Adoption of this amendment will MAINTAIN a 2/3s majority vote requirement for final passage of AB79 (§ 2).
ASSEMBLY ACTION Initial and Date |SENATE ACTION Initial and Date
Adopted Lost | Adopted Lost
Concurred In Not |Concurred In Not
Receded Not | Receded Not
Amend section 1, page 2, by deleting lines 2 and 3 and inserting:
“adding thereto the provisions set forth as sections 2 and 3 of this act.
Sec. 2. 1. An external review organization shall not conduct an”.
Amend section 1, page 2, line 5, by deleting:
“6 to 14,” and inserting:
“16 to 28,”.
Amend section 1, page 2, line 25, by deleting:
“6 to 14,” and inserting:
“16 to 28,”.
Amend section 1, page 2, line 34, by deleting:
“6 to 14,” and inserting:
“16 to 28,”.
Amend section 1, page 3, by deleting lines 40 through 43 and inserting:
“(a) “Adverse determination” has the meaning ascribed to it in section 16 of this act.
(b) “External review organization” has the meaning ascribed to it in section 19 of this act.”.
Amend section 1, page 4, by deleting lines 2 and 3 and inserting:
“person who is licensed in this state or is licensed, certified or otherwise authorized by any other state to provide any health care service.”.
Amend the bill as a whole by renumbering sections 2 and 3 as sections 11 and 12 and adding new sections designated sections 3 through 10, following section 1, to read as follows:
“Sec. 3. As soon as practicable after preparing an annual list of external review organizations pursuant to subsection 8 of section 2 of this act, the Commissioner shall submit a copy of the list to the Office for Consumer Health Assistance. If a change occurs in the list, the Commissioner shall notify the Office for Consumer Health Assistance of the change.
Sec. 4. NRS 689A.745 is hereby amended to read as follows:
689A.745 1. [Each] Except as otherwise provided in subsection 4, each insurer that issues a policy of health insurance in this state shall establish a system for resolving any complaints of an insured concerning health care services covered under the policy. The system must be approved by the Commissioner in consultation with the State Board of Health.
2. A system for resolving complaints established pursuant to subsection 1 must include an initial investigation, a review of the complaint by a review board and a procedure for appealing a determination regarding the complaint. The majority of the members on a review board must be insureds who receive health care services pursuant to a policy of health insurance issued by the insurer.
3. The Commissioner or the State Board of Health may examine the system for resolving complaints established pursuant to [this section] subsection 1 at such times as either deems necessary or appropriate.
4. Each insurer that issues a policy of health insurance in this state that provides, delivers, arranges for, pays for or reimburses any cost of health care services through managed care shall provide a system for resolving any complaints of an insured concerning those health care services that complies with the provisions of sections 16 to 28, inclusive, of this act and NRS 695G.200 to 695G.230, inclusive.
Sec. 5. NRS 689A.750 is hereby amended to read as follows:
689A.750 1. Each insurer that issues a policy of health insurance in this state shall submit to the Commissioner and the State Board of Health an annual report regarding its system for resolving complaints established pursuant to subsection 1 of NRS 689A.745 on a form prescribed by the Commissioner in consultation with the State Board of Health which includes, without limitation:
(a) A description of the procedures used for resolving any complaints of an insured;
(b) The total number of complaints and appeals handled through the system for resolving complaints since the last report and a compilation of the causes underlying the complaints filed;
(c) The current status of each complaint and appeal filed; and
(d) The average amount of time that was needed to resolve a complaint and an appeal, if any.
2. Each insurer shall maintain records of complaints filed with it which concern something other than health care services and shall submit to the Commissioner a report summarizing such complaints at such times and in such format as the Commissioner may require.
Sec. 6. NRS 689B.0285 is hereby amended to read as follows:
689B.0285 1. [Each] Except as otherwise provided in subsection 4, each insurer that issues a policy of group health insurance in this state shall establish a system for resolving any complaints of an insured concerning health care services covered under the policy. The system must be approved by the Commissioner in consultation with the State Board of Health.
