health care” means:

             (1) A hospital; or

             (2) A person licensed pursuant to chapter 630, 631 or 633 of NRS.

      (Added to NRS by 2003, 3528; A 2005, 2018; 2013, 3641, effective January 1, 2014)

      NRS 695C.1694  Required provision concerning coverage of drug or device for contraception and of hormone replacement therapy in certain circumstances; prohibited actions by health maintenance organization; exceptions.

      1.  Except as otherwise provided in subsection 5, a health maintenance organization which offers or issues a health care plan that provides coverage for prescription drugs or devices shall include in the plan coverage for:

      (a) Any type of drug or device for contraception; and

      (b) Any type of hormone replacement therapy,

Ê which is lawfully prescribed or ordered and which has been approved by the Food and Drug Administration.

      2.  A health maintenance organization that offers or issues a health care plan that provides coverage for prescription drugs shall not:

      (a) Require an enrollee to pay a higher deductible, copayment or coinsurance or require a longer waiting period or other condition for coverage for a prescription for a contraceptive or hormone replacement therapy than is required for other prescription drugs covered by the plan;

      (b) Refuse to issue a health care plan or cancel a health care plan solely because the person applying for or covered by the plan uses or may use in the future any of the services listed in subsection 1;

      (c) Offer or pay any type of material inducement or financial incentive to an enrollee to discourage the enrollee from accessing any of the services listed in subsection 1;

      (d) Penalize a provider of health care who provides any of the services listed in subsection 1 to an enrollee, including, without limitation, reducing the reimbursement of the provider of health care; or

      (e) Offer or pay any type of material inducement, bonus or other financial incentive to a provider of health care to deny, reduce, withhold, limit or delay any of the services listed in subsection 1 to an enrollee.

      3.  Except as otherwise provided in subsection 5, evidence of coverage subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 1999, has the legal effect of including the coverage required by subsection 1, and any provision of the evidence of coverage or the renewal which is in conflict with this section is void.

      4.  The provisions of this section do not:

      (a) Require a health maintenance organization to provide coverage for fertility drugs.

      (b) Prohibit a health maintenance organization from requiring an enrollee to pay a deductible, copayment or coinsurance for the coverage required by paragraphs (a) and (b) of subsection 1 that is the same as the enrollee is required to pay for other prescription drugs covered by the plan.

      5.  A health maintenance organization which offers or issues a health care plan and which is affiliated with a religious organization is not required to provide the coverage required by paragraph (a) of subsection 1 if the health maintenance organization objects on religious grounds. The health maintenance organization shall, before the issuance of a health care plan and before renewal of enrollment in such a plan, provide to the group policyholder or prospective enrollee, as applicable, written notice of the coverage that the health maintenance organization refuses to provide pursuant to this subsection. The health maintenance organization shall provide notice to each enrollee, at the time the enrollee receives his or her evidence of coverage, that the health maintenance organization refused to provide coverage pursuant to this subsection.

      6.  If a health maintenance organization refuses, pursuant to subsection 5, to provide the coverage required by paragraph (a) of subsection 1, an employer may otherwise provide for the coverage for the employees of the employer.

      7.  As used in this section, “provider of health care” has the meaning ascribed to it in NRS 629.031.

      (Added to NRS by 1999, 2001)

      NRS 695C.1695  Required provision concerning coverage of health care services related to contraceptives and hormone replacement therapy in certain circumstances; prohibited actions by health maintenance organization; exceptions.

      1.  Except as otherwise provided in subsection 5, a health maintenance organization that offers or issues a health care plan which provides coverage for outpatient care shall include in the plan coverage for any health care service related to contraceptives or hormone replacement therapy.

      2.  A health maintenance organization that offers or issues a health care plan that provides coverage for outpatient care shall not:

      (a) Require an enrollee to pay a higher deductible, copayment or coinsurance or require a longer waiting period or other condition for coverage for outpatient care related to contraceptives or hormone replacement therapy than is required for other outpatient care covered by the plan;

      (b) Refuse to issue a health care plan or cancel a health care plan solely because the person applying for or covered by the plan uses or may use in the future any of the services listed in subsection 1;

      (c) Offer or pay any type of material inducement or financial incentive to an enrollee to discourage the enrollee from accessing any of the services listed in subsection 1;

      (d) Penalize a provider of health care who provides any of the services listed in subsection 1 to an enrollee, including, without limitation, reducing the reimbursement of the provider of health care; or

      (e) Offer or pay any type of material inducement, bonus or other financial incentive to a provider of health care to deny, reduce, withhold, limit or delay any of the services listed in subsection 1 to an enrollee.

      3.  Except as otherwise provided in subsection 5, evidence of coverage subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 1999, has the legal effect of including the coverage required by subsection 1, and any provision of the evidence of coverage or the renewal which is in conflict with this section is void.

      4.  The provisions of this section do not prohibit a health maintenance organization from requiring an enrollee to pay a deductible, copayment or coinsurance for the coverage required by subsection 1 that is the same as the enrollee is required to pay for other outpatient care covered by the plan.

      5.  A health maintenance organization which offers or issues a health care plan and which is affiliated with a religious organization is not required to provide the coverage for health care service related to contraceptives required by this section if the health maintenance organization objects on religious grounds. The health maintenance organization shall, before the issuance of a health care plan and before renewal of enrollment in such a plan, provide to the group policyholder or prospective enrollee, as applicable, written notice of the coverage that the health maintenance organization refuses to provide pursuant to this subsection. The health maintenance organization shall provide notice to each enrollee, at the time the enrollee receives his or her evidence of coverage, that the health maintenance organization refused to provide coverage pursuant to this subsection.

      6.  If a health maintenance organization refuses, pursuant to subsection 5, to provide the coverage required by paragraph (a) of subsection 1, an employer may otherwise provide for the coverage for the employees of the employer.

      7.  As used in this section, “provider of health care” has the meaning ascribed to it in NRS 629.031.

      (Added to NRS by 1999, 2002)

      NRS 695C.170  Evidence of coverage: Issuance; form and contents.

      1.  Every enrollee residing in this state is entitled to evidence of coverage under a health care plan. If the enrollee obtains coverage under a health care plan through an insurance policy, whether by option or otherwise, the insurer shall issue the evidence of coverage. Otherwise, the health maintenance organization shall issue the evidence of coverage.

      2.  Evidence of coverage or amendment thereto must not be issued or delivered to any person in this state until a copy of the form of the evidence of coverage or amendment thereto has been filed with and approved by the Commissioner.

      3.  An evidence of coverage:

      (a) Must not contain any provisions or statements which are unjust, unfair, inequitable, misleading, deceptive, which encourage misrepresentation or which are untrue, misleading or deceptive as defined in subsection 1 of NRS 695C.300; and

      (b) Must contain a clear and complete statement, if a contract, or a reasonably complete summary if a certificate, of:

             (1) The health care services and the insurance or other benefits, if any, to which the enrollee is entitled under the health care plan;

             (2) Any limitations on the services, kind of services, benefits, or kind of benefits, to be provided, including any deductible or copayment feature;

             (3) Where and in what manner the services may be obtained; and

             (4) The total amount of payment for health care services and the indemnity or service benefits, if any, which the enrollee is obligated to pay.

Ê Any subsequent change may be evidenced in a separate document issued to the enrollee.

      4.  A copy of the form of the evidence of coverage to be used in this state and any amendment thereto is subject to the requirements for filing and approval of subsection 2 unless it is subject to the jurisdiction of the Commissioner under the laws governing health insurance, in which event the provisions for filing and approval of those laws apply. To the extent that such provisions do not apply to the requirements in subsection 3, such provisions are amended to incorporate the requirements of subsection 3 in approving or disapproving an evidence of coverage required by subsection 2.

      (Added to NRS by 1973, 1251; A 1975, 1852; 1979, 1182; 1983, 2041; 2009, 1817)

      NRS 695C.1703  Coverage for prescription drugs: Provision of notice and information regarding use of formulary.

      1.  A health maintenance organization or insurer that offers or issues evidence of coverage which provides coverage for prescription drugs shall include with any evidence of that coverage provided to an enrollee, notice of whether a formulary is used and, if so, of the opportunity to secure information regarding the formulary from the organization or insurer pursuant to subsection 2. The notice required by this subsection must:

      (a) Be in a language that is easily understood and in a format that is easy to understand;

      (b) Include an explanation of what a formulary is; and

      (c) If a formulary is used, include:

             (1) An explanation of:

                   (I) How often the contents of the formulary are reviewed; and

                   (II) The procedure and criteria for determining which prescription drugs are included in and excluded from the formulary; and

             (2) The telephone number of the organization or insurer for making a request for information regarding the formulary pursuant to subsection 2.

      2.  If a health maintenance organization or insurer offers or issues evidence of coverage which provides coverage for prescription drugs and a formulary is used, the organization or insurer shall:

      (a) Provide to any enrollee or participating provider of health care upon request:

             (1) Information regarding whether a specific drug is included in the formulary.

             (2) Access to the most current list of prescription drugs in the formulary, organized by major therapeutic category, with an indication of whether any listed drugs are preferred over other listed drugs. If more than one formulary is maintained, the organization or insurer shall notify the requester that a choice of formulary lists is available.

      (b) Notify each person who requests information regarding the formulary, that the inclusion of a drug in the formulary does not guarantee that a provider of health care will prescribe that drug for a particular medical condition.

      (Added to NRS by 2001, 863)

      NRS 695C.1705  Group health care plan issued to replace discontinued policy or coverage: Requirements; notice of reduction of benefits; statement of benefits; applicability to self-insured employer. [Effective through December 31, 2013.]  Except as otherwise provided in the provisions of NRS 689B.340 to 689B.590, inclusive, and chapter 689C of NRS relating to the portability and accountability of health insurance:

      1.  A group health care plan issued by a health maintenance organization to replace any discontinued policy or coverage for group health insurance must:

      (a) Provide coverage for all persons who were covered under the previous policy or coverage on the date it was discontinued; and

      (b) Except as otherwise provided in subsection 2, provide benefits which are at least as extensive as the benefits provided by the previous policy or coverage, except that benefits may be reduced or excluded to the extent that such a reduction or exclusion was permissible under the terms of the previous policy or coverage,

Ê if that plan is issued within 60 days after the date on which the previous policy or coverage was discontinued.

      2.  If an employer obtains a replacement plan pursuant to subsection 1 to cover the employees of the employer, any benefits provided by the previous policy or coverage may be reduced if notice of the reduction is given to the employees pursuant to NRS 608.1577.

      3.  Any health maintenance organization which issues a replacement plan pursuant to subsection 1 may submit a written request to the insurer which provided the previous policy or coverage for a statement of benefits which were provided under that policy or coverage. Upon receiving such a request, the insurer shall give a written statement to the organization indicating what benefits were provided and what exclusions or reductions were in effect under the previous policy or coverage.

      4.  If an employee or enrollee was a recipient of benefits under the coverage provided pursuant to NRS 695C.1709, the employee or enrollee is not entitled to have issued to him or her by a health maintenance organization a replacement plan unless the employee or enrollee has reported for his or her normal employment for a period of 90 consecutive days after last being eligible to receive any benefits under the coverage provided pursuant to NRS 695C.1709.

