Nevada Administrative Code

NAC 695C.065 “Preexisting condition” defined. (NRS 679B.130) “Preexisting condition” means a medical condition of an enrollee for which he or she has received treatment during the 6 months preceding enrollment in the organization. (Added to NAC by Comm’r of Insurance, eff. 6-11-8…

NAC 695C.070 “Primary physician” defined. (NRS 679B.130) “Primary physician” means the physician who or group of physicians which: 1. Is responsible for the initial and primary care given to an enrollee; 2. Is responsible for maintaining the continuity of care to an enrollee; and…

NAC 695C.075 “Provider-sponsored organization” defined. (NRS 679B.130) “Provider-sponsored organization” means an entity that satisfies all the requirements set forth in 42 U.S.C. § 1395w-25(d) and the federal regulations adopted pursuant thereto. (Added to NAC by Comm’r of Insur…

NAC 695C.080 “Subscriber” defined. (NRS 679B.130) “Subscriber” means an employer or other person purchasing a health care plan for himself or herself or others pursuant to a written contract with an organization. (Added to NAC by Comm’r of Insurance, eff. 6-11-86)

NAC 695C.090 “Uncovered expenditures” defined. (NRS 679B.130) “Uncovered expenditures” means the cost of those services, including services provided during an emergency, rendered by a provider and paid for by an organization during its operation for which: 1. There is no agreemen…

NAC 695C.095 Certain provisions of NRS not applicable to provider-sponsored organizations. (NRS 679B.130, 695C.275) 1. Except as otherwise provided in this chapter or in specific provisions of title 57 of NRS, the provisions of title 57 of NRS are not applicable to any provider-s…

NAC 695C.100 Applicability of certain provisions of NRS to provider-sponsored organizations. (NRS 679B.130, 695C.275) 1. The provisions of NRS 449.465, 679B.159, subsections 2, 4, 17, 18 and 31 of NRS 680B.010, NRS 680B.025 to 680B.060, inclusive, chapter 685B of NRS and NRS 695G…

NAC 695C.105 Treatment of applications, filings and reports as public documents. (NRS 679B.130) All applications, filings and reports required under this chapter must be treated as public documents except as otherwise provided in this chapter. (Added to NAC by Comm’r of Insurance…

NAC 695C.111 Provider-sponsored organization: Certificate required to offer Medicare + Choice plan. (NRS 679B.130, 695C.275) 1. To offer a Medicare + Choice plan in this State, a provider-sponsored organization must file an application with the Commissioner and obtain a certifica…

NAC 695C.115 Application of provider-sponsored organization. (NRS 679B.130, 695C.275) For a provider-sponsored organization, an application for a certificate of authority must be verified by an officer or authorized representative of the applicant, must be in a form prescribed by…

NAC 695C.120 Application: Required documents. (NRS 679B.130, 695C.070, 695C.270, 695C.275) An application for a certificate of authority must be accompanied by all forms specifically required by chapter 695C of NRS and provided by the Division and by: 1. All documents describing …

NAC 695C.121 Application: Submission; incomplete application deemed withdrawn; notice of review; deadline. (NRS 679B.130, 695C.070, 695C.275) 1. Any person applying for a certificate of authority as an organization shall file an application as follows: (a) An original and three c…

NAC 695C.122 Application: Member of insurance holding company system. (NRS 679B.130, 695C.070, 695C.275) 1. Any organization which is wholly or partially owned by an insurance company or other entity defined in NRS 692C.060 shall describe that relationship in its application for …

NAC 695C.1225 Provider-sponsored organization: Transmittal of information to State Board of Health; conditions for issuance of certificate. (NRS 679B.130, 695C.275) Upon the receipt of an application for a certificate of authority, the Commissioner will transmit a copy of the app…

NAC 695C.123 Federal qualification: Information required. (NRS 679B.130, 695C.275) 1. Any organization which holds a certificate of authority issued by the Commissioner and is seeking qualification as a health maintenance organization pursuant to 42 U.S.C. § 300e-9(c) or qualifie…

