exempt

                                                 (Reprinted with amendments adopted on April 21, 2003)

 

Assembly Bill No. 320–Committee on Judiciary

 

March 14, 2003

____________

 

Referred to Committee on Judiciary

 

SUMMARY—Makes various changes regarding malpractice. (BDR 57‑868)

 

FISCAL NOTE:    Effect on Local Government: No.

                             Effect on the State: Yes.

 

~

 

EXPLANATION – Matter in bolded italics is new; matter between brackets [omitted material] is material to be omitted.

 

AN ACT relating to malpractice; requiring insurers and defendants to attend certain settlement conferences; providing for certain defendants in malpractice actions to receive specified information and independent counsel; requiring insurers to pay certain judgments in excess of policy limits; setting forth circumstances in which an insurer is deemed to have acted in bad faith; prohibiting hospitals and certain organizations from charging a fee for including the name of a provider of health care on a panel of providers of health care under certain circumstances; prohibiting a contract with a provider of health care from including various provisions relating to amendments to the terms of the contract; requiring the development and use of a uniform form for obtaining information regarding the credentials of providers of health care for the purposes of contracts; requiring the submission of a schedule of payments to a provider of health care under certain circumstances; expanding the scope of certain deceptive trade practices to include health maintenance organizations; expanding the scope of statutorily defined unfair practices to include certain actions by managed care organizations; requiring revocation of the authority of certain insuring entities for failure to timely pay approved claims; authorizing intervention in certain insurance ratemaking proceedings; requiring the Commissioner of Insurance to disapprove a proposed

increase in rates for malpractice insurance under certain circumstances; prescribing procedures for withdrawal of certain insurers from the malpractice insurance market in this state; requiring disclosure of reasons for certain underwriting decisions; limiting rates and premiums and proposed increases in rates and premiums for certain malpractice insurance; requiring certain policies of health insurance and health care plans to provide coverage for continued medical treatment by a provider of health care under certain circumstances; revising the circumstances under which the Commissioner of Insurance may suspend or revoke a certificate of authority issued to a health maintenance organization; requiring certain public organizations that provide health insurance to provide coverage for continued medical treatment by a provider of health care under certain circumstances; and providing other matters properly relating thereto.

 

THE PEOPLE OF THE STATE OF NEVADA, REPRESENTED IN

SENATE AND ASSEMBLY, DO ENACT AS FOLLOWS:

 

1-1  Section 1.  Chapter 679A of NRS is hereby amended by

1-2  adding thereto a new section to read as follows:

1-3  1.  If an organization establishes a panel of providers of

1-4  health care and makes the panel available for use by an insurer

1-5  when offering health care services pursuant to chapter 689A,

1-6  689B, 689C, 695A, 695B or 695C of NRS, the organization shall

1-7  not charge the insurer or a provider of health care:

1-8  (a) A fee to include the name of the provider on the panel of

1-9  providers of health care; or

1-10      (b) Any other fee related to establishing a provider of health

1-11  care as a provider for the organization.

1-12      2.  If an organization violates the provisions of subsection 1,

1-13  the organization shall pay to the insurer or provider of health

1-14  care, as appropriate, an amount that is equal to twice the fee

1-15  charged to the insurer or provider of health care.

1-16      3.  A court shall award costs and reasonable attorney’s fees to

1-17  the prevailing party in an action brought pursuant to this section.

1-18      4.  In addition to any relief granted pursuant to this section, if

1-19  an organization violates the provisions of subsection 1, and if an

1-20  insurer offering health care services pursuant to chapter 689A,

1-21  689B, 689C, 695A, 695B or 695C of NRS has a contract with or

1-22  otherwise uses the services of the organization, the Division shall

1-23  require the insurer to suspend its performance under the contract

2-1  or discontinue using those services until the organization, as

2-2  determined by the Division:

2-3  (a) Complies with the provisions of subsection 1; and

2-4  (b) Refunds to all providers of health care any fees obtained by

2-5  the organization in violation of subsection 1.

2-6  Sec. 2.  Chapter 683A of NRS is hereby amended by adding

2-7  thereto a new section to read as follows:

2-8  If an administrator, managing general agent or producer of

2-9  insurance, or a health maintenance organization when acting as

2-10  an administrator pursuant to NRS 683A.0851 or a nonprofit

2-11  corporation for hospital or medical services when acting as an

2-12  administrator pursuant to NRS 683A.0852, contracts with a

2-13  provider of health care to provide health care to an insured

2-14  pursuant to this chapter, the administrator, managing general

2-15  agent, producer of insurance, health maintenance organization or

2-16  nonprofit corporation for hospital or medical services shall:

2-17      1.  If requested by the provider of health care at the time the

2-18  contract is made, submit to the provider of health care a copy of

2-19  the schedule of payments applicable to the provider of health care;

2-20  or

2-21      2.  If requested by the provider of health care at any other

2-22  time, submit to the provider of health care the schedule of

2-23  payments specified in subsection 1 within 7 days after receiving

2-24  the request.

2-25      Sec. 3. NRS 683A.0879 is hereby amended to read as follows:

2-26      683A.0879  1.  Except as otherwise provided in subsection 2,

2-27  an administrator shall approve or deny a claim relating to health

2-28  insurance coverage within 30 days after the administrator receives

2-29  the claim. If the claim is approved, the administrator shall pay the

2-30  claim within 30 days after it is approved. Except as otherwise

2-31  provided in this section, if the approved claim is not paid within that

2-32  period, the administrator shall pay interest on the claim at a rate of

2-33  interest equal to the prime rate at the largest bank in Nevada, as

2-34  ascertained by the Commissioner of Financial Institutions, on

2-35  January 1 or July 1, as the case may be, immediately preceding the

2-36  date on which the payment was due, plus 6 percent. The interest

2-37  must be calculated from 30 days after the date on which the claim is

2-38  approved until the date on which the claim is paid.

2-39      2.  If the administrator requires additional information to

2-40  determine whether to approve or deny the claim, he shall notify the

2-41  claimant of his request for the additional information within 20 days

2-42  after he receives the claim. The administrator shall notify the

2-43  provider of health care of all the specific reasons for the delay in

2-44  approving or denying the claim. The administrator shall approve or

2-45  deny the claim within 30 days after receiving the additional

3-1  information. If the claim is approved, the administrator shall pay the

3-2  claim within 30 days after he receives the additional information. If

3-3  the approved claim is not paid within that period, the administrator

3-4  shall pay interest on the claim in the manner prescribed in

3-5  subsection 1.

3-6  3.  An administrator shall not request a claimant to resubmit

3-7  information that the claimant has already provided to the

3-8  administrator, unless the administrator provides a legitimate reason

3-9  for the request and the purpose of the request is not to delay the

3-10  payment of the claim, harass the claimant or discourage the filing of

3-11  claims.

3-12      4.  An administrator shall not pay only part of a claim that has

3-13  been approved and is fully payable.

3-14      5.  A court shall award costs and reasonable attorney’s fees to

3-15  the prevailing party in an action brought pursuant to this section.

3-16      6.  The payment of interest provided for in this section for the

3-17  late payment of an approved claim may be waived only if the

3-18  payment was delayed because of an act of God or another cause

3-19  beyond the control of the administrator.

3-20      7. Except as otherwise provided in subsections 8 and 9:

3-21      (a) The Commissioner may require an administrator to provide

3-22  evidence which demonstrates that the administrator has substantially

3-23  complied with the requirements set forth in this section . [,

3-24  including, without limitation, payment within 30 days of at least 95

3-25  percent of approved claims or at least 90 percent of the total dollar

3-26  amount for approved claims.]

3-27      (b) If the Commissioner determines that an administrator is not

3-28  in substantial compliance with the requirements set forth in this

3-29  section, the Commissioner may require the administrator to pay an

3-30  administrative fine in an amount to be determined by the

3-31  Commissioner.

3-32      8.  The Commissioner shall require an administrator to

3-33  provide evidence which demonstrates that the administrator pays

3-34  at least:

3-35      (a) Ninety-five percent of approved claims within 30 days after

3-36  the date of approval; and

3-37      (b) Ninety percent of the total dollar amount for approved

3-38  claims within 30 days after the date of approval.

3-39      9.  If the Commissioner determines, after notice and a

3-40  hearing, that an administrator is not in complete compliance with

3-41  the requirements set forth in subsection 8, the Commissioner shall

3-42  revoke the certificate of registration of the administrator.

3-43  Notwithstanding any other provision of law, if revocation is

3-44  required pursuant to this subsection, a lesser form of penalty,

4-1  including, without limitation, a suspension or a fine, must not be

4-2  substituted in lieu of the revocation.

4-3  Sec. 4.  NRS 686A.310 is hereby amended to read as follows:

4-4  686A.310  1.  Engaging in any of the following activities is

4-5  considered to be an unfair practice:

4-6  (a) Misrepresenting to insureds or claimants pertinent facts or

4-7  insurance policy provisions relating to any coverage at issue.

4-8  (b) Failing to acknowledge and act reasonably promptly upon

4-9  communications with respect to claims arising under insurance

4-10  policies.

4-11      (c) Failing to adopt and implement reasonable standards for the

4-12  prompt investigation and processing of claims arising under

4-13  insurance policies.

4-14      (d) Failing to affirm or deny coverage of claims within a

4-15  reasonable time after proof of loss requirements have been

4-16  completed and submitted by the insured.

4-17      (e) Failing to effectuate prompt, fair and equitable settlements of

4-18  claims in which liability of the insurer has become reasonably clear.

4-19      (f) Compelling insureds to institute litigation to recover amounts

4-20  due under an insurance policy by offering substantially less than the

4-21  amounts ultimately recovered in actions brought by such insureds,

4-22  when the insureds have made claims for amounts reasonably similar

4-23  to the amounts ultimately recovered.

4-24      (g) Attempting to settle a claim by an insured for less than the

4-25  amount to which a reasonable person would have believed he was

4-26  entitled by reference to written or printed advertising material

4-27  accompanying or made part of an application.

4-28      (h) Attempting to settle claims on the basis of an application

4-29  which was altered without notice to, or knowledge or consent of, the

4-30  insured, his representative, agent or broker.

4-31      (i) Failing, upon payment of a claim, to inform insureds or

4-32  beneficiaries of the coverage under which payment is made.

4-33      (j) Making known to insureds or claimants a practice of the

4-34  insurer of appealing from arbitration awards in favor of insureds or

4-35  claimants for the purpose of compelling them to accept settlements

4-36  or compromises less than the amount awarded in arbitration.

4-37      (k) Delaying the investigation or payment of claims by requiring

4-38  an insured or a claimant, or the physician of either, to submit a

4-39  preliminary claim report, and then requiring the subsequent

4-40  submission of formal proof of loss forms, both of which

4-41  submissions contain substantially the same information.

4-42      (l) Failing to settle claims promptly, where liability has become

4-43  reasonably clear, under one portion of the insurance policy coverage

4-44  in order to influence settlements under other portions of the

4-45  insurance policy coverage.

5-1  (m) Failing to comply with the provisions of NRS 687B.310 to

5-2  687B.390, inclusive, or 687B.410.

5-3  (n) Failing to provide promptly to an insured a reasonable

5-4  explanation of the basis in the insurance policy, with respect to the

5-5  facts of the insured’s claim and the applicable law, for the denial of

5-6  his claim or for an offer to settle or compromise his claim.