      5.  The provisions of this section apply to a self-insured employer who provides health benefits to the employees of the self-insured employer and replaces those benefits with a group health care plan issued by a health maintenance organization.

      (Added to NRS by 1987, 850; A 1989, 1253; 1997, 2958)

      NRS 695C.1705  Group health care plan issued to replace discontinued policy or coverage: Requirements; notice of reduction of benefits; statement of benefits; applicability to self-insured employer. [Effective January 1, 2014.]  Except as otherwise provided in the provisions of NRS 689B.340 to 689B.580, inclusive, and chapter 689C of NRS relating to the portability and accountability of health insurance:

      1.  A group health care plan issued by a health maintenance organization to replace any discontinued policy or coverage for group health insurance must:

      (a) Provide coverage for all persons who were covered under the previous policy or coverage on the date it was discontinued; and

      (b) Except as otherwise provided in subsection 2, provide benefits which are at least as extensive as the benefits provided by the previous policy or coverage, except that benefits may be reduced or excluded to the extent that such a reduction or exclusion was permissible under the terms of the previous policy or coverage,

Ê if that plan is issued within 60 days after the date on which the previous policy or coverage was discontinued.

      2.  If an employer obtains a replacement plan pursuant to subsection 1 to cover the employees of the employer, any benefits provided by the previous policy or coverage may be reduced if notice of the reduction is given to the employees pursuant to NRS 608.1577.

      3.  Any health maintenance organization which issues a replacement plan pursuant to subsection 1 may submit a written request to the insurer which provided the previous policy or coverage for a statement of benefits which were provided under that policy or coverage. Upon receiving such a request, the insurer shall give a written statement to the organization indicating what benefits were provided and what exclusions or reductions were in effect under the previous policy or coverage.

      4.  If an employee or enrollee was a recipient of benefits under the coverage provided pursuant to NRS 695C.1709, the employee or enrollee is not entitled to have issued to him or her by a health maintenance organization a replacement plan unless the employee or enrollee has reported for his or her normal employment for a period of 90 consecutive days after last being eligible to receive any benefits under the coverage provided pursuant to NRS 695C.1709.

      5.  The provisions of this section apply to a self-insured employer who provides health benefits to the employees of the self-insured employer and replaces those benefits with a group health care plan issued by a health maintenance organization.

      (Added to NRS by 1987, 850; A 1989, 1253; 1997, 2958; 2013, 3644, effective January 1, 2014)

      NRS 695C.1707  Required provision for continuation of coverage. [Effective through December 31, 2013.]  Any policy of group insurance to which an enrollee is entitled under a health care plan provided by a health maintenance organization must contain a provision which permits the continuation of coverage pursuant to the provisions of NRS 689B.245 to 689B.249, inclusive, 689B.340 to 689B.590, inclusive, and chapter 689C of NRS relating to the portability and accountability of health insurance.

      (Added to NRS by 1987, 2235; A 1997, 2959; R 2013, 3661, effective January 1, 2014)

      NRS 695C.1709  Required provision concerning coverage for enrollee on leave without pay as result of total disability.

      1.  As used in this section, “total disability” and “totally disabled” mean the continuing inability of the enrollee, because of an injury or illness, to perform substantially the duties related to his or her employment for which the enrollee is otherwise qualified.

      2.  No policy of group insurance to which an enrollee is entitled under a health care plan provided by a health maintenance organization may be delivered or issued for delivery in this state unless it provides continuing coverage for an enrollee and dependents of the enrollee who are otherwise covered by the policy while the enrollee is on leave without pay as a result of a total disability. The coverage must be for any injury or illness suffered by the enrollee which is not related to the total disability or for any injury or illness suffered by a dependent of the enrollee. The coverage must be equal to or greater than the coverage otherwise provided by the policy.

      3.  The coverage required pursuant to subsection 2 must continue until:

      (a) The date on which the employment of the enrollee is terminated;

      (b) The date on which the enrollee obtains another policy of health insurance;

      (c) The date on which the policy of group insurance is terminated; or

      (d) After a period of 12 months in which benefits under such coverage are provided to the enrollee,

Ê whichever occurs first.

      (Added to NRS by 1989, 1253)

      NRS 695C.171  Required provision concerning coverage relating to mastectomy.

      1.  A health maintenance plan which provides coverage for the surgical procedure known as a mastectomy must also provide commensurate coverage for:

      (a) Reconstruction of the breast on which the mastectomy has been performed;

      (b) Surgery and reconstruction of the other breast to produce a symmetrical structure; and

      (c) Prostheses and physical complications for all stages of mastectomy, including lymphedemas.

      2.  The provision of services must be determined by the attending physician and the patient.

      3.  The plan or issuer may require deductibles and coinsurance payments if they are consistent with those established for other benefits.

      4.  Written notice of the availability of the coverage must be given upon enrollment and annually thereafter. The notice must be sent to all participants:

      (a) In the next mailing made by the plan or issuer to the participant or beneficiary; or

      (b) As part of any annual information packet sent to the participant or beneficiary,

Ê whichever is earlier.

      5.  A plan or issuer may not:

      (a) Deny eligibility, or continued eligibility, to enroll or renew coverage, in order to avoid the requirements of subsections 1 to 4, inclusive; or

      (b) Penalize, or limit reimbursement to, a provider of care, or provide incentives to a provider of care, in order to induce the provider not to provide the care listed in subsections 1 to 4, inclusive.

      6.  A plan or issuer may negotiate rates of reimbursement with providers of care.

      7.  If reconstructive surgery is begun within 3 years after a mastectomy, the amount of the benefits for that surgery must equal those amounts provided for in the policy at the time of the mastectomy. If the surgery is begun more than 3 years after the mastectomy, the benefits provided are subject to all of the terms, conditions and exclusions contained in the policy at the time of the reconstructive surgery.

      8.  A policy subject to the provisions of this chapter which is delivered, issued for delivery or renewed on or after October 1, 2001, has the legal effect of including the coverage required by this section, and any provision of the policy or the renewal which is in conflict with this section is void.

      9.  For the purposes of this section, “reconstructive surgery” means a surgical procedure performed following a mastectomy on one breast or both breasts to re-establish symmetry between the two breasts. The term includes, but is not limited to, augmentation mammoplasty, reduction mammoplasty and mastopexy.

      (Added to NRS by 1983, 615; A 1989, 1891; 2001, 2250)

      NRS 695C.1713  Required provision concerning coverage of certain gynecological and obstetrical services without authorization or referral from primary care physician.

      1.  A health care plan must include a provision authorizing a woman covered by the plan to obtain covered gynecological or obstetrical services without first receiving authorization or a referral from her primary care physician.

      2.  The provisions of this section do not authorize a woman covered by a health care plan to designate an obstetrician or gynecologist as her primary care physician.

      3.  An evidence of coverage subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 1999, has the legal effect of including the coverage required by this section, and any provision of the evidence of coverage or the renewal which is in conflict with this section is void.

      4.  As used in this section, “primary care physician” has the meaning ascribed to it in NRS 695G.060.

      (Added to NRS by 1999, 1944)

      NRS 695C.1717  Required provision concerning coverage for autism spectrum disorders.

      1.  A health care plan issued by a health maintenance organization must provide coverage for screening for and diagnosis of autism spectrum disorders and for treatment of autism spectrum disorders to persons covered by the health care plan under the age of 18 or, if enrolled in high school, until the person reaches the age of 22.

      2.  Coverage provided under this section is subject to:

      (a) A maximum benefit of $36,000 per year for applied behavior analysis treatment; and

      (b) Copayment, deductible and coinsurance provisions and any other general exclusion or limitation of a health care plan to the same extent as other medical services or prescription drugs covered by the plan.

      3.  A health care plan issued by a health maintenance organization that provides coverage for outpatient care shall not:

      (a) Require an enrollee to pay a higher deductible, copayment or coinsurance or require a longer waiting period for coverage for outpatient care related to autism spectrum disorders than is required for other outpatient care covered by the plan; or

      (b) Refuse to issue a health care plan or cancel a health care plan solely because the person applying for or covered by the plan uses or may use in the future any of the services listed in subsection 1.

      4.  Except as provided in subsections 1 and 2, a health maintenance organization shall not limit the number of visits an enrollee may make to any person, entity or group for treatment of autism spectrum disorders.

      5.  Treatment of autism spectrum disorders must be identified in a treatment plan and may include medically necessary habilitative or rehabilitative care, prescription care, psychiatric care, psychological care, behavior therapy or therapeutic care that is:

      (a) Prescribed for a person diagnosed with an autism spectrum disorder by a licensed physician or licensed psychologist; and

      (b) Provided for a person diagnosed with an autism spectrum disorder by a licensed physician, licensed psychologist, licensed behavior analyst or other provider that is supervised by the licensed physician, psychologist or behavior analyst.

Ê A health maintenance organization may request a copy of and review a treatment plan created pursuant to this subsection.

      6.  Evidence of coverage subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2011, has the legal effect of including the coverage required by subsection 1, and any provision of the evidence of coverage or the renewal which is in conflict with subsection 1 or 2 is void.

      7.  Nothing in this section shall be construed as requiring a health maintenance organization to provide reimbursement to an early intervention agency or school for services delivered through early intervention or school services.

      8.  As used in this section:

      (a) “Applied behavior analysis” means the design, implementation and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including, without limitation, the use of direct observation, measurement and functional analysis of the relations between environment and behavior.

      (b) “Autism spectrum disorders” means a neurobiological medical condition including, without limitation, autistic disorder, Asperger’s Disorder and Pervasive Developmental Disorder Not Otherwise Specified.

      (c) “Behavioral therapy” means any interactive therapy derived from evidence-based research, including, without limitation, discrete trial training, early intensive behavioral intervention, intensive intervention programs, pivotal response training and verbal behavior provided by a licensed psychologist, licensed behavior analyst, licensed assistant behavior analyst or certified autism behavior interventionist.

      (d) “Certified autism behavior interventionist” means a person who is certified as an autism behavior interventionist by the Board of Psychological Examiners and who provides behavior therapy under the supervision of:

             (1) A licensed psychologist;

             (2) A licensed behavior analyst; or

             (3) A licensed assistant behavior analyst.

      (e) “Evidence-based research” means research that applies rigorous, systematic and objective procedures to obtain valid knowledge relevant to autism spectrum disorders.

      (f) “Habilitative or rehabilitative care” means counseling, guidance and professional services and treatment programs, including, without limitation, applied behavior analysis, that are necessary to develop, maintain and restore, to the maximum extent practicable, the functioning of a person.

      (g) “Licensed assistant behavior analyst” means a person who holds current certification or meets the standards to be certified as a board certified assistant behavior analyst issued by the Behavior Analyst Certification Board, Inc., or any successor in interest to that organization, who is licensed as an assistant behavior analyst by the Board of Psychological Examiners and who provides behavioral therapy under the supervision of a licensed behavior analyst or psychologist.