2. A system for resolving complaints established pursuant to subsection 1 must include an initial investigation, a review of the complaint by a review board and a procedure for appealing a determination regarding the complaint. The majority of the members on a review board must be insureds who receive health care services pursuant to a policy of group health insurance issued by the insurer.
3. The Commissioner or the State Board of Health may examine the system for resolving complaints established pursuant to [this section] subsection 1 at such times as either deems necessary or appropriate.
4. Each insurer that issues a policy of group health insurance in this state that provides, delivers, arranges for, pays for or reimburses any cost of health care services through managed care shall provide a system for resolving any complaints of an insured concerning the health care services that complies with the provisions of sections 16 to 28, inclusive, of this act and NRS 695G.200 to 695G.230, inclusive.
Sec. 7. NRS 689B.029 is hereby amended to read as follows:
689B.029 1. Each insurer that issues a policy of group health insurance in this state shall submit to the Commissioner and the State Board of Health an annual report regarding its system for resolving complaints established pursuant to subsection 1 of NRS 689B.0285 on a form prescribed by the Commissioner in consultation with the State Board of Health which includes, without limitation:
(a) A description of the procedures used for resolving any complaints of an insured;
(b) The total number of complaints and appeals handled through the system for resolving complaints since the last report and a compilation of the causes underlying the complaints filed;
(c) The current status of each complaint and appeal filed; and
(d) The average amount of time that was needed to resolve a complaint and an appeal, if any.
2. Each insurer shall maintain records of complaints filed with it which concern something other than health care services and shall submit to the Commissioner a report summarizing such complaints at such times and in such format as the Commissioner may require.
Sec. 8. NRS 689C.156 is hereby amended to read as follows:
689C.156 1. As a condition of transacting business in this state with small employers, a carrier shall actively market to a small employer each health benefit plan which is actively marketed in this state by the carrier to any small employer in this state. The health insurance plans marketed pursuant to this section by the carrier must include, without limitation, a basic health benefit plan and a standard health benefit plan. A carrier shall be deemed to be actively marketing a health benefit plan when it makes available any of its plans to a small employer that is not currently receiving coverage under a health benefit plan issued by that carrier.
2. A carrier shall issue to a small employer any health benefit plan marketed in accordance with this section if the eligible small employer applies for the plan and agrees to make the required premium payments and satisfy the other reasonable provisions of the health benefit plan that are not inconsistent with NRS 689C.015 to 689C.355, inclusive, and 689C.610 to 689C.980, inclusive, except that a carrier is not required to issue a health benefit plan to a self-employed person who is covered by, or is eligible for coverage under, a health benefit plan offered by another employer.
3. If a health benefit plan marketed pursuant to this section provides, delivers, arranges for, pays for or reimburses any cost of health care services through managed care, the carrier shall provide a system for resolving any complaints of an employee concerning those health care services that complies with the provisions of sections 16 to 28, inclusive, of this act and NRS 695G.200 to 695G.230, inclusive.
Sec. 9. NRS 695B.380 is hereby amended to read as follows:
695B.380 1. [Each] Except as otherwise provided in subsection 4, each insurer that issues a contract for hospital or medical services in this state shall establish a system for resolving any complaints of an insured concerning health care services covered under the policy. The system must be approved by the Commissioner in consultation with the State Board of Health.
2. A system for resolving complaints established pursuant to subsection 1 must include an initial investigation, a review of the complaint by a review board and a procedure for appealing a determination regarding the complaint. The majority of the members on a review board must be insureds who receive health care services pursuant to a contract for hospital or medical services issued by the insurer.
3. The Commissioner or the State Board of Health may examine the system for resolving complaints established pursuant to [this section] subsection 1 at such times as either deems necessary or appropriate.