5-7  (o) Advising an insured or claimant not to seek legal counsel.

5-8  (p) Misleading an insured or claimant concerning any applicable

5-9  statute of limitations.

5-10      (q) Failing to comply with the provisions of chapter 695G of

5-11  NRS.

5-12      2.  In addition to any rights or remedies available to the

5-13  Commissioner, an insurer is liable to its insured for any damages

5-14  sustained by the insured as a result of the commission of any act set

5-15  forth in subsection 1 as an unfair practice.

5-16      Sec. 5.  Chapter 686B of NRS is hereby amended by adding

5-17  thereto a new section to read as follows:

5-18      If a filing made with the Commissioner pursuant to subsection

5-19  1 of NRS 686B.070 pertains to insurance covering the liability of a

5-20  practitioner licensed pursuant to chapter 630, 631, 632 or 633 of

5-21  NRS for a breach of his professional duty toward a patient, any

5-22  interested person or entity may intervene as a matter of right in

5-23  any hearing or other proceeding conducted to determine whether

5-24  the applicable rate or proposed increase thereto:

5-25      1.  Complies with the standards set forth in NRS 686B.050.

5-26      2.  Should be approved or disapproved.

5-27      Sec. 6.  NRS 686B.020 is hereby amended to read as follows:

5-28      686B.020  As used in NRS 686B.010 to 686B.1799, inclusive,

5-29  and section 5 of this act, unless the context otherwise requires:

5-30      1.  “Advisory organization,” except as limited by NRS

5-31  686B.1752, means any person or organization which is controlled

5-32  by or composed of two or more insurers and which engages in

5-33  activities related to rate making. For the purposes of this subsection,

5-34  two or more insurers with common ownership or operating in this

5-35  state under common ownership constitute a single insurer. An

5-36  advisory organization does not include:

5-37      (a) A joint underwriting association;

5-38      (b) An actuarial or legal consultant; or

5-39      (c) An employee or manager of an insurer.

5-40      2.  “Market segment” means any line or kind of insurance or, if

5-41  it is described in general terms, any subdivision thereof or any class

5-42  of risks or combination of classes.

5-43      3.  “Rate service organization” means any person, other than an

5-44  employee of an insurer, who assists insurers in rate making or filing

5-45  by:

6-1  (a) Collecting, compiling and furnishing loss or expense

6-2  statistics;

6-3  (b) Recommending, making or filing rates or supplementary rate

6-4  information; or

6-5  (c) Advising about rate questions, except as an attorney giving

6-6  legal advice.

6-7  4.  “Supplementary rate information” includes any manual or

6-8  plan of rates, statistical plan, classification, rating schedule,

6-9  minimum premium, policy fee, rating rule, rule of underwriting

6-10  relating to rates and any other information prescribed by regulation

6-11  of the Commissioner.

6-12      Sec. 7.  NRS 686B.040 is hereby amended to read as follows:

6-13      686B.040  [The]

6-14      1.  Except as otherwise provided in subsection 2, the

6-15  Commissioner may by rule exempt any person or class of persons or

6-16  any market segment from any or all of the provisions of NRS

6-17  686B.010 to 686B.1799, inclusive, and section 5 of this act, if and

6-18  to the extent that he finds their application unnecessary to achieve

6-19  the purposes of those sections.

6-20      2.  The Commissioner may not, by rule or otherwise, exempt

6-21  an insurer from the provisions of NRS 686B.010 to 686B.1799,

6-22  inclusive, and section 5 of this act, with regard to insurance

6-23  covering the liability of a practitioner licensed pursuant to chapter

6-24  630, 631, 632 or 633 of NRS for a breach of his professional duty

6-25  toward a patient.

6-26      Sec. 8.  NRS 686B.110 is hereby amended to read as follows:

6-27      686B.110  1.  The Commissioner shall consider each proposed

6-28  increase or decrease in the rate of any kind or line of insurance or

6-29  subdivision thereof that is filed with [him] the Commissioner

6-30  pursuant to NRS 686B.070. [If]

6-31      2.  The Commissioner shall disapprove the proposal if the

6-32  Commissioner finds that [a proposed increase] the proposal will

6-33  result in a rate which is not in compliance with NRS 686B.050 . [,

6-34  he shall disapprove the proposal.]

6-35      3.  In addition to the grounds for disapproval set forth in

6-36  subsection 2, if the proposal will increase the rate of insurance

6-37  covering the liability of a practitioner licensed pursuant to chapter

6-38  630, 631, 632 or 633 of NRS for a breach of his professional duty

6-39  toward a patient, the Commissioner shall disapprove the proposal,

6-40  or any constituent part thereof, if the Commissioner finds that the

6-41  proposal, or the constituent part thereof, has been proposed or is

6-42  necessitated because:

6-43      (a) The insurer has experienced or is reasonably likely to

6-44  experience capital losses, or diminished dividends, returns or

7-1  income or any other financial loss as a result of the imprudent

7-2  investment of money;

7-3  (b) The insurer or any director, partner, officer, employee,

7-4  agent or contractor of the insurer has engaged in:

7-5       (1) Any fraudulent accounting practice;

7-6       (2) Any form of corporate fraud or securities fraud; or

7-7       (3) Any willful misconduct or wrongdoing that violates the

7-8  laws or regulations of the United States, this state or any other

7-9  state;

7-10      (c) The insurer has experienced or is reasonably likely to

7-11  experience losses or expenses as a result of the insurer or any

7-12  director, partner, officer, employee, agent or contractor of the

7-13  insurer having engaged in litigation unreasonably or vexatiously

7-14  after one or more opposing parties have made a reasonable offer

7-15  of settlement; or

7-16      (d) The insurer has experienced losses or expenses as a result

7-17  of the insurer providing insurance to a practitioner licensed

7-18  pursuant to chapter 630, 631, 632 or 633 of NRS for whom the

7-19  insurer has paid not less than:

7-20          (1) Ten judgments or settlements with regard to claims for

7-21  breach of the practitioner’s professional duty toward a patient;

7-22  and

7-23          (2) A total of $5,000,000 with regard to the judgments and

7-24  settlements identified in subparagraph (1).

7-25      4.  The Commissioner shall approve or disapprove each

7-26  proposal no later than 60 days after it is determined by him to be

7-27  complete pursuant to subsection [4.] 7. If the Commissioner fails to

7-28  approve or disapprove the proposal within that period, the proposal

7-29  shall be deemed approved.

7-30      [2.] 5.  Whenever an insurer has no legally effective rates as a

7-31  result of the Commissioner’s disapproval of rates or other act, the

7-32  Commissioner shall , on request , specify interim rates for the

7-33  insurer that are high enough to protect the interests of all parties and

7-34  may order that a specified portion of the premiums be placed in an

7-35  escrow account approved by him. When new rates become legally

7-36  effective, the Commissioner shall order the escrowed funds or any

7-37  overcharge in the interim rates to be distributed appropriately,

7-38  except that refunds to policyholders that are de minimis must not be

7-39  required.

7-40      [3.] 6.  If the Commissioner disapproves a proposed rate and an

7-41  insurer requests a hearing to determine the validity of his action, the

7-42  insurer has the burden of showing compliance with the applicable

7-43  standards for rates established in NRS 686B.010 to 686B.1799,

7-44  inclusive[.] , and section 5 of this act. Any such hearing must be

7-45  held:

8-1  (a) Within 30 days after the request for a hearing has been

8-2  submitted to the Commissioner; or

8-3  (b) Within a period agreed upon by the insurer and the

8-4  Commissioner.

8-5  If the hearing is not held within the period specified in paragraph (a)

8-6  or (b), or if the Commissioner fails to issue an order concerning the

8-7  proposed rate for which the hearing is held within 45 days after the

8-8  hearing, the proposed rate shall be deemed approved.

8-9  [4.] 7.  The Commissioner shall [by regulation] specify the

8-10  documents or any other information which must be included in a

8-11  proposal to increase or decrease a rate submitted to him pursuant to

8-12  [subsection 1.] this section. Each such proposal shall be deemed

8-13  complete upon its filing with the Commissioner, unless the

8-14  Commissioner, within 15 business days after the proposal is filed

8-15  with him, determines that the proposal is incomplete because the

8-16  proposal does not comply with the regulations adopted by him

8-17  pursuant to this [subsection.] section.

8-18      8.  The Commissioner shall adopt such regulations as are

8-19  necessary to carry out the provisions of this section, including,

8-20  without limitation, regulations which define words and terms used

8-21  in this section.

8-22      Sec. 9.  Chapter 689A of NRS is hereby amended by adding

8-23  thereto a new section to read as follows:

8-24      1.  The provisions of this section apply to a policy of health

8-25  insurance offered or issued by an insurer if an insured covered by

8-26  the policy receives health care through a defined set of providers

8-27  of health care who are under contract with the insurer.

8-28      2.  Except as otherwise provided in this section, if an insured

8-29  who is covered by a policy described in subsection 1 is receiving

8-30  medical treatment for a medical condition from a provider of

8-31  health care whose contract with the insurer is terminated during

8-32  the course of the medical treatment, the policy must provide that:

8-33      (a) The insured may continue to obtain medical treatment for

8-34  the medical condition from the provider of health care pursuant to

8-35  this section; and

8-36      (b) The provider of health care is entitled to receive

8-37  reimbursement from the insurer for the medical treatment he

8-38  provides to the insured pursuant to this section at the same rate

8-39  and under the same conditions as before the contract was

8-40  terminated.

8-41      3.  The coverage required by subsection 2 must be provided

8-42  until the later of:

8-43      (a) The 180th day after the date the contract is terminated; or

8-44      (b) If the medical condition is pregnancy, the 45th day after:

8-45          (1) The date of delivery; or

9-1       (2) If the pregnancy does not end in delivery, the date of the

9-2  end of the pregnancy.

9-3  4.  The requirements of this section do not apply to a provider

9-4  of health care if:

9-5  (a) The provider of health care was under contract with the

9-6  insurer and the insurer terminated that contract because of the

9-7  incompetence or misconduct of the provider of health care; and

9-8  (b) The insurer did not enter into another contract with the

9-9  provider of health care after the contract was terminated pursuant

9-10  to paragraph (a).

9-11      5.  A policy subject to the provisions of this chapter that is

9-12  delivered, issued for delivery or renewed on or after October 1,

9-13  2003, has the legal effect of including the coverage required by

9-14  this section, and any provision of the policy or renewal thereof

9-15  that is in conflict with this section is void.

9-16      6.  The Commissioner shall adopt regulations to carry out the

9-17  provisions of this section.

9-18      Sec. 10.  NRS 689A.035 is hereby amended to read as follows:

9-19      689A.035  1.  An insurer shall not charge a provider of health

9-20  care a fee to include the name of the provider on a list of providers

9-21  of health care given by the insurer to its insureds.

9-22      2.  An insurer shall not contract with a provider of health care

9-23  to provide health care to an insured unless:

9-24      (a) The insurer uses the form prescribed by the Commissioner

9-25  to obtain any information related to the credentials of the provider

9-26  of health care; and

9-27      (b) The contract complies with the provisions of this section.