      (h) “Licensed behavior analyst” means a person who holds current certification or meets the standards to be certified as a board certified behavior analyst or a board certified assistant behavior analyst issued by the Behavior Analyst Certification Board, Inc., or any successor in interest to that organization and who is licensed as a behavior analyst by the Board of Psychological Examiners.

      (i) “Prescription care” means medications prescribed by a licensed physician and any health-related services deemed medically necessary to determine the need or effectiveness of the medications.

      (j) “Psychiatric care” means direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.

      (k) “Psychological care” means direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.

      (l) “Screening for autism spectrum disorders” means medically necessary assessments, evaluations or tests to screen and diagnose whether a person has an autism spectrum disorder.

      (m) “Therapeutic care” means services provided by licensed or certified speech pathologists, occupational therapists and physical therapists.

      (n) “Treatment plan” means a plan to treat an autism spectrum disorder that is prescribed by a licensed physician or licensed psychologist and may be developed pursuant to a comprehensive evaluation in coordination with a licensed behavior analyst.

      (Added to NRS by 2009, 1471)

      NRS 695C.172  Required provision concerning coverage relating to complications of pregnancy. [Effective through December 31, 2013.]

      1.  No health maintenance organization may issue evidence of coverage under a health care plan to any enrollee in this state if it contains any exclusion, reduction or other limitation of coverage relating to complications of pregnancy unless the provision applies generally to all benefits payable under the policy and complies with the provisions of NRS 689B.340 to 689B.590, inclusive, and chapter 689C of NRS relating to the portability and accountability of health insurance.

      2.  As used in this section, the term “complications of pregnancy” includes any condition which requires hospital confinement for medical treatment and:

      (a) If the pregnancy is not terminated, is caused by an injury or sickness not directly related to the pregnancy or by acute nephritis, nephrosis, cardiac decompensation, missed abortion or similar medically diagnosed conditions; or

      (b) If the pregnancy is terminated, results in nonelective cesarean section, ectopic pregnancy or spontaneous termination.

      3.  Evidence of coverage under a health care plan subject to the provisions of this chapter which is issued on or after July 1, 1977, has the legal effect of including the coverage required by this section, and any provision which is in conflict with this section is void.

      (Added to NRS by 1977, 416; A 1997, 2959)

      NRS 695C.172  Required provision concerning coverage relating to complications of pregnancy. [Effective January 1, 2014.]

      1.  No health maintenance organization may issue evidence of coverage under a health care plan to any enrollee in this state if it contains any exclusion, reduction or other limitation of coverage relating to complications of pregnancy unless the provision applies generally to all benefits payable under the policy and complies with the provisions of NRS 689B.340 to 689B.580, inclusive, and chapter 689C of NRS relating to the portability and accountability of health insurance.

      2.  As used in this section, the term “complications of pregnancy” includes any condition which requires hospital confinement for medical treatment and:

      (a) If the pregnancy is not terminated, is caused by an injury or sickness not directly related to the pregnancy or by acute nephritis, nephrosis, cardiac decompensation, missed abortion or similar medically diagnosed conditions; or

      (b) If the pregnancy is terminated, results in nonelective cesarean section, ectopic pregnancy or spontaneous termination.

      3.  Evidence of coverage under a health care plan subject to the provisions of this chapter which is issued on or after July 1, 1977, has the legal effect of including the coverage required by this section, and any provision which is in conflict with this section is void.

      (Added to NRS by 1977, 416; A 1997, 2959; 2013, 3644, effective January 1, 2014)

      NRS 695C.1723  Required provision concerning coverage for treatment of certain inherited metabolic diseases.

      1.  A health maintenance plan must provide coverage for:

      (a) Enteral formulas for use at home that are prescribed or ordered by a physician as medically necessary for the treatment of inherited metabolic diseases characterized by deficient metabolism, or malabsorption originating from congenital defects or defects arising shortly after birth, of amino acid, organic acid, carbohydrate or fat; and

      (b) At least $2,500 per year for special food products which are prescribed or ordered by a physician as medically necessary for the treatment of a person described in paragraph (a).

      2.  The coverage required by subsection 1 must be provided whether or not the condition existed when the health maintenance plan was purchased.

      3.  Any evidence of coverage subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 1998, has the legal effect of including the coverage required by this section, and any provision of the evidence of coverage or the renewal which is in conflict with this section is void.

      4.  As used in this section:

      (a) “Inherited metabolic disease” means a disease caused by an inherited abnormality of the body chemistry of a person.

      (b) “Special food product” means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be consumed under the direction of a physician for the dietary treatment of an inherited metabolic disease. The term does not include a food that is naturally low in protein.

      (Added to NRS by 1997, 1527)

      NRS 695C.1727  Required provision concerning coverage for management and treatment of diabetes. [Effective through December 31, 2013.]

      1.  No evidence of coverage that provides coverage for hospital, medical or surgical expenses may be delivered or issued for delivery in this state unless the evidence of coverage includes coverage for the management and treatment of diabetes, including, without limitation, coverage for the self-management of diabetes.

      2.  An insurer who delivers or issues for delivery an evidence of coverage specified in subsection 1:

      (a) Shall include in the disclosure required pursuant to NRS 695C.193 notice to each enrollee under the evidence of coverage of the availability of the benefits required by this section.

      (b) Shall provide the coverage required by this section subject to the same deductible, copayment, coinsurance and other such conditions for the evidence of coverage that are required under the evidence of coverage.

      3.  Evidence of coverage subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 1998, has the legal effect of including the coverage required by this section, and any provision of the evidence of coverage that conflicts with this section is void.

      4.  As used in this section:

      (a) “Coverage for the management and treatment of diabetes” includes coverage for medication, equipment, supplies and appliances that are medically necessary for the treatment of diabetes.

      (b) “Coverage for the self-management of diabetes” includes:

             (1) The training and education provided to the enrollee after the enrollee is initially diagnosed with diabetes which is medically necessary for the care and management of diabetes, including, without limitation, counseling in nutrition and the proper use of equipment and supplies for the treatment of diabetes;

             (2) Training and education which is medically necessary as a result of a subsequent diagnosis that indicates a significant change in the symptoms or condition of the enrollee and which requires modification of the enrollee’s program of self-management of diabetes; and

             (3) Training and education which is medically necessary because of the development of new techniques and treatment for diabetes.

      (c) “Diabetes” includes type I, type II and gestational diabetes.

      (Added to NRS by 1997, 745)

      NRS 695C.1727  Required provision concerning coverage for management and treatment of diabetes. [Effective January 1, 2014.]

      1.  No evidence of coverage that provides coverage for hospital, medical or surgical expenses may be delivered or issued for delivery in this state unless the evidence of coverage includes coverage for the management and treatment of diabetes, including, without limitation, coverage for the self-management of diabetes.

      2.  An insurer who delivers or issues for delivery an evidence of coverage specified in subsection 1 shall provide the coverage required by this section subject to the same deductible, copayment, coinsurance and other such conditions for the evidence of coverage that are required under the evidence of coverage.

      3.  Evidence of coverage subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 1998, has the legal effect of including the coverage required by this section, and any provision of the evidence of coverage that conflicts with this section is void.

      4.  As used in this section:

      (a) “Coverage for the management and treatment of diabetes” includes coverage for medication, equipment, supplies and appliances that are medically necessary for the treatment of diabetes.

      (b) “Coverage for the self-management of diabetes” includes:

             (1) The training and education provided to the enrollee after the enrollee is initially diagnosed with diabetes which is medically necessary for the care and management of diabetes, including, without limitation, counseling in nutrition and the proper use of equipment and supplies for the treatment of diabetes;

             (2) Training and education which is medically necessary as a result of a subsequent diagnosis that indicates a significant change in the symptoms or condition of the enrollee and which requires modification of the enrollee’s program of self-management of diabetes; and

             (3) Training and education which is medically necessary because of the development of new techniques and treatment for diabetes.

      (c) “Diabetes” includes type I, type II and gestational diabetes.

      (Added to NRS by 1997, 745; A 2013, 3645, effective January 1, 2014)

      NRS 695C.173  Required provision concerning coverage for newly born and adopted children and children placed for adoption.

      1.  All individual and group health care plans which provide coverage for a family member of the enrollee must as to such coverage provide that the health care services applicable for children are payable with respect to:

      (a) A newly born child of the enrollee from the moment of birth;

      (b) An adopted child from the date the adoption becomes effective, if the child was not placed in the home before adoption; and

      (c) A child placed with the enrollee for the purpose of adoption from the moment of placement as certified by the public or private agency making the placement. The coverage of such a child ceases if the adoption proceedings are terminated as certified by the public or private agency making the placement.

Ê The plans must provide the coverage specified in subsection 3, and must not exclude premature births.

      2.  The evidence of coverage may require that notification of:

      (a) The birth of a newly born child;

      (b) The effective date of adoption of a child; or

      (c) The date of placement of a child for adoption,

Ê and payments of the required charge, if any, must be furnished to the health maintenance organization within 31 days after the date of birth, adoption or placement for adoption in order to have the coverage continue beyond the 31-day period.

      3.  The coverage for newly born and adopted children and children placed for adoption consists of preventive health care services as well as coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities and, within the limits of the policy, necessary transportation costs from place of birth to the nearest specialized treatment center under major medical policies, and with respect to basic policies to the extent such costs are charged by the treatment center.

      4.  A health maintenance organization shall not restrict the coverage of a dependent child adopted or placed for adoption solely because of a preexisting condition the child has at the time the child would otherwise become eligible for coverage pursuant to that plan. Any provision relating to an exclusion for a preexisting condition must comply with NRS 689B.500 or 689C.190, as appropriate.

      5.  For covered services provided to the child, the health maintenance organization shall reimburse noncontracted providers of health care to an amount equal to the average amount of payment for which the organization has agreements, contracts or arrangements for those covered services.

      (Added to NRS by 1975, 1110; A 1989, 741; 1995, 2436; 1997, 2959)

      NRS 695C.1731  Required provision concerning coverage for screening for colorectal cancer.

      1.  A health care plan issued by a health maintenance organization that provides coverage for the treatment of colorectal cancer must provide coverage for colorectal cancer screening in accordance with:

      (a) The guidelines concerning colorectal cancer screening which are published by the American Cancer Society; or

      (b) Other guidelines or reports concerning colorectal cancer screening which are published by nationally recognized professional organizations and which include current or prevailing supporting scientific data.

      2.  An evidence of coverage for a health care plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 2003, has the legal effect of including the coverage required by this section, and any provision of the evidence of coverage that conflicts with the provisions of this section is void.

      (Added to NRS by 2003, 1335)

      NRS 695C.1733  Required provision concerning coverage for certain drugs for treatment of cancer.  Except as otherwise provided in NRS 695C.1693:

      1.  No evidence of coverage that provides coverage for a drug approved by the Food and Drug Administration for use in the treatment of an illness, disease or other medical condition may be delivered or issued for delivery in this state unless the evidence of coverage includes coverage for any other use of the drug for the treatment of cancer, if that use is:

      (a) Specified in the most recent edition of or supplement to:

             (1) The United States Pharmacopoeia Drug Information; or

             (2) The American Hospital Formulary Service Drug Information; or

      (b) Supported by at least two articles reporting the results of scientific studies that are published in scientific or medical journals, as defined in 21 C.F.R. § 99.3.