NAC 695C.124 Application: Public inspection; notice of hearing. (NRS 679B.130, 695C.275) 1. Any person wishing to review an application for issuance of a certificate of authority for an organization shall submit a request to the Division in writing. The application may be reviewe…

NAC 695C.125 Application of health maintenance organization: Evaluation by Division of Public and Behavioral Health. (NRS 439.200, 679B.130, 695C.080) 1. The Division of Public and Behavioral Health shall study each application for a certificate of authority to establish and oper…

NAC 695C.1255 Application: Organization to establish that it has met requirements. (NRS 439.200, 679B.130, 695C.080, 695C.275) 1. An organization applying for a certificate of authority must establish that: (a) The organization has an adequate number of providers in each category…

NAC 695C.126 Application of health maintenance organization: Effect of change after review. (NRS 679B.130) If an applicant for a certificate of authority to establish and operate a health maintenance organization submits information changing its application after review by the St…

NAC 695C.127 Licensure in another state: Application for this State; copy of license; notice of disciplinary action. (NRS 679B.130, 695C.275) 1. Any applicant for a certificate of authority who is licensed to operate an organization in another state or whose affiliate or subsidia…

NAC 695C.128 Licensure in another state: Contract with providers of medical care in state contiguous to Nevada; plan for operation. (NRS 679B.130, 695C.275) 1. If an organization holding a certificate of authority in this State is licensed in a state contiguous to this State and …

NAC 695C.1282 Provider-sponsored organization: Denial of certificate. (NRS 679B.130, 695C.275) The Commissioner may deny a certificate of authority only after he or she has complied with NAC 695C.1286. (Added to NAC by Comm’r of Insurance by R148-99, eff. 1-27-2000)

NAC 695C.1284 Provider-sponsored organization: Grounds for suspension or revocation of certificate; effect of revocation. (NRS 679B.130, 695C.275) 1. The Commissioner may suspend or revoke any certificate of authority issued to a provider-sponsored organization pursuant to the pr…

NAC 695C.1286 Provider-sponsored organization: Notice of hearing; action by Commissioner; judicial review. (NRS 679B.130, 695C.275) 1. When the Commissioner has cause to believe that grounds for the denial of an application for a certificate of authority to operate a provider-spo…

NAC 695C.1288 Provider-sponsored organization: Penalties and remedies for violations; cease and desist order; request for hearing; injunctive relief. (NRS 679B.130, 695C.275) 1. The Commissioner may, in lieu of suspension or revocation of a certificate of authority of a provider-…

NAC 695C.129 Hearings and proceedings. (NRS 679B.130, 695C.275) 1. Any person not entitled to a hearing pursuant to NRS 695C.340 or NAC 695C.1286 who is aggrieved by an action of the Commissioner in his or her approval, denial or revocation of a certificate of authority for an or…

NAC 695C.130 Health maintenance organization: Financial requirements; modification to approved plan of operations. (NRS 679B.130, 695C.140) 1. Except as otherwise provided in this section, a health maintenance organization which receives a certificate of authority shall maintain …

NAC 695C.135 Contract of insurance for health maintenance organization: Amount required; provision concerning insolvency of organization; notice of cancellation. (NRS 679B.130) 1. Each health maintenance organization shall obtain a contract of insurance for the cost of providing …

NAC 695C.136 Contract of insurance for provider-sponsored organization: Amount determined by Commissioner; provision concerning insolvency of organization; notice of cancellation. (NRS 679B.130, 695C.275) 1. A provider-sponsored organization shall obtain a contract of insurance f…

NAC 695C.137 Health maintenance organization: Reserves. (NRS 679B.130) 1. After the first year of operation, as a protection against insolvency, each health maintenance organization shall retain as reserves an amount equal to twice its actual average monthly uncovered expenditure…

NAC 695C.140 Advertising and solicitation. (NRS 679B.130, 695C.275, 695C.300) 1. An organization which advertises its benefits must, in that same advertisement, plainly state the exclusions or limitations of the plan. 2. Any period of waiting required before an enrollee is eligib…