9-28      3.  The contract must not contain any provision that

9-29  authorizes an insurer to amend the material terms of the contract

9-30  or any manual, policy or procedure document which is

9-31  incorporated in or referenced by the contract unless:

9-32      (a) The provider of health care agrees to the amendment; or

9-33      (b) The amendment is necessary to comply with state or federal

9-34  law or the accreditation requirements of a private accreditation

9-35  organization. If an amendment is necessary pursuant to this

9-36  paragraph, the provider of health care may terminate the contract.

9-37      4.  The contract must not contain any provision that requires

9-38  the provider of health care to comply with quality improvement or

9-39  utilization management programs or procedures unless the

9-40  requirement is:

9-41      (a) Fully disclosed to the provider of health care not later than

9-42  15 business days before the date the contract is executed; or

9-43      (b) Necessary to comply with accreditation requirements of

9-44  state or federal law or a private accreditation organization. If an

10-1  amendment is necessary pursuant to this paragraph, the provider

10-2  of health care may terminate the contract.

10-3      5.  The contract must not contain any provision that requires

10-4  or permits access to information relating to an insured in violation

10-5  of state or federal law concerning the confidentiality of such

10-6  information.

10-7      6.  The contract must not contain any provision that waives or

10-8  conflicts with any provision of this section.

10-9      7.  A contract that contains any provision in violation of this

10-10  section is void.

10-11     8.  The Commissioner shall develop the form required by

10-12  subsection 2.

10-13     9.  If an insurer contracts with a provider of health care to

10-14  provide health care to an insured, the insurer shall:

10-15     (a) If requested by the provider of health care at the time the

10-16  contract is made, submit to the provider of health care the

10-17  schedule of payments applicable to the provider of health care; or

10-18     (b) If requested by the provider of health care at any other

10-19  time, submit to the provider of health care the schedule of

10-20  payments specified in paragraph (a) within 7 days after receiving

10-21  the request.

10-22     Sec. 11.  NRS 689A.330 is hereby amended to read as follows:

10-23     689A.330  If any policy is issued by a domestic insurer for

10-24  delivery to a person residing in another state, and if the insurance

10-25  commissioner or corresponding public officer of that other state has

10-26  informed the Commissioner that the policy is not subject to approval

10-27  or disapproval by that officer, the Commissioner may by ruling

10-28  require that the policy meet the standards set forth in NRS 689A.030

10-29  to 689A.320, inclusive[.] , and section 9 of this act.

10-30     Sec. 12.  NRS 689A.410 is hereby amended to read as follows:

10-31     689A.410  1.  Except as otherwise provided in subsection 2,

10-32  an insurer shall approve or deny a claim relating to a policy of

10-33  health insurance within 30 days after the insurer receives the claim.

10-34  If the claim is approved, the insurer shall pay the claim within 30

10-35  days after it is approved. Except as otherwise provided in this

10-36  section, if the approved claim is not paid within that period, the

10-37  insurer shall pay interest on the claim at a rate of interest equal to

10-38  the prime rate at the largest bank in Nevada, as ascertained by the

10-39  Commissioner of Financial Institutions, on January 1 or July 1, as

10-40  the case may be, immediately preceding the date on which the

10-41  payment was due, plus 6 percent. The interest must be calculated

10-42  from 30 days after the date on which the claim is approved until the

10-43  date on which the claim is paid.

10-44     2.  If the insurer requires additional information to determine

10-45  whether to approve or deny the claim, it shall notify the claimant of

11-1  its request for the additional information within 20 days after it

11-2  receives the claim. The insurer shall notify the provider of health

11-3  care of all the specific reasons for the delay in approving or denying

11-4  the claim. The insurer shall approve or deny the claim within 30

11-5  days after receiving the additional information. If the claim is

11-6  approved, the insurer shall pay the claim within 30 days after it

11-7  receives the additional information. If the approved claim is not paid

11-8  within that period, the insurer shall pay interest on the claim in the

11-9  manner prescribed in subsection 1.

11-10     3.  An insurer shall not request a claimant to resubmit

11-11  information that the claimant has already provided to the insurer,

11-12  unless the insurer provides a legitimate reason for the request and

11-13  the purpose of the request is not to delay the payment of the claim,

11-14  harass the claimant or discourage the filing of claims.

11-15     4.  An insurer shall not pay only part of a claim that has been

11-16  approved and is fully payable.

11-17     5.  A court shall award costs and reasonable attorney’s fees to

11-18  the prevailing party in an action brought pursuant to this section.

11-19     6.  The payment of interest provided for in this section for the

11-20  late payment of an approved claim may be waived only if the

11-21  payment was delayed because of an act of God or another cause

11-22  beyond the control of the insurer.

11-23     7.  Except as otherwise provided in subsections 8 and 9:

11-24     (a) The Commissioner may require an insurer to provide

11-25  evidence which demonstrates that the insurer has substantially

11-26  complied with the requirements set forth in this section . [,

11-27  including, without limitation, payment within 30 days of at least 95

11-28  percent of approved claims or at least 90 percent of the total dollar

11-29  amount for approved claims.]

11-30     (b) If the Commissioner determines that an insurer is not in

11-31  substantial compliance with the requirements set forth in this

11-32  section, the Commissioner may require the insurer to pay an

11-33  administrative fine in an amount to be determined by the

11-34  Commissioner.

11-35     8.  The Commissioner shall require an insurer to provide

11-36  evidence which demonstrates that the insurer pays at least:

11-37     (a) Ninety-five percent of approved claims within 30 days after

11-38  the date of approval; and

11-39     (b) Ninety percent of the total dollar amount for approved

11-40  claims within 30 days after the date of approval.

11-41     9.  If the Commissioner determines, after notice and a

11-42  hearing, that an insurer is not in complete compliance with the

11-43  requirements set forth in subsection 8, the Commissioner shall

11-44  revoke the certificate of authority of the insurer. Notwithstanding

11-45  any other provision of law, if revocation is required pursuant to

12-1  this subsection, a lesser form of penalty, including, without

12-2  limitation, a suspension or a fine, must not be substituted in lieu of

12-3  the revocation.

12-4      Sec. 13.  Chapter 689B of NRS is hereby amended by adding

12-5  thereto a new section to read as follows:

12-6      1.  The provisions of this section apply to a policy of group

12-7  health insurance offered or issued by an insurer if an insured

12-8  covered by the policy receives health care through a defined set of

12-9  providers of health care who are under contract with the insurer.

12-10     2.  Except as otherwise provided in this section, if an insured

12-11  who is covered by a policy described in subsection 1 is receiving

12-12  medical treatment for a medical condition from a provider of

12-13  health care whose contract with the insurer is terminated during

12-14  the course of the medical treatment, the policy must provide that:

12-15     (a) The insured may continue to obtain medical treatment for

12-16  the medical condition from the provider of health care pursuant to

12-17  this section; and

12-18     (b) The provider of health care is entitled to receive

12-19  reimbursement from the insurer for the medical treatment he

12-20  provides to the insured pursuant to this section at the same rate

12-21  and under the same conditions as before the contract was

12-22  terminated.

12-23     3.  The coverage required by subsection 2 must be provided

12-24  until the later of:

12-25     (a) The 180th day after the date the contract is terminated; or

12-26     (b) If the medical condition is pregnancy, the 45th day after:

12-27         (1) The date of delivery; or

12-28         (2) If the pregnancy does not end in delivery, the date of the

12-29  end of the pregnancy.

12-30     4.  The requirements of this section do not apply to a provider

12-31  of health care if:

12-32     (a) The provider of health care was under contract with the

12-33  insurer and the insurer terminated that contract because of the

12-34  incompetence or misconduct of the provider of health care; and

12-35     (b) The insurer did not enter into another contract with the

12-36  provider of health care after the contract was terminated pursuant

12-37  to paragraph (a).

12-38     5.  A policy subject to the provisions of this chapter that is

12-39  delivered, issued for delivery or renewed on or after October 1,

12-40  2003, has the legal effect of including the coverage required by

12-41  this section, and any provision of the policy or renewal thereof

12-42  that is in conflict with this section is void.

12-43     6.  The Commissioner shall adopt regulations to carry out the

12-44  provisions of this section.

 

13-1      Sec. 14.  NRS 689B.015 is hereby amended to read as follows:

13-2      689B.015  1.  An insurer that issues a policy of group health

13-3  insurance shall not charge a provider of health care a fee to include

13-4  the name of the provider on a list of providers of health care given

13-5  by the insurer to its insureds.

13-6      2.  An insurer specified in subsection 1 shall not contract with

13-7  a provider of health care to provide health care to an insured

13-8  unless:

13-9      (a) The insurer uses the form prescribed by the Commissioner

13-10  to obtain any information related to the credentials of the provider

13-11  of health care; and

13-12     (b) The contract complies with the provisions of this section.

13-13     3.  The contract must not contain any provision that

13-14  authorizes an insurer to amend the material terms of the contract

13-15  or any manual, policy or procedure document which is

13-16  incorporated in or referenced by the contract unless:

13-17     (a) The provider of health care agrees to the amendment; or

13-18     (b) The amendment is necessary to comply with state or federal

13-19  law or the accreditation requirements of a private accreditation

13-20  organization. If an amendment is necessary pursuant to this

13-21  paragraph, the provider of health care may terminate the contract.

13-22     4.  The contract must not contain any provision that requires

13-23  the provider of health care to comply with quality improvement or

13-24  utilization management programs or procedures unless the

13-25  requirement is:

13-26     (a) Fully disclosed to the provider of health care not later than

13-27  15 business days before the date the contract is executed; or

13-28     (b) Necessary to comply with accreditation requirements of

13-29  state or federal law or a private accreditation organization. If an

13-30  amendment is necessary pursuant to this paragraph, the provider

13-31  of health care may terminate the contract.

13-32     5.  The contract must not contain any provision that requires

13-33  or permits access to information relating to an insured in violation

13-34  of state or federal law concerning the confidentiality of such

13-35  information.

13-36     6.  The contract must not contain any provision that waives or

13-37  conflicts with any provision of this section.

13-38     7.  A contract that contains any provision in violation of this

13-39  section is void.

13-40     8.  The Commissioner shall develop the form required by

13-41  subsection 2.

13-42     9.  If an insurer specified in subsection 1 contracts with a

13-43  provider of health care to provide health care to an insured, the

13-44  insurer shall:

14-1      (a) If requested by the provider of health care at the time the

14-2  contract is made, submit to the provider of health care the

14-3  schedule of payments applicable to the provider of health care; or

14-4      (b) If requested by the provider of health care at any other

14-5  time, submit to the provider of health care the schedule of

14-6  payments specified in paragraph (a) within 7 days after receiving

14-7  the request.

14-8      Sec. 15.  NRS 689B.255 is hereby amended to read as follows:

14-9      689B.255  1.  Except as otherwise provided in subsection 2, an

14-10  insurer shall approve or deny a claim relating to a policy of group

14-11  health insurance or blanket insurance within 30 days after the

14-12  insurer receives the claim. If the claim is approved, the insurer shall

14-13  pay the claim within 30 days after it is approved. Except as

14-14  otherwise provided in this section, if the approved claim is not paid

14-15  within that period, the insurer shall pay interest on the claim at a rate

14-16  of interest equal to the prime rate at the largest bank in Nevada, as

14-17  ascertained by the Commissioner of Financial Institutions, on

14-18  January 1 or July 1, as the case may be, immediately preceding the

14-19  date on which the payment was due, plus 6 percent. The interest

14-20  must be calculated from 30 days after the date on which the claim is

14-21  approved until the date on which the claim is paid.