      2.  The coverage required pursuant to this section:

      (a) Includes coverage for any medical services necessary to administer the drug to the enrollee.

      (b) Does not include coverage for any:

             (1) Experimental drug used for the treatment of cancer if that drug has not been approved by the Food and Drug Administration; or

             (2) Use of a drug that is contraindicated by the Food and Drug Administration.

      3.  Any evidence of coverage subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 1999, has the legal effect of including the coverage required by this section, and any provision of the evidence of coverage that conflicts with the provisions of this section is void.

      (Added to NRS by 1999, 761; A 2003, 3531)

      NRS 695C.17335  Required provision concerning coverage for orally administered chemotherapy.

      1.  A health maintenance organization that offers or issues a health care plan which provides coverage for the treatment of cancer through the use of chemotherapy shall not:

      (a) Require a copayment, deductible or coinsurance amount for chemotherapy administered orally by means of a prescription drug in a combined amount that is more than $100 per prescription. The limitation on the amount of the deductible that may be required pursuant to this paragraph does not apply to a health benefit plan, as defined in NRS 687B.470, if the health benefit plan is a high deductible health plan, as defined in 26 U.S.C. § 223, and the amount of the annual deductible has not been satisfied.

      (b) Make the coverage subject to monetary limits that are less favorable for chemotherapy administered orally by means of a prescription drug than the monetary limits applicable to chemotherapy which is administered by injection or intravenously.

      (c) Decrease the monetary limits applicable to such chemotherapy administered orally by means of a prescription drug or to chemotherapy which is administered by injection or intravenously to meet the requirements of this section.

      2.  Evidence of coverage subject to the provisions of this chapter which provides coverage for the treatment of cancer through the use of chemotherapy and that is delivered, issued for delivery or renewed on or after January 1, 2015, has the legal effect of providing that coverage subject to the requirements of this section, and any provision of the evidence of coverage or the renewal which is in conflict with this section is void.

      3.  Nothing in this section shall be construed as requiring a health maintenance organization to provide coverage for the treatment of cancer through the use of chemotherapy administered by injection or intravenously or administered orally by means of a prescription drug.

      (Added to NRS by 2013, 1999; A 2013, 3659)

      NRS 695C.1734  Required provision concerning coverage for prescription drug previously approved for medical condition of enrollee.

      1.  Except as otherwise provided in this section, evidence of coverage which provides coverage for prescription drugs must not limit or exclude coverage for a drug if the drug:

      (a) Had previously been approved for coverage by the health maintenance organization or insurer for a medical condition of an enrollee and the enrollee’s provider of health care determines, after conducting a reasonable investigation, that none of the drugs which are otherwise currently approved for coverage are medically appropriate for the enrollee; and

      (b) Is appropriately prescribed and considered safe and effective for treating the medical condition of the enrollee.

      2.  The provisions of subsection 1 do not:

      (a) Apply to coverage for any drug that is prescribed for a use that is different from the use for which that drug has been approved for marketing by the Food and Drug Administration;

      (b) Prohibit:

             (1) The health maintenance organization or insurer from charging a deductible, copayment or coinsurance for the provision of benefits for prescription drugs to the enrollee or from establishing, by contract, limitations on the maximum coverage for prescription drugs;

             (2) A provider of health care from prescribing another drug covered by the evidence of coverage that is medically appropriate for the enrollee; or

             (3) The substitution of another drug pursuant to NRS 639.23286 or 639.2583 to 639.2597, inclusive; or

      (c) Require any coverage for a drug after the term of the evidence of coverage.

      3.  Any provision of an evidence of coverage subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 2001, which is in conflict with this section is void.

      (Added to NRS by 2001, 863; A 2003, 2300)

      NRS 695C.1735  Required provision concerning coverage for cytologic screening tests and mammograms for certain women.

      1.  A health maintenance plan must provide coverage for benefits payable for expenses incurred for:

      (a) An annual cytologic screening test for women 18 years of age or older;

      (b) A baseline mammogram for women between the ages of 35 and 40; and

      (c) An annual mammogram for women 40 years of age or older.

      2.  A health maintenance plan must not require an insured to obtain prior authorization for any service provided pursuant to subsection 1.

      3.  A policy subject to the provisions of this chapter which is delivered, issued for delivery or renewed on or after October 1, 1989, has the legal effect of including the coverage required by subsection 1, and any provision of the policy or the renewal which is in conflict with subsection 1 is void.

      (Added to NRS by 1989, 1891; A 1997, 1730)

      NRS 695C.1745  Required provision concerning coverage for human papillomavirus vaccine. [Effective through December 31, 2013.]

      1.  A health care plan of a health maintenance organization must provide coverage for benefits payable for expenses incurred for administering the human papillomavirus vaccine to women and girls at such ages as recommended for vaccination by a competent authority, including, without limitation, the Centers for Disease Control and Prevention of the United States Department of Health and Human Services, the Food and Drug Administration or the manufacturer of the vaccine.

      2.  A health care plan of a health maintenance organization must not require an insured to obtain prior authorization for any service provided pursuant to subsection 1.

      3.  Any evidence of coverage subject to the provisions of this chapter which is delivered, issued for delivery or renewed on or after July 1, 2007, has the legal effect of including the coverage required by subsection 1, and any provision of the evidence of coverage or the renewal which is in conflict with subsection 1 is void.

      4.  For the purposes of this section, “human papillomavirus vaccine” means the Quadrivalent Human Papillomavirus Recombinant Vaccine or its successor which is approved by the Food and Drug Administration for the prevention of human papillomavirus infection and cervical cancer.

      (Added to NRS by 2007, 3239)

      NRS 695C.1745  Required provision concerning coverage for human papillomavirus vaccine. [Effective January 1, 2014.]

      1.  A health care plan of a health maintenance organization must provide coverage for benefits payable for expenses incurred for administering the human papillomavirus vaccine as recommended for vaccination by a competent authority, including, without limitation, the Centers for Disease Control and Prevention of the United States Department of Health and Human Services, the Food and Drug Administration or the manufacturer of the vaccine.

      2.  A health care plan of a health maintenance organization must not require an insured to obtain prior authorization for any service provided pursuant to subsection 1.

      3.  Any evidence of coverage subject to the provisions of this chapter which is delivered, issued for delivery or renewed on or after July 1, 2007, has the legal effect of including the coverage required by subsection 1, and any provision of the evidence of coverage or the renewal which is in conflict with subsection 1 is void.

      4.  For the purposes of this section, “human papillomavirus vaccine” means the Quadrivalent Human Papillomavirus Recombinant Vaccine or its successor which is approved by the Food and Drug Administration for the prevention of human papillomavirus infection and cervical cancer.

      (Added to NRS by 2007, 3239; A 2013, 3645, effective January 1, 2014)

      NRS 695C.1751  Required provision concerning coverage for prostate cancer screening.

      1.  A health care plan of a health maintenance organization that provides coverage for the treatment of prostate cancer must provide coverage for prostate cancer screening in accordance with:

      (a) The guidelines concerning prostate cancer screening which are published by the American Cancer Society; or

      (b) Other guidelines or reports concerning prostate cancer screening which are published by nationally recognized professional organizations and which include current or prevailing supporting scientific data.

      2.  A health care plan of a health maintenance organization that provides coverage for the treatment of prostate cancer must not require an insured to obtain prior authorization for any service provided pursuant to subsection 1.

      3.  Any evidence of coverage for a health care plan of a health maintenance organization that provides coverage for the treatment of prostate cancer which is delivered, issued for delivery or renewed on or after July 1, 2007, has the legal effect of including the coverage required by subsection 1, and any provision of the evidence of coverage or the renewal which is in conflict with subsection 1 is void.

      (Added to NRS by 2007, 3239)

      NRS 695C.1755  Required provision concerning coverage for treatment of temporomandibular joint.

      1.  Except as otherwise provided in this section, no evidence of coverage may be delivered or issued for delivery in this state if it contains an exclusion of coverage of the treatment of the temporomandibular joint whether by specific language in the evidence of coverage or by a claims settlement practice. An evidence of coverage may exclude coverage of those methods of treatment which are recognized as dental procedures, including, but not limited to, the extraction of teeth and the application of orthodontic devices and splints.

      2.  The health maintenance organization may limit its liability on the treatment of the temporomandibular joint to:

      (a) No more than 50 percent of the usual and customary charges for such treatment actually received by an enrollee, but in no case more than 50 percent of the maximum benefits provided by the evidence of coverage for such treatment; and

      (b) Treatment which is medically necessary.

      3.  Any provision of an evidence of coverage subject to the provisions of this chapter and issued or delivered on or after January 1, 1990, which is in conflict with this section is void.

      (Added to NRS by 1989, 2139)

      NRS 695C.176  Required provision concerning coverage for hospice care.  Each health care plan must provide benefits for hospice care.

      (Added to NRS by 1983, 1936; A 1985, 1779; 1989, 1033)

REIMBURSEMENT

      NRS 695C.1765  Reimbursement for acupuncture.  If any evidence of coverage provides coverage for acupuncture performed by a physician, the insured is entitled to reimbursement for acupuncture performed by a person who is licensed pursuant to chapter 634A of NRS.

      (Added to NRS by 1991, 1134)

      NRS 695C.177  Reimbursement for treatments by licensed psychologist.  If any evidence of coverage provides coverage for treatment of an illness which is within the authorized scope of the practice of a qualified psychologist, the insured is entitled to reimbursement for treatments by a psychologist who is licensed pursuant to chapter 641 of NRS.

      (Added to NRS by 1981, 576; A 1989, 1553)

      NRS 695C.1773  Reimbursement for treatment by licensed marriage and family therapist or licensed clinical professional counselor.  If any evidence of coverage provides coverage for treatment of an illness which is within the authorized scope of practice of a licensed marriage and family therapist or licensed clinical professional counselor, the insured is entitled to reimbursement for treatment by a marriage and family therapist or clinical professional counselor who is licensed pursuant to chapter 641A of NRS.

      (Added to NRS by 1987, 2134; A 2007, 3094)

      NRS 695C.1775  Reimbursement for treatment by licensed associate in social work, social worker, independent social worker or clinical social worker.  If any evidence of coverage provides coverage for treatment of an illness which is within the authorized scope of the practice of a licensed associate in social work, social worker, independent social worker or clinical social worker, the insured is entitled to reimbursement for treatment by an associate in social work, social worker, independent social worker or clinical social worker who is licensed pursuant to chapter 641B of NRS.

      (Added to NRS by 1987, 1123)

      NRS 695C.178  Reimbursement for treatment by chiropractor.

      1.  If any evidence of coverage provides coverage for treatment of an illness which is within the authorized scope of practice of a qualified chiropractor, the insured is entitled to reimbursement for treatments by a chiropractor who is licensed pursuant to chapter 634 of NRS.