4. Each insurer that issues a contract specified in subsection 1 shall, if the contract provides, delivers, arranges for, pays for or reimburses any cost of health care services through managed care, provide a system for resolving any complaints of an insured concerning those health care services that complies with the provisions of sections 16 to 28, inclusive, of this act and NRS 695G.200 to 695G.230, inclusive.
Sec. 10. NRS 695B.390 is hereby amended to read as follows:
695B.390 1. Each insurer that issues a contract for hospital or medical services in this state shall submit to the Commissioner and the State Board of Health an annual report regarding its system for resolving complaints established pursuant to subsection 1 of NRS 695B.380 on a form prescribed by the Commissioner in consultation with the State Board of Health which includes, without limitation:
(a) A description of the procedures used for resolving any complaints of an insured;
(b) The total number of complaints and appeals handled through the system for resolving complaints since the last report and a compilation of the causes underlying the complaints filed;
(c) The current status of each complaint and appeal filed; and
(d) The average amount of time that was needed to resolve a complaint and an appeal, if any.
2. Each insurer shall maintain records of complaints filed with it which concern something other than health care services and shall submit to the Commissioner a report summarizing such complaints at such times and in such format as the Commissioner may require.”.
Amend sec. 3, page 5, lines 18 and 19, by deleting:
“6 to 14,” and inserting:
“16 to 28,”.
Amend the bill as a whole by renumbering section 4 as section 13.
Amend sec. 4, page 6, line 13, by deleting:
“6 to 14,” and inserting:
“16 to 28,”.
Amend the bill as a whole by renumbering sec. 5 as sec. 15 and adding a new section designated sec. 14, following sec. 4, to read as follows:
“Sec. 14. NRS 695F.230 is hereby amended to read as follows:
695F.230 1. Each prepaid limited health service organization shall establish a system for the resolution of written complaints submitted by enrollees and providers.
2. The provisions of subsection 1 do not prohibit an enrollee or provider from filing a complaint with the Commissioner or limit the Commissioner’s authority to investigate such a complaint.
3. Each prepaid limited health service organization that issues any evidence of coverage that provides, delivers, arranges for, pays for or reimburses any cost of health care services through managed care shall provide a system for resolving any complaints of an enrollee or subscriber concerning those health care services that complies with the provisions of sections 16 to 28, inclusive, of this act and NRS 695G.200 to 695G.230, inclusive.”.
Amend sec. 5, page 6, line 40, by deleting:
“6 to 14,” and inserting:
“16 to 28,”.
Amend the bill as a whole by renumbering sec. 6 as sec. 17 and adding a new section designated sec. 16, following sec. 5, to read as follows:
“Sec. 16. “Adverse determination” means a determination of a managed care organization that an allocation of health care resources and services that is provided or proposed to be provided to an insured is not medically necessary or appropriate or is experimental or investigational. The term does not include a determination of a managed care organization that such an allocation is not a covered benefit.”.
Amend sec. 6, page 6, line 45, by deleting:
“6 to 14,” and inserting:
“16 to 28,”.
Amend the bill as a whole by renumbering sec. 7 as sec. 18.
Amend sec. 7, page 7, lines 3 and 4, by deleting:
“the Board of Medical Examiners” and inserting:
“a member board of the American Board of Medical Specialties”.
Amend the bill as a whole by deleting sections 8 and 9, renumbering sec. 10 as sec. 20 and adding a new section designated sec. 19, following sec. 7, to read as follows:
“Sec. 19. “External review organization” means an organization that:
1. Conducts an external review of a final adverse determination; and
2. Is certified by the Commissioner in accordance with section 2 of this act.”.
Amend sec. 10, page 7, line 29, by deleting “are:” and inserting:
“are necessary and:”.
Amend sec. 10, page 7, line 33, by deleting “and”.
Amend sec. 10, page 7, line 35, by deleting “care.” and inserting:
“care;
4. Required to improve a specific health condition of an insured or to preserve his existing state of health; and
5. The most clinically appropriate level of health care that may be safely provided to the insured.”.
Amend the bill as a whole by renumbering sec. 11 as sec. 22 and adding a new section designated sec. 21, following sec. 10, to read as follows:
“Sec. 21. 1. For the purposes of sections 16 to 28, inclusive, of this act and NRS 695G.200 to 695G.230, inclusive, an adverse determination is final if the insured has exhausted all procedures set forth in the health care plan for reviewing the adverse determination within the managed care organization.