14-22     2.  If the insurer requires additional information to determine

14-23  whether to approve or deny the claim, it shall notify the claimant of

14-24  its request for the additional information within 20 days after it

14-25  receives the claim. The insurer shall notify the provider of health

14-26  care of all the specific reasons for the delay in approving or denying

14-27  the claim. The insurer shall approve or deny the claim within 30

14-28  days after receiving the additional information. If the claim is

14-29  approved, the insurer shall pay the claim within 30 days after it

14-30  receives the additional information. If the approved claim is not paid

14-31  within that period, the insurer shall pay interest on the claim in the

14-32  manner prescribed in subsection 1.

14-33     3.  An insurer shall not request a claimant to resubmit

14-34  information that the claimant has already provided to the insurer,

14-35  unless the insurer provides a legitimate reason for the request and

14-36  the purpose of the request is not to delay the payment of the claim,

14-37  harass the claimant or discourage the filing of claims.

14-38     4.  An insurer shall not pay only part of a claim that has been

14-39  approved and is fully payable.

14-40     5.  A court shall award costs and reasonable attorney’s fees to

14-41  the prevailing party in an action brought pursuant to this section.

14-42     6.  The payment of interest provided for in this section for the

14-43  late payment of an approved claim may be waived only if the

14-44  payment was delayed because of an act of God or another cause

14-45  beyond the control of the insurer.

15-1      7.  Except as otherwise provided in subsections 8 and 9:

15-2      (a) The Commissioner may require an insurer to provide

15-3  evidence which demonstrates that the insurer has substantially

15-4  complied with the requirements set forth in this section . [,

15-5  including, without limitation, payment within 30 days of at least 95

15-6  percent of approved claims or at least 90 percent of the total dollar

15-7  amount for approved claims.]

15-8      (b) If the Commissioner determines that an insurer is not in

15-9  substantial compliance with the requirements set forth in this

15-10  section, the Commissioner may require the insurer to pay an

15-11  administrative fine in an amount to be determined by the

15-12  Commissioner.

15-13     8.  The Commissioner shall require an insurer to provide

15-14  evidence which demonstrates that the insurer pays at least:

15-15     (a) Ninety-five percent of approved claims within 30 days after

15-16  the date of approval; and

15-17     (b) Ninety percent of the total dollar amount for approved

15-18  claims within 30 days after the date of approval.

15-19     9.  If the Commissioner determines, after notice and a

15-20  hearing, that an insurer is not in complete compliance with the

15-21  requirements set forth in subsection 8, the Commissioner shall

15-22  revoke the certificate of authority of the insurer. Notwithstanding

15-23  any other provision of law, if revocation is required pursuant to

15-24  this subsection, a lesser form of penalty, including, without

15-25  limitation, a suspension or a fine, must not be substituted in lieu of

15-26  the revocation.

15-27     Sec. 16.  NRS 689C.435 is hereby amended to read as follows:

15-28     689C.435  1.  A carrier serving small employers and a carrier

15-29  that offers a contract to a voluntary purchasing group shall not

15-30  charge a provider of health care a fee to include the name of the

15-31  provider on a list of providers of health care given by the carrier to

15-32  its insureds.

15-33     2.  A carrier specified in subsection 1 shall not contract with a

15-34  provider of health care to provide health care to an insured

15-35  unless:

15-36     (a) The carrier uses the form prescribed by the Commissioner

15-37  to obtain any information related to the credentials of the provider

15-38  of health care; and

15-39     (b) The contract complies with the provisions of this section.

15-40     3.  The contract must not contain any provision that

15-41  authorizes a carrier to amend the material terms of the contract or

15-42  any manual, policy or procedure document which is incorporated

15-43  in or referenced by the contract unless:

15-44     (a) The provider of health care agrees to the amendment; or

16-1      (b) The amendment is necessary to comply with state or federal

16-2  law or the accreditation requirements of a private accreditation

16-3  organization. If an amendment is necessary pursuant to this

16-4  paragraph, the provider of health care may terminate the contract.

16-5      4.  The contract must not contain any provision that requires

16-6  the provider of health care to comply with quality improvement or

16-7  utilization management programs or procedures unless the

16-8  requirement is:

16-9      (a) Fully disclosed to the provider of health care not later than

16-10  15 business days before the date the contract is executed; or

16-11     (b) Necessary to comply with accreditation requirements of

16-12  state or federal law or a private accreditation organization. If an

16-13  amendment is necessary pursuant to this paragraph, the provider

16-14  of health care may terminate the contract.

16-15     5.  The contract must not contain any provision that requires

16-16  or permits access to information relating to an insured in violation

16-17  of state or federal law concerning the confidentiality of such

16-18  information.

16-19     6.  The contract must not contain any provision that waives or

16-20  conflicts with any provision of this section.

16-21     7.  A contract that contains any provision in violation of this

16-22  section is void.

16-23     8.  The Commissioner shall develop the form required by

16-24  subsection 2.

16-25     9.  If a carrier specified in subsection 1 contracts with a

16-26  provider of health care to provide health care to an insured, the

16-27  carrier shall:

16-28     (a) If requested by the provider of health care at the time the

16-29  contract is made, submit to the provider of health care the

16-30  schedule of payments applicable to the provider of health care; or

16-31     (b) If requested by the provider of health care at any other

16-32  time, submit to the provider of health care the schedule of

16-33  payments specified in paragraph (a) within 7 days after receiving

16-34  the request.

16-35     Sec. 17.  NRS 689C.485 is hereby amended to read as follows:

16-36     689C.485  1.  Except as otherwise provided in subsection 2, a

16-37  carrier serving small employers and a carrier that offers a contract to

16-38  a voluntary purchasing group shall approve or deny a claim relating

16-39  to a policy of health insurance within 30 days after the carrier

16-40  receives the claim. If the claim is approved, the carrier shall pay the

16-41  claim within 30 days after it is approved. Except as otherwise

16-42  provided in this section, if the approved claim is not paid within that

16-43  period, the carrier shall pay interest on the claim at a rate of interest

16-44  equal to the prime rate at the largest bank in Nevada, as ascertained

16-45  by the Commissioner of Financial Institutions, on January 1 or

 

17-1  July 1, as the case may be, immediately preceding the date on which

17-2  the payment was due, plus 6 percent. The interest must be calculated

17-3  from 30 days after the date on which the claim is approved until the

17-4  date on which the claim is paid.

17-5      2.  If the carrier requires additional information to determine

17-6  whether to approve or deny the claim, it shall notify the claimant of

17-7  its request for the additional information within 20 days after it

17-8  receives the claim. The carrier shall notify the provider of health

17-9  care of all the specific reasons for the delay in approving or denying

17-10  the claim. The carrier shall approve or deny the claim within 30

17-11  days after receiving the additional information. If the claim is

17-12  approved, the carrier shall pay the claim within 30 days after it

17-13  receives the additional information. If the approved claim is not paid

17-14  within that period, the carrier shall pay interest on the claim in the

17-15  manner prescribed in subsection 1.

17-16     3.  A carrier shall not request a claimant to resubmit

17-17  information that the claimant has already provided to the carrier,

17-18  unless the carrier provides a legitimate reason for the request and the

17-19  purpose of the request is not to delay the payment of the claim,

17-20  harass the claimant or discourage the filing of claims.

17-21     4.  A carrier shall not pay only part of a claim that has been

17-22  approved and is fully payable.

17-23     5.  A court shall award costs and reasonable attorney’s fees to

17-24  the prevailing party in an action brought pursuant to this section.

17-25     6.  The payment of interest provided for in this section for the

17-26  late payment of an approved claim may be waived only if the

17-27  payment was delayed because of an act of God or another cause

17-28  beyond the control of the carrier.

17-29     7.  Except as otherwise provided in subsections 8 and 9:

17-30     (a) The Commissioner may require a carrier to provide evidence

17-31  which demonstrates that the carrier has substantially complied with

17-32  the requirements set forth in this section . [, including, without

17-33  limitation, payment within 30 days of at least 95 percent of

17-34  approved claims or at least 90 percent of the total dollar amount for

17-35  approved claims.]

17-36     (b) If the Commissioner determines that a carrier is not in

17-37  substantial compliance with the requirements set forth in this

17-38  section, the Commissioner may require the carrier to pay an

17-39  administrative fine in an amount to be determined by the

17-40  Commissioner.

17-41     8.  The Commissioner shall require a carrier to provide

17-42  evidence which demonstrates that the carrier pays at least:

17-43     (a) Ninety-five percent of approved claims within 30 days after

17-44  the date of approval; and

18-1      (b) Ninety percent of the total dollar amount for approved

18-2  claims within 30 days after the date of approval.

18-3      9.  If the Commissioner determines, after notice and a

18-4  hearing, that a carrier is not in complete compliance with the

18-5  requirements set forth in subsection 8, the Commissioner shall

18-6  revoke the certificate of authority of the carrier. Notwithstanding

18-7  any other provision of law, if revocation is required pursuant to

18-8  this subsection, a lesser form of penalty, including, without

18-9  limitation, a suspension or a fine, must not be substituted in lieu of

18-10  the revocation.

18-11     Sec. 18.  Chapter 690B of NRS is hereby amended by adding

18-12  thereto the provisions set forth as sections 19 to 22, inclusive, of this

18-13  act.

18-14     Sec. 19.  An insurer shall not cancel, refuse to renew or

18-15  increase the premium for renewal of a policy of insurance

18-16  covering the liability of a practitioner licensed pursuant to chapter

18-17  630, 631, 632 or 633 of NRS for a breach of his professional duty

18-18  toward a patient as a result of a claim against the practitioner

18-19  pursuant to the policy if the insurer:

18-20     1.  Makes a payment with respect to the claim in an amount

18-21  that exceeds the limit of the coverage under the policy;

18-22     2.  Had the opportunity to settle the claim for an amount

18-23  equal to or less than the limit of the coverage under the policy:

18-24  and

18-25     3.  Did not settle the claim for an amount equal to or less than

18-26  the limit of the coverage under the policy.

18-27     Sec. 20.  If an insurer declines to issue to a practitioner

18-28  licensed pursuant to chapter 630, 631, 632 or 633 of NRS a policy

18-29  of insurance covering the liability of the practitioner for a breach

18-30  of his professional duty toward a patient, the insurer shall, upon

18-31  the request of the practitioner, disclose to the practitioner the

18-32  reasons the insurer declined to issue the policy.

18-33     Sec. 21.  1.  If an insurer, for a policy of insurance covering

18-34  the liability of a practitioner licensed pursuant to chapter 630, 631,

18-35  632 or 633 of NRS for a breach of his professional duty toward a

18-36  patient, sets the premium for the policy for the practitioner at a

18-37  rate that is higher than the applicable average rate determined

18-38  pursuant to subsection 2, the insurer shall, upon the request of the

18-39  practitioner, disclose to the practitioner the reasons the insurer set

18-40  the premium for the policy at a rate that is higher than the

18-41  applicable average rate determined pursuant to subsection 2.