      2.  The terms of the policy must not limit:

      (a) Coverage for treatments by a chiropractor to a number less than for treatments by other physicians.

      (b) Reimbursement for treatments by a chiropractor to an amount less than that charged for similar treatments by other physicians.

      (Added to NRS by 1981, 930; A 1983, 328)

      NRS 695C.1783  Reimbursement for treatment by podiatrist.

      1.  If any evidence of coverage provides coverage for treatment of an illness which is within the authorized scope of practice of a qualified podiatrist, the insured is entitled to reimbursement for treatments by a podiatrist who is licensed pursuant to chapter 635 of NRS.

      2.  The terms of the policy must not limit:

      (a) Coverage for treatments by a podiatrist to a number less than for treatments by other physicians.

      (b) Reimbursement for treatments by a podiatrist to an amount less than that reimbursed for similar treatments by other physicians.

      (Added to NRS by 2007, 1046)

      NRS 695C.1789  Reimbursement for treatment by licensed clinical alcohol and drug abuse counselor.  If any evidence of coverage provides coverage for treatment of an illness which is within the authorized scope of practice of a licensed clinical alcohol and drug abuse counselor, the insured is entitled to reimbursement for treatment by a clinical alcohol and drug abuse counselor who is licensed pursuant to chapter 641C of NRS.

      (Added to NRS by 2007, 3094)

      NRS 695C.179  Reimbursement for services provided by certain nurses; prohibited limitations; exceptions.

      1.  If any evidence of coverage provides coverage for services which are within the authorized scope of practice of a registered nurse who is authorized pursuant to chapter 632 of NRS to perform additional acts in an emergency or under other special conditions as prescribed by the State Board of Nursing, and which are reimbursed when provided by another provider of health care, the insured is entitled to reimbursement for services provided by such a registered nurse.

      2.  The terms of the evidence of coverage must not limit:

      (a) Coverage for services provided by such a registered nurse to a number of occasions less than for services provided by another provider of health care.

      (b) Reimbursement for services provided by such a registered nurse to an amount less than that reimbursed for similar services provided by another provider of health care.

      3.  An insurer is not required to pay for services provided by such a registered nurse which duplicate services provided by another provider of health care.

      (Added to NRS by 1985, 1448)

      NRS 695C.1795  Reimbursement to provider of medical transportation.

      1.  Except as otherwise provided in subsection 3, every evidence of coverage amended, delivered or issued for delivery in this State after October 1, 1989, that provides coverage for medical transportation, must contain a provision for the direct reimbursement of a provider of medical transportation for covered services if that provider does not receive reimbursement from any other source.

      2.  The enrollee or the provider may submit the claim for reimbursement. The provider shall not demand payment from the enrollee until after that reimbursement has been granted or denied.

      3.  Subsection 1 does not apply to any agreement between a health maintenance organization and a provider of medical transportation for the direct payment by the organization for the provider’s services.

      (Added to NRS by 1989, 1274)

MISCELLANEOUS PROVISIONS

      NRS 695C.180  Schedule of charges. [Effective through December 31, 2013.]

      1.  No schedule of charges for enrollee coverage for health care services or amendment thereto may be used in conjunction with any health care plan until a copy of such schedule or amendment thereto has been filed with and approved by the Commissioner.

      2.  Such charges may be established in accordance with actuarial principles for various categories of enrollees. However the charges shall not be excessive, inadequate nor unfairly discriminatory. A certification by a qualified actuary to the adequacy of the charges shall accompany the filing along with adequate supporting information.

      (Added to NRS by 1973, 1251; R 2013, 3661, effective January 1, 2014)

      NRS 695C.185  Approval or denial of claims; payment of claims and interest; requests for additional information; award of costs and attorney’s fees; compliance with requirements.

      1.  Except as otherwise provided in subsection 2, a health maintenance organization shall approve or deny a claim relating to a health care plan within 30 days after the health maintenance organization receives the claim. If the claim is approved, the health maintenance organization shall pay the claim within 30 days after it is approved. Except as otherwise provided in this section, if the approved claim is not paid within that period, the health maintenance organization shall pay interest on the claim at a rate of interest equal to the prime rate at the largest bank in Nevada, as ascertained by the Commissioner of Financial Institutions, on January 1 or July 1, as the case may be, immediately preceding the date on which the payment was due, plus 6 percent. The interest must be calculated from 30 days after the date on which the claim is approved until the date on which the claim is paid.

      2.  If the health maintenance organization requires additional information to determine whether to approve or deny the claim, it shall notify the claimant of its request for the additional information within 20 days after it receives the claim. The health maintenance organization shall notify the provider of health care services of all the specific reasons for the delay in approving or denying the claim. The health maintenance organization shall approve or deny the claim within 30 days after receiving the additional information. If the claim is approved, the health maintenance organization shall pay the claim within 30 days after it receives the additional information. If the approved claim is not paid within that period, the health maintenance organization shall pay interest on the claim in the manner prescribed in subsection 1.

      3.  A health maintenance organization shall not request a claimant to resubmit information that the claimant has already provided to the health maintenance organization, unless the health maintenance organization provides a legitimate reason for the request and the purpose of the request is not to delay the payment of the claim, harass the claimant or discourage the filing of claims.

      4.  A health maintenance organization shall not pay only part of a claim that has been approved and is fully payable.

      5.  A court shall award costs and reasonable attorney’s fees to the prevailing party in an action brought pursuant to this section.

      6.  The payment of interest provided for in this section for the late payment of an approved claim may be waived only if the payment was delayed because of an act of God or another cause beyond the control of the health maintenance organization.

      7.  The Commissioner may require a health maintenance organization to provide evidence which demonstrates that the health maintenance organization has substantially complied with the requirements set forth in this section, including, without limitation, payment within 30 days of at least 95 percent of approved claims or at least 90 percent of the total dollar amount for approved claims.

      8.  If the Commissioner determines that a health maintenance organization is not in substantial compliance with the requirements set forth in this section, the Commissioner may require the health maintenance organization to pay an administrative fine in an amount to be determined by the Commissioner. Upon a second or subsequent determination that a health maintenance organization is not in substantial compliance with the requirements set forth in this section, the Commissioner may suspend or revoke the certificate of authority of the health maintenance organization.

      (Added to NRS by 1991, 1331; A 1999, 1651; 2001, 2735; 2003, 3368)

      NRS 695C.187  Schedule for payment of claims: Mandatory inclusion in arrangements for provision of health care.

      1.  A health maintenance organization shall not:

      (a) Enter into any contract or agreement, or make any other arrangements, with a provider for the provision of health care; or

      (b) Employ a provider pursuant to a contract, an agreement or any other arrangement to provide health care,

Ê unless the contract, agreement or other arrangement specifically provides that the health maintenance organization and provider agree to the schedule for the payment of claims set forth in NRS 695C.185.

      2.  Any contract, agreement or other arrangement between a health maintenance organization and a provider that is entered into or renewed on or after October 1, 2001, that does not specifically include a provision concerning the schedule for the payment of claims as required by subsection 1 shall be deemed to conform with the requirements of subsection 1 by operation of law.

      (Added to NRS by 2001, 2734)

      NRS 695C.190  Commissioner may require submission of information.  The Commissioner may require the submission of whatever relevant information the Commissioner deems necessary in determining whether to approve or disapprove a filing made pursuant to NRS 695C.170 to 695C.200, inclusive.

      (Added to NRS by 1973, 1252; A 1985, 1448; 1989, 1274)

      NRS 695C.193  Summary of coverage: Contents of disclosure; approval by Commissioner; regulations. [Effective through December 31, 2013.]

      1.  The Commissioner shall adopt regulations which require a health maintenance organization to file with the Commissioner, for approval by the Commissioner, a disclosure summarizing the coverage provided by each health care plan offered by the health maintenance organization. The disclosure must include:

      (a) Any significant exception, reduction or limitation that applies to the plan; and

      (b) Any other information,

Ê that the Commissioner finds necessary to provide for full and fair disclosure of the provisions of the plan.

      2.  The disclosure must be written in language which is easily understood and must include a statement that the disclosure is a summary of the plan only, and that the evidence of coverage itself should be read to determine the governing contractual provisions.

      3.  The Commissioner shall not approve any proposed disclosure submitted to the Commissioner pursuant to this section which does not comply with the requirements of this section and the applicable regulations.

      (Added to NRS by 1989, 1253; R 2013, 3661, effective January 1, 2014)

      NRS 695C.195  Summary of coverage: Copy to be provided before policy issued; policy not to be offered unless summary approved by Commissioner. [Effective through December 31, 2013.]  A health maintenance organization shall provide to the group policyholder to whom it offers a health care plan a copy of the disclosure approved for that plan pursuant to NRS 695C.193 before the plan is issued. A health maintenance organization shall not offer a health care plan unless the disclosure for that plan has been approved by the Commissioner.

      (Added to NRS by 1989, 1253; R 2013, 3661, effective January 1, 2014)

      NRS 695C.200  Approval of forms and schedules. [Effective through December 31, 2013.]  The Commissioner shall within a reasonable period approve any form if the requirements of NRS 695C.170 are met and any schedule of charges if the requirements of NRS 695C.180 are met. It is unlawful to issue such form or to use such schedule of charges until approved. If the Commissioner disapproves such filing, the Commissioner shall notify the filer. In the notice, the Commissioner shall specify the reasons for disapproval. A hearing will be granted within 90 days after a request in writing by the person filing.

      (Added to NRS by 1973, 1251)

      NRS 695C.200  Approval of forms and schedules. [Effective January 1, 2014.]  The Commissioner shall within a reasonable period approve any form if the requirements of NRS 695C.170 are met. It is unlawful to issue such form or to use such schedule of charges until approved. If the Commissioner disapproves such filing, the Commissioner shall notify the filer. In the notice, the Commissioner shall specify the reasons for disapproval. A hearing will be granted within 90 days after a request in writing by the person filing.

      (Added to NRS by 1973, 1251; A 2013, 3646, effective January 1, 2014)

      NRS 695C.201  Offering policy of health insurance for purposes of establishing health savings account.  A health maintenance organization may, subject to regulation by the Commissioner, offer a policy of health insurance that has a high deductible and is in compliance with 26 U.S.C. § 223 for the purposes of establishing a health savings account.

      (Added to NRS by 2005, 2158)

      NRS 695C.203  Denying coverage solely because person was victim of domestic violence prohibited.  A health maintenance organization shall not deny a claim, refuse to issue a policy or cancel a policy solely because the claim involves an act that constitutes domestic violence pursuant to NRS 33.018, or because the person applying for or covered by the policy was the victim of such an act of domestic violence, regardless of whether the insured or applicant contributed to any loss or injury.

      (Added to NRS by 1997, 1096)

      NRS 695C.205  Denying coverage solely because insured was intoxicated or under the influence of controlled substance prohibited; exceptions.

      1.  Except as otherwise provided in subsection 2, a health maintenance organization shall not:

      (a) Deny a claim under a health care plan solely because the claim involves an injury sustained by an enrollee as a consequence of being intoxicated or under the influence of a controlled substance.