2. An adverse determination shall be deemed final for the purpose of submitting the adverse determination to an external review organization for an external review:
(a) If an insured exhausts all procedures set forth in the health care plan for reviewing the adverse determination within the managed care organization and the managed care organization fails to render a decision within the period required to render that decision set forth in the health care plan; or
(b) If the managed care organization submits the adverse determination to the external review organization without requiring the insured to exhaust all procedures set forth in the health care plan for reviewing the adverse determination within the managed care organization.”.
Amend sec. 11, page 8, by deleting lines 8 through 20 and inserting:
“3. As soon as practicable after receiving a notice pursuant to subsection 2, the Office for Consumer Health Assistance shall assign an external review organization from the list maintained pursuant to section 2 of this act. Each assignment made pursuant to this subsection must be completed on a rotating basis.
4. Within 5 days after receiving notification from the Office for Consumer Health Assistance specifying the external review organization assigned pursuant to”.
Amend sec. 12, page 8, by deleting lines 35 and 36 and inserting:
“Sec. 23. 1. Except as otherwise provided in section 24 of this act, upon receipt of a request for an external review pursuant to section 22 of this act, the external review organization”.
Amend sec. 12, page 8, line 39, by deleting “11” and inserting “22”.
Amend sec. 12, page 8, line 43, by deleting “subsection 3,” and inserting:
“section 24 of this act,”.
Amend sec. 12, page 9, line 6, after “any;” by inserting “and”.
Amend sec. 12, page 9, by deleting lines 7 through 30 and inserting:
“(d) The managed care organization.”.
Amend the bill as a whole by renumbering sec. 13 as sec. 26 and adding new sections designated sections 24 and 25, following sec. 12, to read as follows:
“Sec. 24. 1. A managed care organization shall approve or deny a request for an external review of a final adverse determination in an expedited manner not later than 72 hours after it receives proof from the insured’s provider of health care that failure to proceed in an expedited manner may jeopardize the life or health of the insured.
2. If a managed care organization approves a request for an external review pursuant to subsection 1, the managed care organization shall:
(a) In accordance with subsections 4 and 5, assign the request to an external review organization not later than 1 working day after approving the request; and
(b) At the time of assigning the request, provide to the external review organization all documents and materials specified in subsection 4 of section 22 of this act.
3. An external review organization that is assigned to conduct an external review pursuant to subsection 2 shall, if it accepts the assignment:
(a) Complete its external review not later than 2 working days after receiving the assignment, unless the insured and the managed care organization agree to a longer period;
(b) Not later than 1 working day after completing its external review, notify the insured, the physician of the insured, the authorized representative of the insured, if any, and the managed care organization by telephone of its determination; and
(c) Not later than 5 working days after completing its external review, submit a written decision of its external review to the insured, the physician of the insured, the authorized representative of the insured, if any, and the managed care organization.
4. At least once each month, the Office for Consumer Health Assistance shall designate at least 2 external review organizations to conduct external reviews in an expedited manner pursuant to this section. As soon as practicable after designating an external review organization pursuant to this section, the Office for Consumer Health Assistance shall notify each managed care organization of the designation.
5. As soon as practicable after assigning an external review organization to conduct an external review pursuant to this section, the managed care organization shall notify the Office for Consumer Health Assistance of the assignment. Each assignment made by a managed care organization pursuant to this section must be completed on a rotating basis.