18-42     2.  For the purposes of this section, the Commissioner shall

18-43  determine an average rate for the premium for a policy of

18-44  insurance covering the liability of a practitioner licensed pursuant

18-45  to chapter 630, 631, 632 or 633 of NRS for a breach of his

19-1  professional duty toward a patient. The Commissioner may

19-2  determine different average rates applicable to different:

19-3      (a) Types of policies, including, without limitation, policies of

19-4  claims-made insurance and policies of occurrence-based

19-5  insurance;

19-6      (b) Types and specialties of practitioners; and

19-7      (c) Geographic areas of this state within which a practitioner

19-8  may practice.

19-9      3.  The Commissioner shall review and update the average

19-10  rates determined pursuant to subsection 2 not less than once every

19-11  2 years.

19-12     Sec. 22.  1.  The Commissioner shall, on or before April 1 of

19-13  each year:

19-14     (a) Specify for the purposes of this section, by regulation,

19-15  categories of practitioners licensed pursuant to chapter 630, 631,

19-16  632 or 633 of NRS;

19-17     (b) Determine for each category of practitioner specified

19-18  pursuant to paragraph (a), using data applicable to the previous

19-19  calendar year, the relative market share in this state among

19-20  insurers with respect to policies of insurance issued to cover the

19-21  liability of the practitioners within the category for breach of

19-22  professional duty toward a patient; and

19-23     (c) Provide notice of the applicability of this section to each

19-24  insurer whom the Commissioner determines, pursuant to

19-25  paragraph (b), possesses more than 40 percent of the market in

19-26  this state within a category of practitioner.

19-27     2.  A determination by the Commissioner pursuant to

19-28  subsection 1 that an insurer possesses more than 40 percent of the

19-29  market in this state within a category of practitioner is valid for

19-30  the period beginning on April 1 of the year in which the

19-31  determination is made and ending on March 31 of the following

19-32  year, without regard to any actual change in market share during

19-33  that period.

19-34     3.  During any period specified in subsection 2 for which an

19-35  insurer is determined by the Commissioner pursuant to subsection

19-36  1 to possess more than 40 percent of the market in this state within

19-37  a category of practitioner, the insurer shall, before withdrawing

19-38  from that market, comply with the provisions of subsections 4

19-39  and 5.

19-40     4.  An insurer described in subsection 3 shall, at least 120

19-41  days before withdrawing:

19-42     (a) Give written notice of its intent to withdraw to the

19-43  Commissioner and to each practitioner within the applicable

19-44  category whom the insurer insures against liability for a breach of

19-45  his professional duty toward a patient; and

20-1      (b) Submit to the Commissioner a written plan providing for

20-2  the insurer’s orderly withdrawal from the market so as to

20-3  minimize the effect of the withdrawal on the public generally and

20-4  on the practitioners within the applicable category whom the

20-5  insurer insures against liability for a breach of professional duty

20-6  toward a patient.

20-7      5.  After complying with the requirements set forth in

20-8  subsection 4, an insurer described in subsection 3:

20-9      (a) Shall not take any action toward withdrawal until the

20-10  Commissioner determines that the written plan required pursuant

20-11  to paragraph (b) of subsection 4 complies with the regulations

20-12  adopted pursuant to paragraph (a) of subsection 7.

20-13     (b) Shall ensure that any action it takes toward withdrawal is

20-14  in compliance with the written plan required pursuant to

20-15  paragraph (b) of subsection 4.

20-16     6.  The Commissioner has the final authority to determine

20-17  whether a particular action taken by an insurer is in compliance

20-18  with the written plan required pursuant to paragraph (b) of

20-19  subsection 4.

20-20     7.  The Commissioner shall adopt regulations:

20-21     (a) Prescribing the form, content and method of submission of

20-22  a written plan required pursuant to paragraph (b) of subsection 4.

20-23     (b) Providing a procedure for determining, pursuant to

20-24  subsection 1, the relative market share in this state among

20-25  insurers with respect to policies of insurance issued to cover the

20-26  liability of a practitioner licensed pursuant to chapter 630, 631,

20-27  632 or 633 of NRS for a breach of his professional duty toward a

20-28  patient.

20-29     Sec. 23.  NRS 695A.095 is hereby amended to read as follows:

20-30     695A.095  1.  A society shall not charge a provider of health

20-31  care a fee to include the name of the provider on a list of providers

20-32  of health care given by the society to its insureds.

20-33     2.  A society shall not contract with a provider of health care

20-34  to provide health care to an insured unless:

20-35     (a) The society uses the form prescribed by the Commissioner

20-36  to obtain any information related to the credentials of the provider

20-37  of health care; and

20-38     (b) The contract complies with the provisions of this section.

20-39     3.  The contract must not contain any provision that

20-40  authorizes a society to amend the material terms of the contract or

20-41  any manual, policy or procedure document which is incorporated

20-42  in or referenced by the contract unless:

20-43     (a) The provider of health care agrees to the amendment; or

20-44     (b) The amendment is necessary to comply with state or federal

20-45  law or the accreditation requirements of a private accreditation

21-1  organization. If an amendment is necessary pursuant to this

21-2  paragraph, the provider of health care may terminate the contract.

21-3      4.  The contract must not contain any provision that requires

21-4  the provider of health care to comply with quality improvement or

21-5  utilization management programs or procedures unless the

21-6  requirement is:

21-7      (a) Fully disclosed to the provider of health care not later than

21-8  15 business days before the date the contract is executed; or

21-9      (b) Necessary to comply with accreditation requirements of

21-10  state or federal law or a private accreditation organization. If an

21-11  amendment is necessary pursuant to this paragraph, the provider

21-12  of health care may terminate the contract.

21-13     5.  The contract must not contain any provision that requires

21-14  or permits access to information relating to an insured in violation

21-15  of state or federal law concerning the confidentiality of such

21-16  information.

21-17     6.  The contract must not contain any provision that waives or

21-18  conflicts with any provision of this section.

21-19     7.  A contract that contains any provision in violation of this

21-20  section is void.

21-21     8.  The Commissioner shall develop the form required by

21-22  subsection 2.

21-23     9.  If a society contracts with a provider of health care to

21-24  provide health care to an insured, the society shall:

21-25     (a) If requested by the provider of health care at the time the

21-26  contract is made, submit to the provider of health care the

21-27  schedule of payments applicable to the provider of health care; or

21-28     (b) If requested by the provider of health care at any other

21-29  time, submit to the provider of health care the schedule of

21-30  payments specified in paragraph (a) within 7 days after receiving

21-31  the request.

21-32     Sec. 24.  Chapter 695B of NRS is hereby amended by adding

21-33  thereto a new section to read as follows:

21-34     1.  The provisions of this section apply to a policy of health

21-35  insurance offered or issued by a hospital or medical service

21-36  corporation if an insured covered by the policy receives health

21-37  care through a defined set of providers of health care who are

21-38  under contract with the hospital or medical service corporation.

21-39     2.  Except as otherwise provided in this section, if an insured

21-40  who is covered by a policy described in subsection 1 is receiving

21-41  medical treatment for a medical condition from a provider of

21-42  health care whose contract with the hospital or medical service

21-43  corporation is terminated during the course of the medical

21-44  treatment, the policy must provide that:

22-1      (a) The insured may continue to obtain medical treatment for

22-2  the medical condition from the provider of health care pursuant to

22-3  this section; and

22-4      (b) The provider of health care is entitled to receive

22-5  reimbursement from the hospital or medical service corporation

22-6  for the medical treatment he provides to the insured pursuant to

22-7  this section at the same rate and under the same conditions as

22-8  before the contract was terminated.

22-9      3.  The coverage required by subsection 2 must be provided

22-10  until the later of:

22-11     (a) The 180th day after the date the contract is terminated; or

22-12     (b) If the medical condition is pregnancy, the 45th day after:

22-13         (1) The date of delivery; or

22-14         (2) If the pregnancy does not end in delivery, the date of the

22-15  end of the pregnancy.

22-16     4.  The requirements of this section do not apply to a provider

22-17  of health care if:

22-18     (a) The provider of health care was under contract with the

22-19  hospital or medical service corporation and the hospital or

22-20  medical service corporation terminated that contract because of

22-21  the incompetence or misconduct of the provider of health care;

22-22  and

22-23     (b) The hospital or medical service corporation did not enter

22-24  into another contract with the provider of health care after the

22-25  contract was terminated pursuant to paragraph (a).

22-26     5.  A policy subject to the provisions of this chapter that is

22-27  delivered, issued for delivery or renewed on or after October 1,

22-28  2003, has the legal effect of including the coverage required by

22-29  this section, and any provision of the policy or renewal thereof

22-30  that is in conflict with this section is void.

22-31     6.  The Commissioner shall adopt regulations to carry out the

22-32  provisions of this section.

22-33     Sec. 25.  NRS 695B.035 is hereby amended to read as follows:

22-34     695B.035  1.  A corporation subject to the provisions of this

22-35  chapter shall not charge a provider of health care a fee to include the

22-36  name of the provider on a list of providers of health care given by

22-37  the corporation to its insureds.

22-38     2.  A corporation specified in subsection 1 shall not contract

22-39  with a provider of health care to provide health care to an insured

22-40  unless:

22-41     (a) The corporation uses the form prescribed by the

22-42  Commissioner to obtain any information related to the credentials

22-43  of the provider of health care; and

22-44     (b) The contract complies with the provisions of this section.

23-1      3.  The contract must not contain any provision that

23-2  authorizes a corporation to amend the material terms of the

23-3  contract or any manual, policy or procedure document which is

23-4  incorporated in or referenced by the contract unless:

23-5      (a) The provider of health care agrees to the amendment; or

23-6      (b) The amendment is necessary to comply with state or federal

23-7  law or the accreditation requirements of a private accreditation

23-8  organization. If an amendment is necessary pursuant to this

23-9  paragraph, the provider of health care may terminate the contract.

23-10     4.  The contract must not contain any provision that requires

23-11  the provider of health care to comply with quality improvement or

23-12  utilization management programs or procedures unless the

23-13  requirement is:

23-14     (a) Fully disclosed to the provider of health care not later than

23-15  15 business days before the date the contract is executed; or

23-16     (b) Necessary to comply with accreditation requirements of

23-17  state or federal law or a private accreditation organization. If an

23-18  amendment is necessary pursuant to this paragraph, the provider

23-19  of health care may terminate the contract.

23-20     5.  The contract must not contain any provision that requires

23-21  or permits access to information relating to an insured in violation

23-22  of state or federal law concerning the confidentiality of such

23-23  information.

23-24     6.  The contract must not contain any provision that waives or

23-25  conflicts with any provision of this section.

23-26     7.  A contract that contains any provision in violation of this

23-27  section is void.

23-28     8.  The Commissioner shall develop the form required by

23-29  subsection 2.

23-30     9.  If a corporation specified in subsection 1 contracts with a

23-31  provider of health care to provide health care to an insured, the

23-32  corporation shall:

23-33     (a) If requested by the provider of health care at the time the

23-34  contract is made, submit to the provider of health care the

23-35  schedule of payments applicable to the provider of health care; or

23-36     (b) If requested by the provider of health care at any other

23-37  time, submit to the provider of health care the schedule of

23-38  payments specified in paragraph (a) within 7 days after receiving

23-39  the request.