      (b) Cancel participation under a health care plan solely because an enrollee has made a claim involving an injury sustained by the enrollee as a consequence of being intoxicated or under the influence of a controlled substance.

      (c) Refuse participation under a health care plan to an eligible applicant solely because the applicant has made a claim involving an injury sustained by the applicant as a consequence of being intoxicated or under the influence of a controlled substance.

      2.  The provisions of subsection 1 do not prohibit a health maintenance organization from enforcing a provision included in a health care plan to:

      (a) Deny a claim which involves an injury to which a contributing cause was the insured’s commission of or attempt to commit a felony;

      (b) Cancel participation under a health care plan solely because of such a claim; or

      (c) Refuse participation under a health care plan to an eligible applicant solely because of such a claim.

      3.  The provisions of this section do not apply to a health maintenance organization under a health care plan that provides coverage for long-term care or disability income.

      (Added to NRS by 2005, 2345; A 2007, 86)

      NRS 695C.207  Requiring or using information concerning genetic testing.

      1.  A health maintenance organization shall not:

      (a) Require an enrollee or any member of the family of the enrollee to take a genetic test;

      (b) Require an enrollee to disclose whether the enrollee or any member of the family of the enrollee has taken a genetic test or the genetic information of the enrollee or a member of the family of the enrollee; or

      (c) Determine the rates or any other aspect of the coverage or benefits for health care provided to an enrollee based on:

             (1) Whether the enrollee or any member of the family of the enrollee has taken a genetic test; or

             (2) Any genetic information of the enrollee or any member of the family of the enrollee.

      2.  As used in this section:

      (a) “Genetic information” means any information that is obtained from a genetic test.

      (b) “Genetic test” means a test, including a laboratory test which uses deoxyribonucleic acid extracted from the cells of a person or a diagnostic test, to determine the presence of abnormalities or deficiencies, including carrier status, that:

             (1) Are linked to physical or mental disorders or impairments; or

             (2) Indicate a susceptibility to illness, disease, impairment or any other disorder, whether physical or mental.

      (Added to NRS by 1997, 1461)

      NRS 695C.210  Annual report and financial statement required; administrative penalty for failure to file report or statement. [Effective through December 31, 2013.]

      1.  Every health maintenance organization shall file with the Commissioner on or before March 1 of each year a report showing its financial condition on the last day of the preceding calendar year. The report must be verified by at least two principal officers of the organization. The organization shall file a copy of the report with the State Board of Health.

      2.  The report must be on forms prescribed by the Commissioner and must include:

      (a) A financial statement of the organization, including its balance sheet and receipts and disbursements for the preceding calendar year;

      (b) Any material changes in the information submitted pursuant to NRS 695C.070;

      (c) The number of persons enrolled during the year, the number of enrollees as of the end of the year, the number of enrollments terminated during the year and, if requested by the Commissioner, a compilation of the reasons for such terminations;

      (d) The number and amount of malpractice claims initiated against the health maintenance organization and any of the providers used by it during the year broken down into claims with and without form of legal process, and the disposition, if any, of each such claim, if requested by the Commissioner;

      (e) A summary of information compiled pursuant to paragraph (c) of subsection 2 of NRS 695C.080 in such form as required by the State Board of Health; and

      (f) Such other information relating to the performance of the health maintenance organization as is necessary to enable the Commissioner to carry out his or her duties pursuant to this chapter.

      3.  Every health maintenance organization shall file with the Commissioner annually an audited financial statement of the organization prepared by an independent certified public accountant. The statement must cover the preceding 12-month period and must be filed with the Commissioner within 120 days after the end of the organization’s fiscal year. Upon written request, the Commissioner may grant a 30-day extension.

      4.  If an organization fails to file timely the report or financial statement required by this section, it shall pay an administrative penalty of $100 per day until the report or statement is filed, except that the total penalty must not exceed $3,000. The Attorney General shall recover the penalty in the name of the State of Nevada.

      5.  The Commissioner may grant a reasonable extension of time for filing the report or financial statement required by this section, if the request for an extension is submitted in writing and shows good cause.

      (Added to NRS by 1973, 1252; A 1991, 2204; 1995, 1632, 2681)

      NRS 695C.210  Annual report and financial statement required; administrative penalty for failure to file report or statement. [Effective January 1, 2014.]

      1.  Every health maintenance organization shall file with the Commissioner on or before March 1 of each year a report showing its financial condition on the last day of the preceding calendar year. The report must be verified by at least two principal officers of the organization.

      2.  The report must be on forms prescribed by the Commissioner and must include:

      (a) A financial statement of the organization, including its balance sheet and receipts and disbursements for the preceding calendar year;

      (b) Any material changes in the information submitted pursuant to NRS 695C.070;

      (c) The number of persons enrolled during the year, the number of enrollees as of the end of the year, the number of enrollments terminated during the year and, if requested by the Commissioner, a compilation of the reasons for such terminations;

      (d) The number and amount of malpractice claims initiated against the health maintenance organization and any of the providers used by it during the year broken down into claims with and without form of legal process, and the disposition, if any, of each such claim, if requested by the Commissioner;

      (e) A summary of information compiled pursuant to paragraph (c) of subsection 1 of NRS 695C.080 in such form as required by the Commissioner; and

      (f) Such other information relating to the performance of the health maintenance organization as is necessary to enable the Commissioner to carry out his or her duties pursuant to this chapter.

      3.  Every health maintenance organization shall file with the Commissioner annually an audited financial statement of the organization prepared by an independent certified public accountant. The statement must cover the preceding 12-month period and must be filed with the Commissioner within 120 days after the end of the organization’s fiscal year. Upon written request, the Commissioner may grant a 30-day extension.

      4.  If an organization fails to file timely the report or financial statement required by this section, it shall pay an administrative penalty of $100 per day until the report or statement is filed, except that the total penalty must not exceed $3,000. The Attorney General shall recover the penalty in the name of the State of Nevada.

      5.  The Commissioner may grant a reasonable extension of time for filing the report or financial statement required by this section, if the request for an extension is submitted in writing and shows good cause.

      (Added to NRS by 1973, 1252; A 1991, 2204; 1995, 1632, 2681; 2013, 3646, effective January 1, 2014)

      NRS 695C.220  Applications, filings and reports open to public inspection.  All applications, filings and reports required under this chapter shall be treated as public documents except as otherwise provided in this chapter.

      (Added to NRS by 1973, 1258)

      NRS 695C.230  Fees.

      1.  Every health maintenance organization subject to this chapter shall pay to the Commissioner the following fees:

      (a) For filing an application for a certificate of authority, $2,450.

      (b) For issuance of a certificate of authority, $250.

      (c) For an amendment to a certificate of authority, $100.

      (d) For the renewal of a certificate of authority, $2,450.

      (e) For filing each annual report, $25.

      (f) In addition to any other fee or charge, all applicable fees required pursuant to NRS 680C.110.

      2.  At the time of filing the annual report the health maintenance organization shall forward to the department of taxation the tax and any penalty for nonpayment or delinquent payment of the tax in accordance with the provisions of chapter 680B of NRS.

      3.  All fees paid pursuant to this section shall be deemed earned when paid and may not be refunded.

      (Added to NRS by 1973, 1257; A 1987, 470; 1991, 1634; 1993, 1923; 2009, 1818)

      NRS 695C.240  Information required to be available for inspection.  Every health maintenance organization shall have available for inspection the following information:

      1.  A current statement of financial condition including a balance sheet and summary of receipts and disbursements;

      2.  A description of the organizational structure and operation of the health maintenance organization and a summary of any material changes since the issuance of the last report;

      3.  A description of services and information as to where and how to secure them; and

      4.  A clear and understandable description of the health maintenance organization’s method for resolving enrollee complaints.

      (Added to NRS by 1973, 1252)

      NRS 695C.250  Open enrollment. [Effective through December 31, 2013.]

      1.  After a health maintenance organization has been in operation 24 months, it shall have an annual open enrollment commensurate with common practices in the area in which it operates.

      2.  Health maintenance organizations providing services to a specified group or groups may limit the open enrollment to all members of such group or groups. “Specified groups” may include:

      (a) Employees of one or more specified employers;

      (b) Members of one or more specified employee organizations;

      (c) Members of one or more specified associations; and

      (d) Participants in one or more specified group policies issued by one or more specified insurers if the insurer is involved in the operation, management or conduct of the health maintenance organization.

      (Added to NRS by 1973, 1252; R 2013, 3661, effective January 1, 2014)

      NRS 695C.260  Complaint system.  Each health maintenance organization shall establish:

      1.  A system for resolving complaints which complies with the provisions of NRS 695G.200 to 695G.230, inclusive; and

      2.  A system for conducting external reviews of adverse determinations that complies with the provisions of NRS 695G.241 to 695G.310, inclusive.

      (Added to NRS by 1973, 1253; A 1997, 311; 2003, 778; 2011, 3395)

      NRS 695C.265  Required procedure for arbitration of disputes concerning independent medical evaluations.

      1.  If a health maintenance organization, for any final determination of benefits or care, requires an independent evaluation of the medical or chiropractic care of any person for whom such care is provided under the evidence of coverage:

      (a) The evidence of coverage must include a procedure for binding arbitration to resolve disputes concerning independent medical evaluations pursuant to the rules of the American Arbitration Association; and

      (b) Only a physician or chiropractor who is certified to practice in the same field of practice as the primary treating physician or chiropractor or who is formally educated in that field may conduct the independent evaluation.

      2.  The independent evaluation must include a physical examination of the patient, unless the patient is deceased, and a personal review of all X rays and reports prepared by the primary treating physician or chiropractor. A certified copy of all reports of findings must be sent to the primary treating physician or chiropractor and the insured person within 10 working days after the evaluation. If the insured person disagrees with the finding of the evaluation, the insured person must submit an appeal to the insurer pursuant to the procedure for binding arbitration set forth in the evidence of coverage within 30 days after the insured person receives the finding of the evaluation. Upon its receipt of an appeal, the insurer shall so notify in writing the primary treating physician or chiropractor.

      3.  The insurer shall not limit or deny coverage for care related to a disputed claim while the dispute is in arbitration, except that, if the insurer prevails in the arbitration, the primary treating physician or chiropractor may not recover any payment from either the insurer, insured person or the patient for services that the primary treating physician or chiropractor provided to the patient after receiving written notice from the insurer pursuant to subsection 2 concerning the appeal of the insured person.

      (Added to NRS by 1989, 2116)

      NRS 695C.267  Provision requiring binding arbitration authorized; procedures for arbitration; declaratory relief.

      1.  Except as otherwise provided in NRS 695C.265 and subject to the approval of the Commissioner, a health maintenance organization may include in any evidence of coverage issued by the organization a provision which requires an enrollee to whom the evidence of coverage is issued and the health maintenance organization to submit for binding arbitration any dispute between the enrollee and the organization concerning any matter directly or indirectly related to, or associated with, the evidence of coverage or the health care plan or health care services of the health maintenance organization. If such a provision is included in the evidence of coverage:

      (a) An enrollee must be given the opportunity to decline to participate in binding arbitration at the time of his or her enrollment.