NAC 695C.150 Qualifications of agent or broker. (NRS 679B.130, 695C.280) A person shall not solicit or sell to any group or person any health care plan which provides for comprehensive health care services unless he or she: 1. Has a valid agent’s or broker’s license to sell healt…

NAC 695C.165 Geographic area of service: Expansion. (NRS 679B.130, 695C.275) 1. Any organization which wants to expand its geographic area of service from that stated in its application shall submit to the Division: (a) A copy of a written description of the area it proposes to s…

NAC 695C.170 Health maintenance organization: Required services; optional plans. (NRS 679B.130) 1. The comprehensive health care services offered by a health maintenance organization in its evidence of coverage must provide for basic and preventive medical care for the enrollee w…

NAC 695C.175 Health maintenance organization: Removal of prescription drug from approved formulary prohibited; exception; movement to different tier in formulary; addition of drug to formulary. (NRS 679B.130, 687B.120) 1. Except as otherwise provided in this section, a health mai…

NAC 695C.180 Coordination of benefits; lien against recovery from third person. (NRS 679B.130, 695C.275) 1. An organization may coordinate its benefits with any policy of individual or group health insurance offered by an insurance company, trust established by an employer to pay…

NAC 695C.185 Restrictions on benefits payable by more than one insurer to provider. (NRS 679B.130, 695C.275) When the benefits set forth in any evidence of coverage are payable by more than one insurer to a provider, the evidence of coverage must not require the insured, or any s…

NAC 695C.190 Requirements for agreement between provider and organization. (NRS 679B.130, 695C.275) Each agreement between a provider and an organization must: 1. Adequately and completely describe the responsibilities of the provider and organization under the agreement. 2. Spec…

NAC 695C.195 Per capita payments. (NRS 679B.130, 695C.275) 1. An agreement between a primary physician or delivery system intermediary and an organization may provide for per capita payments. If an agreement provides for per capita payments, such payments must be: (a) Paid in adv…

NAC 695C.205 Restriction of choice of primary physician or other provider. (NRS 679B.130, 695C.275) Any organization may restrict the enrollee’s or subscriber’s choice of a primary physician or other provider to those in a preselected group specified in its evidence of coverage o…

NAC 695C.215 Cost sharing. (NRS 679B.130, 695C.275) 1. An organization may establish schedules for cost sharing between an enrollee and the organization. For a benefit provided pursuant to a health care plan by a provider who is under contract with the organization to provide ser…

NAC 695C.217 Approval of contract for marketing, enrollment, administration or health care services; effect of agreement. (NRS 679B.130, 695C.275) 1. Any organization contracting with a third party for services for marketing, enrollment, administration or health care services sha…

NAC 695C.220 Enrollment, cancellation and termination. (NRS 679B.130, 695C.275) 1. The period of open enrollment to allow eligible persons to become enrolled must be: (a) For any individual contract, at least 30 days per year; (b) For any group contract, at least 30 days per year…

NAC 695C.230 System for resolving complaints of enrollees of health maintenance organizations: Requirements for approval. (NRS 679B.130, 695C.260) 1. To obtain approval of a system for resolving complaints of enrollees concerning health care services covered by a health maintenan…

NAC 695C.235 System for resolving complaints of enrollees of health maintenance organizations: Annual report. (NRS 679B.130, 695C.260) 1. A health maintenance organization shall submit its annual report regarding its system for resolving complaints as required pursuant to NRS 695…

NAC 695C.240 Health maintenance organization: Joint board on consumer satisfaction. (NRS 679B.130) A health maintenance organization shall notify the Division of the names and addresses of enrollees nominated to its joint board on consumer satisfaction within 6 months after the h…

NAC 695C.250 Records: Segregation from records of related corporation. (NRS 679B.130, 695C.275) The records of an organization holding a certificate of authority in Nevada must be segregated from the records of any subsidiary or related corporation and treated as separate corpora…