23-40     Sec. 26.  NRS 695B.2505 is hereby amended to read as

23-41  follows:

23-42     695B.2505  1.  Except as otherwise provided in subsection 2, a

23-43  corporation subject to the provisions of this chapter shall approve or

23-44  deny a claim relating to a contract for dental, hospital or medical

23-45  services within 30 days after the corporation receives the claim. If

24-1  the claim is approved, the corporation shall pay the claim within 30

24-2  days after it is approved. Except as otherwise provided in this

24-3  section, if the approved claim is not paid within that period, the

24-4  corporation shall pay interest on the claim at a rate of interest equal

24-5  to the prime rate at the largest bank in Nevada, as ascertained by the

24-6  Commissioner of Financial Institutions, on January 1 or July 1, as

24-7  the case may be, immediately preceding the date on which the

24-8  payment was due, plus 6 percent. The interest must be calculated

24-9  from 30 days after the date on which the claim is approved until the

24-10  date on which the claim is paid.

24-11     2.  If the corporation requires additional information to

24-12  determine whether to approve or deny the claim, it shall notify the

24-13  claimant of its request for the additional information within 20 days

24-14  after it receives the claim. The corporation shall notify the provider

24-15  of dental, hospital or medical services of all the specific reasons for

24-16  the delay in approving or denying the claim. The corporation shall

24-17  approve or deny the claim within 30 days after receiving the

24-18  additional information. If the claim is approved, the corporation

24-19  shall pay the claim within 30 days after it receives the additional

24-20  information. If the approved claim is not paid within that period, the

24-21  corporation shall pay interest on the claim in the manner prescribed

24-22  in subsection 1.

24-23     3.  A corporation shall not request a claimant to resubmit

24-24  information that the claimant has already provided to the

24-25  corporation, unless the corporation provides a legitimate reason for

24-26  the request and the purpose of the request is not to delay the

24-27  payment of the claim, harass the claimant or discourage the filing of

24-28  claims.

24-29     4.  A corporation shall not pay only part of a claim that has

24-30  been approved and is fully payable.

24-31     5.  A court shall award costs and reasonable attorney’s fees to

24-32  the prevailing party in an action brought pursuant to this section.

24-33     6.  The payment of interest provided for in this section for the

24-34  late payment of an approved claim may be waived only if the

24-35  payment was delayed because of an act of God or another cause

24-36  beyond the control of the corporation.

24-37     7.  Except as otherwise provided in subsections 8 and 9:

24-38     (a) The Commissioner may require a corporation to provide

24-39  evidence which demonstrates that the corporation has substantially

24-40  complied with the requirements set forth in this section . [,

24-41  including, without limitation, payment within 30 days of at least 95

24-42  percent of approved claims or at least 90 percent of the total dollar

24-43  amount for approved claims.]

24-44     (b) If the Commissioner determines that a corporation is not in

24-45  substantial compliance with the requirements set forth in this

25-1  section, the Commissioner may require the corporation to pay an

25-2  administrative fine in an amount to be determined by the

25-3  Commissioner.

25-4      8.  The Commissioner shall require a corporation to provide

25-5  evidence which demonstrates that the corporation pays at least:

25-6      (a) Ninety-five percent of approved claims within 30 days after

25-7  the date of approval; and

25-8      (b) Ninety percent of the total dollar amount for approved

25-9  claims within 30 days after the date of approval.

25-10     9.  If the Commissioner determines, after notice and a

25-11  hearing, that a corporation is not in complete compliance with the

25-12  requirements set forth in subsection 8, the Commissioner shall

25-13  revoke the certificate of authority of the corporation.

25-14  Notwithstanding any other provision of law, if revocation is

25-15  required pursuant to this subsection, a lesser form of penalty,

25-16  including, without limitation, a suspension or a fine, must not be

25-17  substituted in lieu of the revocation.

25-18     Sec. 27.  Chapter 695C of NRS is hereby amended by adding

25-19  thereto a new section to read as follows:

25-20     1.  The provisions of this section apply to a health care plan

25-21  offered or issued by a health maintenance organization if an

25-22  insured covered by the health care plan receives health care

25-23  through a defined set of providers of health care who are under

25-24  contract with the health maintenance organization.

25-25     2.  Except as otherwise provided in this section, if an insured

25-26  who is covered by a health care plan described in subsection 1 is

25-27  receiving medical treatment for a medical condition from a

25-28  provider of health care whose contract with the health

25-29  maintenance organization is terminated during the course of the

25-30  medical treatment, the health care plan must provide that:

25-31     (a) The insured may continue to obtain medical treatment for

25-32  the medical condition from the provider of health care pursuant to

25-33  this section; and

25-34     (b) The provider of health care is entitled to receive

25-35  reimbursement from the health maintenance organization for the

25-36  medical treatment he provides to the insured pursuant to this

25-37  section at the same rate and under the same conditions as before

25-38  the contract was terminated.

25-39     3.  The coverage required by subsection 2 must be provided

25-40  until the later of:

25-41     (a) The 180th day after the date the contract is terminated; or

25-42     (b) If the medical condition is pregnancy, the 45th day after:

25-43         (1) The date of delivery; or

25-44         (2) If the pregnancy does not end in delivery, the date of the

25-45  end of the pregnancy.

26-1      4.  The requirements of this section do not apply to a provider

26-2  of health care if:

26-3      (a) The provider of health care was under contract with the

26-4  health maintenance organization and the health maintenance

26-5  organization terminated that contract because of the incompetence

26-6  or misconduct of the provider of health care; and

26-7      (b) The health maintenance organization did not enter into

26-8  another contract with the provider of health care after the contract

26-9  was terminated pursuant to paragraph (a).

26-10     5.  An evidence of coverage for a health care plan subject to

26-11  the provisions of this chapter that is delivered, issued for delivery

26-12  or renewed on or after October 1, 2003, has the legal effect of

26-13  including the coverage required by this section, and any provision

26-14  of the evidence of coverage or renewal thereof that is in conflict

26-15  with this section is void.

26-16     6.  The Commissioner shall adopt regulations to carry out the

26-17  provisions of this section.

26-18     Sec. 28.  NRS 695C.050 is hereby amended to read as follows:

26-19     695C.050  1.  Except as otherwise provided in this chapter or

26-20  in specific provisions of this title, the provisions of this title are not

26-21  applicable to any health maintenance organization granted a

26-22  certificate of authority under this chapter. This provision does not

26-23  apply to an insurer licensed and regulated pursuant to this title

26-24  except with respect to its activities as a health maintenance

26-25  organization authorized and regulated pursuant to this chapter.

26-26     2.  Solicitation of enrollees by a health maintenance

26-27  organization granted a certificate of authority, or its representatives,

26-28  must not be construed to violate any provision of law relating to

26-29  solicitation or advertising by practitioners of a healing art.

26-30     3.  Any health maintenance organization authorized under this

26-31  chapter shall not be deemed to be practicing medicine and is exempt

26-32  from the provisions of chapter 630 of NRS.

26-33     4.  The provisions of chapter 686A, NRS 695C.110, 695C.125,

26-34  695C.170 to 695C.200, inclusive, 695C.250 and 695C.265 and

26-35  section 27 of this act do not apply to a health maintenance

26-36  organization that provides health care services through managed

26-37  care to recipients of Medicaid under the State Plan for Medicaid or

26-38  insurance pursuant to the Children’s Health Insurance Program

26-39  pursuant to a contract with the Division of Health Care Financing

26-40  and Policy of the Department of Human Resources. This subsection

26-41  does not exempt a health maintenance organization from any

26-42  provision of this chapter for services provided pursuant to any other

26-43  contract.

26-44     5.  The provisions of NRS 695C.1694 and 695C.1695 apply to

26-45  a health maintenance organization that provides health care services

27-1  through managed care to recipients of Medicaid under the State Plan

27-2  for Medicaid.

27-3      Sec. 29.  NRS 695C.055 is hereby amended to read as follows:

27-4      695C.055  1.  The provisions of NRS 449.465, 679B.700,

27-5  subsections 2, 4, 18, 19 and 32 of NRS 680B.010, NRS 680B.025 to

27-6  680B.060, inclusive, and [chapter] chapters 686A and 695G of

27-7  NRS and section 1 of this act apply to a health maintenance

27-8  organization.

27-9      2.  For the purposes of subsection 1, unless the context requires

27-10  that a provision apply only to insurers, any reference in those

27-11  sections to “insurer” must be replaced by “health maintenance

27-12  organization.”

27-13     Sec. 30.  NRS 695C.125 is hereby amended to read as follows:

27-14     695C.125 [A health maintenance organization shall not charge a

27-15  provider of health care a fee to include the name of the provider on a

27-16  list of providers of health care given by the health maintenance

27-17  organization to its enrollees.]

27-18     1.  A health maintenance organization shall not contract with

27-19  a provider of health care to provide health care to an insured

27-20  unless:

27-21     (a) The health maintenance organization uses the form

27-22  prescribed by the Commissioner to obtain any information related

27-23  to the credentials of the provider of health care; and

27-24     (b) The contract complies with the provisions of this section.

27-25     2.  The contract must not contain any provision that

27-26  authorizes a health maintenance organization to amend the

27-27  material terms of the contract or any manual, policy or procedure

27-28  document which is incorporated in or referenced by the contract

27-29  unless:

27-30     (a) The provider of health care agrees to the amendment; or

27-31     (b) The amendment is necessary to comply with state or federal

27-32  law or the accreditation requirements of a private accreditation

27-33  organization. If an amendment is necessary pursuant to this

27-34  paragraph, the provider of health care may terminate the contract.

27-35     3.  The contract must not contain any provision that requires

27-36  the provider of health care to comply with quality improvement or

27-37  utilization management programs or procedures unless the

27-38  requirement is:

27-39     (a) Fully disclosed to the provider of health care not later than

27-40  15 business days before the date the contract is executed; or

27-41     (b) Necessary to comply with accreditation requirements of

27-42  state or federal law or a private accreditation organization. If an

27-43  amendment is necessary pursuant to this paragraph, the provider

27-44  of health care may terminate the contract.

28-1      4.  The contract must not contain any provision that requires

28-2  or permits access to information relating to an insured in violation

28-3  of state or federal law concerning the confidentiality of such

28-4  information.

28-5      5.  The contract must not contain any provision that waives or

28-6  conflicts with any provision of this section.

28-7      6.  A contract that contains any provision in violation of this

28-8  section is void.

28-9      7.  The Commissioner shall develop the form required by

28-10  subsection 2.

28-11     8.  If a health maintenance organization contracts with a

28-12  provider of health care to provide health care to an enrollee, the

28-13  health maintenance organization shall:

28-14     (a) If requested by the provider of health care at the time the

28-15  contract is made, submit to the provider of health care the

28-16  schedule of payments applicable to the provider of health care; or

28-17     (b) If requested by the provider of health care at any other

28-18  time, submit to the provider of health care the schedule of

28-19  payments specified in paragraph (a) within 7 days after receiving

28-20  the request.