      (b) It must clearly state that the health maintenance organization and an enrollee who has not declined to participate in binding arbitration agree to forego their right to resolve any such dispute in a court of law or equity.

      2.  Except as otherwise provided in subsection 3, the arbitration must be conducted pursuant to the rules for commercial arbitration established by the American Arbitration Association. The health maintenance organization is responsible for any administrative fees and expenses relating to the arbitration, except that the health maintenance organization is not responsible for attorney’s fees and fees for expert witnesses unless those fees are awarded by the arbitrator.

      3.  If a dispute required to be submitted to binding arbitration requires an immediate resolution to protect the physical health of an enrollee, any party to the dispute may waive arbitration and seek declaratory relief in a court of competent jurisdiction.

      4.  If a provision described in subsection 1 is included in any evidence of coverage issued by a health maintenance organization, the provision shall not be deemed unenforceable as an unreasonable contract of adhesion if the provision is included in compliance with the provisions of subsection 1.

      (Added to NRS by 1995, 2559)

      NRS 695C.270  Bond required; waiver.  Each health maintenance organization shall furnish a surety bond in an amount satisfactory to the Commissioner or deposit with the Commissioner cash or securities acceptable to the Commissioner in at least the same amount as a guarantee that the obligations to the enrollees will be performed. The Commissioner may waive this requirement whenever satisfied that the assets of the organization and its contracts with insurers, governments, or other organizations are sufficient to reasonably assure the performance of its obligations.

      (Added to NRS by 1973, 1253)

      NRS 695C.275  Commissioner to adopt regulations for licensing of provider-sponsored organizations.

      1.  To the extent authorized by federal law, the Commissioner shall adopt regulations for the licensing of provider-sponsored organizations in this State.

      2.  As used in this section, “provider-sponsored organization” has the meaning ascribed to it in 42 U.S.C. § 1395w-25(d).

      (Added to NRS by 1999, 2817)

      NRS 695C.280  Commissioner authorized to adopt regulations for licensing of agents or brokers.  The Commissioner may adopt such reasonable regulations as are necessary to provide for the licensing of agents or brokers. An agent is a person directly or indirectly associated with a health care plan who engages in solicitation or enrollment. A broker is a person who is directly involved with the insured in the manner provided in chapter 683A of NRS.

      (Added to NRS by 1973, 1254; A 1981, 107; 1993, 2401)

      NRS 695C.290  Insurance company may establish or contract with health maintenance organization.

      1.  An insurance company licensed in this State may either directly or through a subsidiary or affiliate organize and operate a health maintenance organization under the provisions of this chapter. Notwithstanding any other law which may be inconsistent herewith, any two or more such insurance companies or subsidiaries or affiliates thereof may jointly organize and operate a health maintenance organization. The business of insurance is deemed to include the providing of health care by a health maintenance organization owned or operated by an insurer or a subsidiary thereof.

      2.  An insurer may contract with a health maintenance organization to provide insurance or similar protection against the cost of care provided through health maintenance organizations and to provide coverage in the event of the failure of the health maintenance organization to meet its obligations. Among other things, under such contracts the insurer may make benefit payments to health maintenance organizations for health care services rendered by providers pursuant to the health care plan.

      (Added to NRS by 1973, 1254)

      NRS 695C.300  Prohibited practices.

      1.  No health maintenance organization or representative thereof may cause or knowingly permit the use of advertising which is untrue or misleading, solicitation which is untrue or misleading or any form of evidence of coverage which is deceptive. For purposes of this chapter:

      (a) A statement or item of information shall be deemed to be untrue if it does not conform to fact in any respect which is or may be significant to an enrollee of, or person considering enrollment in, a health care plan.

      (b) A statement or item of information shall be deemed to be misleading, whether or not it may be literally untrue if, in the total context in which such statement is made or such item of information is communicated, such statement or item of information may be reasonably understood by a reasonable person not possessing special knowledge regarding health care coverage, as indicating any benefit or advantage or the absence of any exclusion, limitation or disadvantage of possible significance to an enrollee of, or person considering enrollment in, a health care plan if such benefit or advantage or absence of limitation, exclusion or disadvantage does not in fact exist.

      (c) An evidence of coverage shall be deemed to be deceptive if the evidence of coverage taken as a whole, and with consideration given to typography and format as well as language, shall be such as to cause a reasonable person not possessing special knowledge regarding health care plans and evidences of coverage therefor to expect benefits, services, charges or other advantages which the evidence of coverage does not provide or which the health care plan issuing such evidence of coverage does not regularly make available for enrollees covered under such evidence of coverage.

      2.  NRS 686A.010 to 686A.310, inclusive, shall be construed to apply to health maintenance organizations, health care plans and evidences of coverage except to the extent that the nature of health maintenance organizations, health care plans and evidences of coverage render the sections therein clearly inappropriate.

      3.  An enrollee may not be cancelled or not renewed except for the failure to pay the charge for such coverage or for cause as determined in the master contract.

      4.  No health maintenance organization, unless licensed as an insurer, may use in its name, contracts, or literature any of the words “insurance,” “casualty,” “surety,” “mutual” or any other words descriptive of the insurance, casualty or surety business or deceptively similar to the name or description of any insurance or surety corporation doing business in this State.

      5.  No person not certificated under this chapter shall use in its name, contracts or literature the phrase “health maintenance organization” or the initials “HMO.”

      (Added to NRS by 1973, 1253)

      NRS 695C.310  Examinations. [Effective through December 31, 2013.]

      1.  The Commissioner shall make an examination of the affairs of any health maintenance organization and providers with whom such organization has contracts, agreements or other arrangements pursuant to its health care plan as often as the Commissioner deems it necessary for the protection of the interests of the people of this State. An examination must be made not less frequently than once every 3 years.

      2.  The State Board of Health shall make an examination concerning the quality of health care services of any health maintenance organization and providers with whom such organization has contracts, agreements or other arrangements pursuant to its health care plan as often as it deems necessary for the protection of the interests of the people of this State. An examination must be made not less frequently than once every 3 years.

      3.  Every health maintenance organization and provider shall submit its books and records relating to the health care plan to an examination made pursuant to subsection 1 or 2 and in every way facilitate the examination. Medical records of natural persons and records of physicians providing service pursuant to a contract to the health maintenance organization are not subject to such examination, although the records are subject to subpoena upon a showing of good cause. For the purpose of examinations, the Commissioner and the State Board of Health may administer oaths to, and examine the officers and agents of the health maintenance organization and the principals of such providers concerning their business.

      4.  The expenses of examinations pursuant to this section must be assessed against the organization being examined and remitted to the Commissioner or the State Board of Health, whichever is appropriate.

      5.  In lieu of such examination, the Commissioner may accept the report of an examination made by the insurance commissioner or the state board of health of another state.

      (Added to NRS by 1973, 1255; A 1991, 2036)

      NRS 695C.310  Examinations. [Effective January 1, 2014.]

      1.  The Commissioner shall make an examination of the affairs of any health maintenance organization and providers with whom such organization has contracts, agreements or other arrangements pursuant to its health care plan as often as the Commissioner deems it necessary for the protection of the interests of the people of this State. An examination must be made not less frequently than once every 3 years.

      2.  The Commissioner shall make an examination concerning the quality of health care services of any health maintenance organization and providers with whom such organization has contracts, agreements or other arrangements pursuant to its health care plan as often as it deems necessary for the protection of the interests of the people of this State. An examination must be made not less frequently than once every 3 years.

      3.  Every health maintenance organization and provider shall submit its books and records relating to the health care plan to an examination made pursuant to subsection 1 or 2 and in every way facilitate the examination. Medical records of natural persons and records of physicians providing service pursuant to a contract to the health maintenance organization are not subject to such examination, although the records are subject to subpoena upon a showing of good cause. For the purpose of examinations, the Commissioner may administer oaths to, and examine the officers and agents of the health maintenance organization and the principals of such providers concerning their business.

      4.  The expenses of examinations pursuant to this section must be assessed against the organization being examined and remitted to the Commissioner.

      5.  In lieu of such examination, the Commissioner may accept the report of an examination made by the insurance commissioner or the state board of health of another state.

      (Added to NRS by 1973, 1255; A 1991, 2036; 2013, 3647, effective January 1, 2014)

      NRS 695C.311  Periodic examination by Commissioner to determine financial condition of health maintenance organization.

      1.  For the purpose of determining its financial condition, fulfillment of its contractual obligations and compliance with law, the Commissioner shall, as often as the Commissioner deems advisable, examine the affairs, transactions, accounts, records and assets of a health maintenance organization and of any person as to any matter relevant to the financial affairs of the health maintenance organization or to the examination. Except as otherwise provided in this Code, the Commissioner shall examine each health maintenance organization at least once every 3 years.

      2.  The Commissioner shall examine each health maintenance organization applying for an initial certificate of authority.

      3.  In lieu of making his or her own examination, the Commissioner may, in the discretion of the Commissioner, accept a full report of the last recent examination of a foreign or alien health maintenance organization, certified to by the supervisory officer of insurance of another state.

      4.  To the extent that it is practical, the examination of a foreign or alien health maintenance organization must be made in cooperation with the insurance supervisory officers of other states in which the organization transacts business.

      (Added to NRS by 1991, 2035)

      NRS 695C.313  Financial examination: Procedure; appointment of examiner; maintenance and use of records; penalty for obstruction or interference.

      1.  If the Commissioner determines to examine a health maintenance organization pursuant to NRS 695C.311, the Commissioner shall designate one or more examiners and instruct them as to the scope of the examination. The examiner shall, upon demand, exhibit his or her official credentials to the health maintenance organization being examined.

      2.  The Commissioner shall conduct each examination in an expeditious, fair and impartial manner.

      3.  The Commissioner, or the examiner if the examiner is authorized in writing by the Commissioner, may administer oaths and examine under oath any person concerning any matter relevant to the examination.

      4.  Every health maintenance organization and its officers, attorneys, employees, agents and representatives shall make available to the Commissioner or the examiners of the Commissioner the accounts, records, documents, files, information, assets and matters of the health maintenance organization in his or her possession or control relating to the subject of the examination and shall facilitate the examination.

      5.  If the Commissioner or examiner finds any accounts or records to be inadequate or inadequately kept or posted, he or she shall so notify the health maintenance organization and give the health maintenance organization a reasonable opportunity to reconstruct, rewrite, post or balance the account or record. If the health maintenance organization fails to maintain, complete or correct the records or accounting after the Commissioner or examiner has given the health maintenance organization written notice and a reasonable opportunity to do so, the Commissioner may employ experts to reconstruct, rewrite, post or balance the account or record at the expense of the health maintenance organization being examined.

      6.  The Commissioner or an examiner shall not remove any record, account, document, file or other property of the health maintenance organization being examined from the office or place of business of the health maintenance organization unless the Commissioner or examiner has the written consent of an officer of the health maintenance organization before the removal or pursuant to an order of court. This provision does not prohibit the Commissioner or examiner from making or removing copies or abstracts of a record, account, document or file.