28-21     Sec. 31.  NRS 695C.185 is hereby amended to read as follows:

28-22     695C.185  1.  Except as otherwise provided in subsection 2, a

28-23  health maintenance organization shall approve or deny a claim

28-24  relating to a health care plan within 30 days after the health

28-25  maintenance organization receives the claim. If the claim is

28-26  approved, the health maintenance organization shall pay the claim

28-27  within 30 days after it is approved. Except as otherwise provided in

28-28  this section, if the approved claim is not paid within that period, the

28-29  health maintenance organization shall pay interest on the claim at a

28-30  rate of interest equal to the prime rate at the largest bank in Nevada,

28-31  as ascertained by the Commissioner of Financial Institutions, on

28-32  January 1 or July 1, as the case may be, immediately preceding the

28-33  date on which the payment was due, plus 6 percent. The interest

28-34  must be calculated from 30 days after the date on which the claim is

28-35  approved until the date on which the claim is paid.

28-36     2.  If the health maintenance organization requires additional

28-37  information to determine whether to approve or deny the claim, it

28-38  shall notify the claimant of its request for the additional information

28-39  within 20 days after it receives the claim. The health maintenance

28-40  organization shall notify the provider of health care services of all

28-41  the specific reasons for the delay in approving or denying the claim.

28-42  The health maintenance organization shall approve or deny the

28-43  claim within 30 days after receiving the additional information. If

28-44  the claim is approved, the health maintenance organization shall pay

28-45  the claim within 30 days after it receives the additional information.

29-1  If the approved claim is not paid within that period, the health

29-2  maintenance organization shall pay interest on the claim in the

29-3  manner prescribed in subsection 1.

29-4      3.  A health maintenance organization shall not request a

29-5  claimant to resubmit information that the claimant has already

29-6  provided to the health maintenance organization, unless the health

29-7  maintenance organization provides a legitimate reason for the

29-8  request and the purpose of the request is not to delay the payment of

29-9  the claim, harass the claimant or discourage the filing of claims.

29-10     4.  A health maintenance organization shall not pay only part of

29-11  a claim that has been approved and is fully payable.

29-12     5.  A court shall award costs and reasonable attorney’s fees to

29-13  the prevailing party in an action brought pursuant to this section.

29-14     6.  The payment of interest provided for in this section for the

29-15  late payment of an approved claim may be waived only if the

29-16  payment was delayed because of an act of God or another cause

29-17  beyond the control of the health maintenance organization.

29-18     7.  Except as otherwise provided in subsections 8 and 9:

29-19     (a) The Commissioner may require a health maintenance

29-20  organization to provide evidence which demonstrates that the health

29-21  maintenance organization has substantially complied with the

29-22  requirements set forth in this section . [, including, without

29-23  limitation, payment within 30 days of at least 95 percent of

29-24  approved claims or at least 90 percent of the total dollar amount for

29-25  approved claims.]

29-26     (b) If the Commissioner determines that a health maintenance

29-27  organization is not in substantial compliance with the requirements

29-28  set forth in this section, the Commissioner may require the health

29-29  maintenance organization to pay an administrative fine in an amount

29-30  to be determined by the Commissioner.

29-31     8.  The Commissioner shall require a health maintenance

29-32  organization to provide evidence which demonstrates that the

29-33  health maintenance organization pays at least:

29-34     (a) Ninety-five percent of approved claims within 30 days after

29-35  the date of approval; and

29-36     (b) Ninety percent of the total dollar amount for approved

29-37  claims within 30 days after the date of approval.

29-38     9.  If the Commissioner determines, after notice and a

29-39  hearing, that a health maintenance organization is not in complete

29-40  compliance with the requirements set forth in subsection 8, the

29-41  Commissioner shall revoke the certificate of authority of the

29-42  health maintenance organization. Notwithstanding any other

29-43  provision of law, if revocation is required pursuant to this

29-44  subsection, a lesser form of penalty, including, without limitation,

30-1  a suspension or a fine, must not be substituted in lieu of the

30-2  revocation.

30-3      Sec. 32.  NRS 695C.330 is hereby amended to read as follows:

30-4      695C.330  1.  The Commissioner may suspend or revoke any

30-5  certificate of authority issued to a health maintenance organization

30-6  pursuant to the provisions of this chapter if he finds that any of the

30-7  following conditions exist:

30-8      (a) The health maintenance organization is operating

30-9  significantly in contravention of its basic organizational document,

30-10  its health care plan or in a manner contrary to that described in and

30-11  reasonably inferred from any other information submitted pursuant

30-12  to NRS 695C.060, 695C.070 and 695C.140, unless any amendments

30-13  to those submissions have been filed with and approved by the

30-14  Commissioner;

30-15     (b) The health maintenance organization issues evidence of

30-16  coverage or uses a schedule of charges for health care services

30-17  which do not comply with the requirements of NRS [695C.170]

30-18  695C.1694 to 695C.200, inclusive, [or 695C.1694, 695C.1695] or

30-19  695C.207;

30-20     (c) The health care plan does not furnish comprehensive health

30-21  care services as provided for in NRS 695C.060;

30-22     (d) The State Board of Health certifies to the Commissioner that

30-23  the health maintenance organization:

30-24         (1) Does not meet the requirements of subsection 2 of NRS

30-25  695C.080; or

30-26         (2) Is unable to fulfill its obligations to furnish health care

30-27  services as required under its health care plan;

30-28     (e) The health maintenance organization is no longer financially

30-29  responsible and may reasonably be expected to be unable to meet its

30-30  obligations to enrollees or prospective enrollees;

30-31     (f) The health maintenance organization has failed to put into

30-32  effect a mechanism affording the enrollees an opportunity to

30-33  participate in matters relating to the content of programs pursuant to

30-34  NRS 695C.110;

30-35     (g) The health maintenance organization has failed to put into

30-36  effect the system for resolving complaints required by NRS

30-37  695C.260 in a manner reasonably to dispose of valid complaints;

30-38     (h) The health maintenance organization or any person on its

30-39  behalf has advertised or merchandised its services in an untrue,

30-40  misrepresentative, misleading, deceptive or unfair manner;

30-41     (i) The continued operation of the health maintenance

30-42  organization would be hazardous to its enrollees; [or]

30-43     (j) The health maintenance organization fails to provide the

30-44  coverage required by section 27 of this act; or

31-1      (k) The health maintenance organization has otherwise failed to

31-2  comply substantially with the provisions of this chapter.

31-3      2.  A certificate of authority must be suspended or revoked only

31-4  after compliance with the requirements of NRS 695C.340.

31-5      3.  If the certificate of authority of a health maintenance

31-6  organization is suspended, the health maintenance organization shall

31-7  not, during the period of that suspension, enroll any additional

31-8  groups or new individual contracts, unless those groups or persons

31-9  were contracted for before the date of suspension.

31-10     4.  If the certificate of authority of a health maintenance

31-11  organization is revoked, the organization shall proceed, immediately

31-12  following the effective date of the order of revocation, to wind up its

31-13  affairs and shall conduct no further business except as may be

31-14  essential to the orderly conclusion of the affairs of the organization.

31-15  It shall engage in no further advertising or solicitation of any kind.

31-16  The Commissioner may , by written order , permit such further

31-17  operation of the organization as he may find to be in the best interest

31-18  of enrollees to the end that enrollees are afforded the greatest

31-19  practical opportunity to obtain continuing coverage for health care.

31-20     Sec. 33.  Chapter 695G of NRS is hereby amended by adding

31-21  thereto a new section to read as follows:

31-22     1.  The provisions of this section apply to a health care plan

31-23  offered or issued by a managed care organization if an insured

31-24  covered by the health care plan receives health care through a

31-25  defined set of providers of health care who are under contract with

31-26  the managed care organization.

31-27     2.  Except as otherwise provided in this section, if an insured

31-28  who is covered by a health care plan described in subsection 1 is

31-29  receiving medical treatment for a medical condition from a

31-30  provider of health care whose contract with the managed care

31-31  organization is terminated during the course of the medical

31-32  treatment, the health care plan must provide that:

31-33     (a) The insured may continue to obtain medical treatment for

31-34  the medical condition from the provider of health care pursuant to

31-35  this section; and

31-36     (b) The provider of health care is entitled to receive

31-37  reimbursement from the managed care organization for the

31-38  medical treatment he provides to the insured pursuant to this

31-39  section at the same rate and under the same conditions as before

31-40  the contract was terminated.

31-41     3.  The coverage required by subsection 2 must be provided

31-42  until the later of:

31-43     (a) The 180th day after the date the contract is terminated; or

31-44     (b) If the medical condition is pregnancy, the 45th day after:

31-45         (1) The date of delivery; or

32-1          (2) If the pregnancy does not end in delivery, the date of the

32-2  end of the pregnancy.

32-3      4.  The requirements of this section do not apply to a provider

32-4  of health care if:

32-5      (a) The provider of health care was under contract with the

32-6  managed care organization and the managed care organization

32-7  terminated that contract because of the incompetence or

32-8  misconduct of the provider of health care; and

32-9      (b) The managed care organization did not enter into another

32-10  contract with the provider of health care after the contract was

32-11  terminated pursuant to paragraph (a).

32-12     5.  An evidence of coverage for a health care plan subject to

32-13  the provisions of this chapter that is delivered, issued for delivery

32-14  or renewed on or after October 1, 2003, has the legal effect of

32-15  including the coverage required by this section, and any provision

32-16  of the evidence of coverage or renewal thereof that is in conflict

32-17  with this section is void.

32-18     6.  The Commissioner shall adopt regulations to carry out the

32-19  provisions of this section.

32-20     Sec. 33.5. NRS 695G.090 is hereby amended to read as

32-21  follows:

32-22     695G.090  1.  [The] Except as otherwise provided in

32-23  subsection 3, the provisions of this chapter apply to each

32-24  organization and insurer that operates as a managed care

32-25  organization and may include, without limitation, an insurer that

32-26  issues a policy of health insurance, an insurer that issues a policy of

32-27  individual or group health insurance, a carrier serving small

32-28  employers, a fraternal benefit society, a hospital or medical service

32-29  corporation and a health maintenance organization.

32-30     2.  In addition to the provisions of this chapter, each managed

32-31  care organization shall comply with any other applicable provision

32-32  of this title.

32-33     3.  The provisions of subsections 2 to 9, inclusive, of NRS

32-34  695G.270 and section 33 of this act do not apply to a managed

32-35  care organization that provides health care services to recipients

32-36  of Medicaid under the State Plan for Medicaid or insurance

32-37  pursuant to the Children’s Health Insurance Program pursuant to

32-38  a contract with the Division of Health Care Financing and Policy

32-39  of the Department of Human Resources. This subsection does not

32-40  exempt a managed care organization from any provision of this

32-41  chapter for services provided pursuant to any other contract.

32-42     Sec. 34.  NRS 695G.270 is hereby amended to read as follows:

32-43     695G.270 [A managed care organization that establishes a panel

32-44  of providers of health care for the purpose of offering health care

32-45  services pursuant to chapters 689A, 689B, 689C, 695A, 695B, or

33-1  695C of NRS shall not charge a provider of health care a fee to

33-2  include the name of the provider on the panel of providers of health

33-3  care.]

33-4      1.  A managed care organization shall not contract with a

33-5  provider of health care to provide health care to an insured

33-6  unless:

33-7      (a) The managed care organization uses the form prescribed

33-8  by the Commissioner to obtain any information related to the

33-9  credentials of the provider of health care; and

33-10     (b) The contract complies with the provisions of this section.

33-11     2.  The contract must not contain any provision that

33-12  authorizes a managed care organization to amend the material

33-13  terms of the contract or any manual, policy or procedure

33-14  document which is incorporated in or referenced by the contract

33-15  unless:

33-16     (a) The provider of health care agrees to the amendment; or

33-17     (b) The amendment is necessary to comply with state or federal

33-18  law or the accreditation requirements of a private accreditation

33-19  organization. If an amendment is necessary pursuant to this

33-20  paragraph, the provider of health care may terminate the contract.

33-21     3.  The contract must not contain any provision that requires

33-22  the provider of health care to comply with quality improvement or

33-23  utilization management programs or procedures unless the

33-24  requirement is:

33-25     (a) Fully disclosed to the provider of health care not later than

33-26  15 business days before the date the contract is executed; or

33-27     (b) Necessary to comply with accreditation requirements of

33-28  state or federal law or a private accreditation organization. If an

33-29  amendment is necessary pursuant to this paragraph, the provider

33-30  of health care may terminate the contract.

33-31     4.  The contract must not contain any provision that requires

33-32  or permits access to information relating to an insured in violation

33-33  of state or federal law concerning the confidentiality of such

33-34  information.

33-35     5.  The contract must not contain any provision that waives or

33-36  conflicts with any provision of this section.

33-37     6.  A contract that contains any provision in violation of this

33-38  section is void.

33-39     7.  The Commissioner shall develop the form required by

33-40  subsection 2.

33-41     8.  If a managed care organization contracts with a provider

33-42  of health care to provide health care services pursuant to chapter

33-43  689A, 689B, 689C, 695A, 695B or 695C of NRS, the managed care

33-44  organization shall:

34-1      (a) If requested by the provider of health care at the time the

34-2  contract is made, submit to the provider of health care the

34-3  schedule of payments applicable to the provider of health care; or

34-4      (b) If requested by the provider of health care at any other

34-5  time, submit to the provider of health care the schedule of

34-6  payments specified in paragraph (a) within 7 days after receiving

34-7  the request.

34-8      Sec. 35.  Chapter 41A of NRS is hereby amended by adding

34-9  thereto the provisions set forth as sections 36 and 37 of this act.

34-10     Sec. 36.  1.  In an action for damages for medical

34-11  malpractice or dental malpractice in which the defendant is

34-12  insured pursuant to a policy of insurance covering the liability of

34-13  the defendant for a breach of his professional duty toward a

34-14  patient:

34-15     (a) If a settlement conference is required, the defendant and

34-16  the insurer shall attend.

34-17     (b) If the defendant, at a settlement conference or otherwise,

34-18  receives a settlement demand that is equal to the limits of the

34-19  insurance policy of the defendant, the insurer shall, upon receipt

34-20  of a copy of the demand, inform the defendant of any applicable

34-21  rights and obligations possessed by the defendant, whether or not

34-22  derived from statute or the common law, including, without

34-23  limitation, the right of the defendant to obtain independent

34-24  counsel at the expense of the insurer and the method, described in

34-25  this section, by which the defendant may obtain independent

34-26  counsel.

34-27     (c) If the defendant notifies the judge not later than 15 days

34-28  after receiving a settlement demand described in paragraph (b)

34-29  that the defendant wishes to have independent counsel, the judge

34-30  shall, not later than 15 days after receiving such notice, appoint

34-31  independent counsel to represent the defendant. The fees for any

34-32  independent counsel appointed pursuant to this section must be

34-33  paid by the insurer.

34-34     2.  The Commissioner of Insurance shall prescribe a form

34-35  that may be used by an insurer to fulfill the requirements of

34-36  paragraph (b) of subsection 1.

34-37     Sec. 37.  1.  In an action for damages for medical

34-38  malpractice or dental malpractice in which the defendant is

34-39  insured pursuant to a policy of insurance covering the liability of

34-40  the defendant for a breach of his professional duty toward a

34-41  patient, the insurer that issued the policy is liable for the entire

34-42  amount of the damages to the same extent that the defendant is

34-43  liable to the plaintiff if:

34-44     (a) The plaintiff made a settlement offer within the limits of

34-45  coverage under the policy;

35-1      (b) The liability of the defendant was reasonably clear when

35-2  the plaintiff made the settlement offer;

35-3      (c) The insurer, in contravention of the express instructions of

35-4  the defendant, unreasonably rejected the settlement offer in light

35-5  of all the surrounding facts and circumstances; and

35-6      (d) The court enters a judgment in favor of the plaintiff that

35-7  imposes liability on the defendant for damages in an amount that

35-8  exceeds the limits of coverage under the policy.

35-9      2.  The court may determine the liability of an insurer

35-10  pursuant to this section in the underlying action for medical

35-11  malpractice or dental malpractice or in a separate proceeding.

35-12     3.  If, pursuant to this section, an insurer is found to be liable

35-13  for the entire amount of the damages to the same extent that the

35-14  defendant is liable to the plaintiff, the insurer shall be deemed to

35-15  have acted in bad faith regarding its obligations to provide

35-16  insurance coverage.

35-17     Sec. 38.  NRS 287.010 is hereby amended to read as follows:

35-18     287.010  1.  The governing body of any county, school

35-19  district, municipal corporation, political subdivision, public

35-20  corporation or other public agency of the State of Nevada may:

35-21     (a) Adopt and carry into effect a system of group life, accident

35-22  or health insurance, or any combination thereof, for the benefit of its

35-23  officers and employees, and the dependents of officers and

35-24  employees who elect to accept the insurance and who, where

35-25  necessary, have authorized the governing body to make deductions

35-26  from their compensation for the payment of premiums on the

35-27  insurance.

35-28     (b) Purchase group policies of life, accident or health insurance,

35-29  or any combination thereof, for the benefit of such officers and

35-30  employees, and the dependents of such officers and employees, as

35-31  have authorized the purchase, from insurance companies authorized

35-32  to transact the business of such insurance in the State of Nevada,

35-33  and, where necessary, deduct from the compensation of officers and

35-34  employees the premiums upon insurance and pay the deductions

35-35  upon the premiums.

35-36     (c) Provide group life, accident or health coverage through a

35-37  self-insurance reserve fund and, where necessary, deduct

35-38  contributions to the maintenance of the fund from the compensation

35-39  of officers and employees and pay the deductions into the fund. The

35-40  money accumulated for this purpose through deductions from

35-41  the compensation of officers and employees and contributions of the

35-42  governing body must be maintained as an internal service fund as

35-43  defined by NRS 354.543. The money must be deposited in a state or

35-44  national bank or credit union authorized to transact business in the

35-45  State of Nevada. Any independent administrator of a fund created

36-1  under this section is subject to the licensing requirements of chapter

36-2  683A of NRS, and must be a resident of this state. Any contract

36-3  with an independent administrator must be approved by the

36-4  Commissioner of Insurance as to the reasonableness of

36-5  administrative charges in relation to contributions collected and

36-6  benefits provided. The provisions of NRS 689B.030 to 689B.050,

36-7  inclusive, and 689B.575 and section 13 of this act apply to

36-8  coverage provided pursuant to this paragraph, except that the

36-9  provisions of NRS 689B.0359 do not apply to such coverage.

36-10     (d) Defray part or all of the cost of maintenance of a self-

36-11  insurance fund or of the premiums upon insurance. The money for

36-12  contributions must be budgeted for in accordance with the laws

36-13  governing the county, school district, municipal corporation,

36-14  political subdivision, public corporation or other public agency of

36-15  the State of Nevada.

36-16     2.  If a school district offers group insurance to its officers and

36-17  employees pursuant to this section, members of the board of trustees

36-18  of the school district must not be excluded from participating in the

36-19  group insurance. If the amount of the deductions from compensation

36-20  required to pay for the group insurance exceeds the compensation to

36-21  which a trustee is entitled, the difference must be paid by the trustee.

36-22     Sec. 39.  NRS 287.04335 is hereby amended to read as

36-23  follows:

36-24     287.04335  If the Board provides health insurance through a

36-25  plan of self-insurance, it shall comply with the provisions of NRS

36-26  689B.255, 695G.150, 695G.160, 695G.170 and 695G.200 to

36-27  695G.230, inclusive, and section 33 of this act, in the same manner

36-28  as an insurer that is licensed pursuant to title 57 of NRS is required

36-29  to comply with those provisions.

36-30     Sec. 39.5. Chapter 449 of NRS is hereby amended by adding

36-31  thereto a new section to read as follows:

36-32     1.  If a hospital in this state establishes a panel of providers of

36-33  health care and makes the panel available for use by an insurer

36-34  when offering health care services pursuant to chapter 616A to

36-35  617, inclusive, 689A, 689B, 689C, 695A, 695B or 695C of NRS,

36-36  the hospital shall not charge the insurer or a provider of health

36-37  care:

36-38     (a) A fee to include the name of the provider on the panel of

36-39  providers of health care; or

36-40     (b) Any other fee related to establishing a provider of health

36-41  care as a provider for the hospital.

36-42     2.  If a hospital in this state violates the provisions of

36-43  subsection 1, the hospital shall pay to the insurer or provider of

36-44  health care, as appropriate, an amount that is equal to twice the

36-45  fee charged to the insurer or provider of health care.

36-46     3.  A court shall award costs and reasonable attorney’s fees to

36-47  the prevailing party in an action brought pursuant to this section.

36-48     4.  In addition to any relief granted pursuant to this section, if

36-49  a hospital in this state violates the provisions of subsection 1, and

36-50  if an insurer offering health care services pursuant to chapter

36-51  616A to 617, inclusive, 689A, 689B, 689C, 695A, 695B or 695C of

36-52  NRS has a contract with or otherwise uses the services of the

36-53  hospital, the Division of Insurance of the Department of Business

36-54  and Industry shall require the insurer to suspend its performance

36-55  under the contract or discontinue using those services until the

36-56  hospital, as determined by the Division of Insurance of the

36-57  Department of Business and Industry:

36-58     (a) Complies with the provisions of subsection 1; and

36-59     (b) Refunds to all providers of health care any fees obtained by

36-60  the hospital in violation of subsection 1.

36-61     Sec. 40.  Chapter 616B of NRS is hereby amended by adding

36-62  thereto a new section to read as follows:

36-63     1.  If an insurer establishes a panel of providers of health care

36-64  for the purpose of offering health care services pursuant to

36-65  chapters 616A to 617, inclusive, of NRS, the insurer shall not

36-66  charge a provider of health care:

36-67     (a) A fee to include the name of the provider on the panel of

36-68  providers of health care; or

36-69     (b) Any other fee related to establishing a provider of health

36-70  care as a provider for the insurer.

36-71     2.  If an insurer violates the provisions of subsection 1, the

36-72  insurer shall pay to the provider of health care an amount that is

36-73  equal to twice the fee charged to the provider of health care.

36-74     3.  A court shall award costs and reasonable attorney’s fees to

36-75  the prevailing party in an action brought pursuant to this section.

36-76     Sec. 41.  The amendatory provisions of this act apply to a:

36-77     1.  Policy of insurance issued or renewed on or after October 1,

36-78  2003.

36-79     2.  Offer to issue a policy of insurance communicated to the

36-80  applicant for the policy on or after October 1, 2003.

36-81     3.  Decision with regard to the issuance of a policy of insurance

36-82  communicated to the applicant for the policy on or after October 1,

36-83  2003.

36-84     4.  Cause of action that accrues on or after October 1, 2003.

 

36-85  H