      7.  Any person who, without just cause, refuses to be examined under oath or who willfully obstructs or interferes with an examiner in the exercise of his or her authority is guilty of a misdemeanor.

      (Added to NRS by 1991, 2035)

      NRS 695C.315  Financial examination: Payment of expense.

      1.  The health maintenance organization being examined shall pay the expense of an examination. The expenses to be paid include only the reasonable and proper travel and lodging expenses of the Commissioner and the examiners and assistants of the Commissioner, including expert assistance, reasonable compensation to the examiners and assistants and incidental expenses as necessarily incurred in the examination. The Commissioner shall consider the scales and limitations recommended by the National Association of Insurance Commissioners regarding the expense and compensation for an examination.

      2.  The health maintenance organization shall promptly pay to the Commissioner the expenses of the examination upon presentation by the Commissioner of a reasonably detailed written statement thereof.

      (Added to NRS by 1991, 2036)

      NRS 695C.317  Statutory procedures required for examination and hearing.  The Commissioner shall use the procedures required by:

      1.  NRS 679B.230 to 679B.290, inclusive, when conducting an examination of a health maintenance organization.

      2.  NRS 679B.310 to 679B.370, inclusive, when conducting a hearing involving a health maintenance organization.

      (Added to NRS by 1991, 2036)

      NRS 695C.320  Rehabilitation, liquidation or conservation.  Any rehabilitation, liquidation or conservation of a health maintenance organization shall be deemed to be the rehabilitation, liquidation or conservation of an insurance company and shall be conducted under the supervision of the Commissioner pursuant to the law governing the rehabilitation, liquidation, or conservation of insurance companies.

      (Added to NRS by 1973, 1256)

      NRS 695C.325  Authorization to offer health care plan to small employer for purpose of establishing medical savings accounts.  A health maintenance organization may offer to a small employer who has not less than 2 and not more than 50 employees, a health care plan that has a high deductible and that is in compliance with 26 U.S.C. § 220 for the purposes of establishing medical savings accounts for any person insured by the health care plan.

      (Added to NRS by 1997, 2957)

      NRS 695C.330  Disciplinary proceedings: Grounds; effect of suspension or revocation. [Effective through December 31, 2013.]

      1.  The Commissioner may suspend or revoke any certificate of authority issued to a health maintenance organization pursuant to the provisions of this chapter if the Commissioner finds that any of the following conditions exist:

      (a) The health maintenance 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 NRS 695C.060, 695C.070 and 695C.140, unless any amendments to those submissions have been filed with and approved by the Commissioner;

      (b) The health maintenance organization issues evidence of coverage or uses a schedule of charges for health care services which do not comply with the requirements of NRS 695C.1691 to 695C.200, inclusive, or 695C.207;

      (c) The health care plan does not furnish comprehensive health care services as provided for in NRS 695C.060;

      (d) The State Board of Health certifies to the Commissioner that the health maintenance organization:

             (1) Does not meet the requirements of subsection 2 of NRS 695C.080; or

             (2) Is unable to fulfill its obligations to furnish health care services as required under its health care plan;

      (e) The health maintenance organization is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees;

      (f) The health maintenance organization has failed to put into effect a mechanism affording the enrollees an opportunity to participate in matters relating to the content of programs pursuant to NRS 695C.110;

      (g) The health maintenance organization has failed to put into effect the system required by NRS 695C.260 for:

             (1) Resolving complaints in a manner reasonably to dispose of valid complaints; and

             (2) Conducting external reviews of adverse determinations that comply with the provisions of NRS 695G.241 to 695G.310, inclusive;

      (h) The health maintenance organization or any person on its behalf has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive or unfair manner;

      (i) The continued operation of the health maintenance organization would be hazardous to its enrollees;

      (j) The health maintenance organization fails to provide the coverage required by NRS 695C.1691; or

      (k) The health maintenance organization has otherwise failed to comply substantially with the provisions of this chapter.

      2.  A certificate of authority must be suspended or revoked only after compliance with the requirements of NRS 695C.340.

      3.  If the certificate of authority of a health maintenance organization is suspended, the health maintenance organization shall not, during the period of that suspension, enroll any additional groups or new individual contracts, unless those groups or persons were contracted for before the date of suspension.

      4.  If the certificate of authority of a health maintenance organization is revoked, the organization shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of the organization. It shall engage in no further advertising or solicitation of any kind. The Commissioner may, by written order, permit such further operation of the organization as the Commissioner may find to be in the best interest of enrollees to the end that enrollees are afforded the greatest practical opportunity to obtain continuing coverage for health care.

      (Added to NRS by 1973, 1255; A 1985, 1448; 1997, 745, 1462, 1629; 1999, 417, 419, 761, 2004; 2001, 141, 144; 2003, 778, 1336, 3369, 3532; 2007, 3240; 2009, 1474; 2011, 3395; 2013, 2000)

      NRS 695C.330  Disciplinary proceedings: Grounds; effect of suspension or revocation. [Effective January 1, 2014.]

      1.  The Commissioner may suspend or revoke any certificate of authority issued to a health maintenance organization pursuant to the provisions of this chapter if the Commissioner finds that any of the following conditions exist:

      (a) The health maintenance 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 NRS 695C.060, 695C.070 and 695C.140, unless any amendments to those submissions have been filed with and approved by the Commissioner;

      (b) The health maintenance organization issues evidence of coverage or uses a schedule of charges for health care services which do not comply with the requirements of NRS 695C.1691 to 695C.200, inclusive, or 695C.207;

      (c) The health care plan does not furnish comprehensive health care services as provided for in NRS 695C.060;

      (d) The Commissioner certifies that the health maintenance organization:

             (1) Does not meet the requirements of subsection 1 of NRS 695C.080; or

             (2) Is unable to fulfill its obligations to furnish health care services as required under its health care plan;

      (e) The health maintenance organization is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees;

      (f) The health maintenance organization has failed to put into effect a mechanism affording the enrollees an opportunity to participate in matters relating to the content of programs pursuant to NRS 695C.110;

      (g) The health maintenance organization has failed to put into effect the system required by NRS 695C.260 for:

             (1) Resolving complaints in a manner reasonably to dispose of valid complaints; and

             (2) Conducting external reviews of adverse determinations that comply with the provisions of NRS 695G.241 to 695G.310, inclusive;

      (h) The health maintenance organization or any person on its behalf has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive or unfair manner;

      (i) The continued operation of the health maintenance organization would be hazardous to its enrollees;

      (j) The health maintenance organization fails to provide the coverage required by NRS 695C.1691; or

      (k) The health maintenance organization has otherwise failed to comply substantially with the provisions of this chapter.

      2.  A certificate of authority must be suspended or revoked only after compliance with the requirements of NRS 695C.340.

      3.  If the certificate of authority of a health maintenance organization is suspended, the health maintenance organization shall not, during the period of that suspension, enroll any additional groups or new individual contracts, unless those groups or persons were contracted for before the date of suspension.

      4.  If the certificate of authority of a health maintenance organization is revoked, the organization shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of the organization. It shall engage in no further advertising or solicitation of any kind. The Commissioner may, by written order, permit such further operation of the organization as the Commissioner may find to be in the best interest of enrollees to the end that enrollees are afforded the greatest practical opportunity to obtain continuing coverage for health care.

      (Added to NRS by 1973, 1255; A 1985, 1448; 1997, 745, 1462, 1629; 1999, 417, 419, 761, 2004; 2001, 141, 144; 2003, 778, 1336, 3369, 3532; 2007, 3240; 2009, 1474; 2011, 3395; 2013, 2000, 3647, effective January 1, 2014)

      NRS 695C.340  Disciplinary proceedings: Notice; hearing; judicial review. [Effective through December 31, 2013.]

      1.  When the Commissioner has cause to believe that grounds for the denial of an application for a certificate of authority exist, or that grounds for the suspension or revocation of a certificate of authority exist, the Commissioner shall notify the health maintenance organization and the State Board of Health 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.  The State Board of Health or its delegated representative shall be in attendance at the hearing and shall participate in the proceedings. The recommendation and findings of the State Board of Health with respect to matters relating to the quality of health maintenance services provided in connection with any decision regarding denial, suspension or revocation of a certificate of authority are conclusive and binding upon the Commissioner. After the hearing, or upon the failure of the health maintenance organization to appear at the hearing, the Commissioner shall take action as is deemed advisable on written findings which must be mailed to the health maintenance organization with a copy thereof to the State Board of Health. The action of the Commissioner and the recommendation and findings of the State Board of Health 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 NRS by 1973, 1256; A 1981, 107)

      NRS 695C.340  Disciplinary proceedings: Notice; hearing; judicial review. [Effective January 1, 2014.]

      1.  When the Commissioner has cause to believe that grounds for the denial of an application for a certificate of authority exist, or that grounds for the suspension or revocation of a certificate of authority exist, the Commissioner shall notify the health maintenance 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 health maintenance organization to appear at the hearing, the Commissioner shall take action as is deemed advisable on written findings which must be mailed to the health maintenance organization. The action of the Commissioner is 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 NRS by 1973, 1256; A 1981, 107; 2013, 3649, effective January 1, 2014)

      NRS 695C.350  Violations: Remedies; penalties. [Effective through December 31, 2013.]

      1.  The Commissioner may, in lieu of suspension or revocation of a certificate of authority under NRS 695C.330, 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.  Any person who violates the provisions of this chapter is guilty of a misdemeanor.

      3.  If the Commissioner or the State Board of Health for any reason have cause to believe that any violation of this chapter has occurred or is threatened, the Commissioner or the State Board of Health may give notice to the health maintenance 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.

      4.  The proceedings conducted pursuant to the provisions of subsection 3 must not be governed by any formal procedural requirements, and may be conducted in such manner as the Commissioner or the State Board of Health may deem appropriate under the circumstances.

      5.  The Commissioner may issue an order directing a health maintenance organization or a representative of a health maintenance organization to cease and desist from engaging in any act or practice in violation of the provisions of this chapter.

      6.  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 must be conducted pursuant to the provisions of chapter 233B of NRS and judicial review must be available as provided therein.

      7.  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 5, 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 NRS by 1973, 1257; A 1999, 2817)

      NRS 695C.350  Violations: Remedies; penalties. [Effective January 1, 2014.]

      1.  The Commissioner may, in lieu of suspension or revocation of a certificate of authority under NRS 695C.330, 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.  Any person who violates the provisions of this chapter is guilty of a misdemeanor.

      3.  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 health maintenance 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.

      4.  The proceedings conducted pursuant to the provisions of subsection 3 must not be governed by any formal procedural requirements, and may be conducted in such manner as the Commissioner may deem appropriate under the circumstances.

      5.  The Commissioner may issue an order directing a health maintenance organization or a representative of a health maintenance organization to cease and desist from engaging in any act or practice in violation of the provisions of this chapter.

      6.  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 must be conducted pursuant to the provisions of chapter 233B of NRS and judicial review must be available as provided therein.

      7.  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 5, 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 NRS by 1973, 1257; A 1999, 2817; 2013, 3649, effective January 1, 2014)