Sec. 25. The decision of an external review organization concerning a request for an external review must be based on:
1. Documentary evidence, including any recommendation of the physician of the insured submitted pursuant to section 22 of this act;
2. Medical evidence, including, without limitation:
(a) Professional standards of safety and effectiveness for diagnosis, care and treatment that are generally recognized in the United States;
(b) Any report published in literature that is peer-reviewed;
(c) Evidence-based medicine, including, without limitation, reports and guidelines that are published by professional organizations that are recognized nationally and that include supporting scientific data; and
(d) An opinion of an independent physician who, as determined by the external review organization, is an expert in the health specialty that is the subject of the external review; and
3. The terms and conditions for benefits set forth in the evidence of coverage issued to the insured by the managed care organization.”.
Amend sec. 13, page 9, line 42, by deleting:
“6 to 14,” and inserting:
“16 to 28,”.
Amend sec. 13, page 9, line 43, by deleting:
“to the Office for Consumer Health Assistance”.
Amend the bill as a whole by renumbering sec. 14 as sec. 27.
Amend sec. 14, page 10, line 6, by deleting:
“6 to 14,” and inserting:
“16 to 28,”.
Amend sec. 14, page 10, line 12, by deleting:
“6 to 14,” and inserting:
“16 to 28,”.
Amend the bill as a whole by renumbering sections 15 and 16 as sections 29 and 30 and adding a new section designated sec. 28, following sec. 14, to read as follows:
“Sec. 28. On or before January 31 of each year, each managed care organization shall file a written report with the Office for Consumer Health Assistance setting forth the total number of:
1. Requests for external review that were received by the managed care organization during the immediately preceding year; and
2. Final adverse determinations of the managed care organization that were:
(a) Approved during the immediately preceding year;
(b) Reversed during the immediately preceding year; and
(c) Modified during the immediately preceding year.”.
Amend sec. 15, page 10, line 17, by deleting:
“6 to 10,” and inserting:
“16 to 20,”.
Amend sec. 16, page 10, line 25, by deleting:
“6 to 14,” and inserting:
“16 to 28,”.
Amend the bill as a whole by renumbering sections 17 and 18 as sections 32 and 33 and adding a new section designated sec. 31, following sec. 16, to read as follows:
“Sec. 31. NRS 695G.090 is hereby amended to read as follows:
695G.090 1. The provisions of this chapter apply to each organization and insurer that operates as a managed care organization and may include, without limitation, an insurer that issues a policy of health insurance, an insurer that issues a policy of individual or group health insurance, a carrier serving small employers, a fraternal benefit society, a hospital or medical service corporation , and a health maintenance organization.
2. In addition to the provisions of this chapter, each managed care organization shall comply with any other applicable provision of this title.
3. The provisions of NRS 695G.200 to 695G.230, inclusive, do not apply to an organization that provides health care services through managed care to recipients of Medicaid under the State Plan for Medicaid or insurance pursuant to the Children’s Health Insurance Program pursuant to a contract with the Division of Health Care Financing and Policy of the Department of Human Resources. This subsection does not exempt a managed care organization from any provision of this chapter for services provided pursuant to any other contract.”.
Amend sec. 17, page 10, line 28, by deleting “14” and inserting “27”.
Amend sec. 18, page 11, line 35, by deleting:
“6 to 14,” and inserting:
“16 to 28,”.
Amend the bill as a whole by deleting sec. 19 and renumbering sec. 20 as sec. 34.
Amend sec. 20, page 13, lines 18 and 19, by deleting:
“6 to 14,” and inserting:
“16 to 28,”.
Amend sec. 20, page 13, line 20, by deleting “reviews.” and inserting:
“reviews as reported pursuant to section 28 of this act.”.
Amend the bill as a whole by renumbering sec. 21 as sec. 35.
Amend sec. 21, page 13, line 25, by deleting:
“6 to 14,” and inserting:
“16 to 28,”.
Amend the bill as a whole by renumbering sec. 22 as sec. 37 and adding a new section designated sec. 36, following sec. 22, to read as follows:
“Sec. 36. NRS 422.273 is hereby amended to read as follows:
422.273 1. For any Medicaid managed care program established in the State of Nevada, the Department shall contract only with a health maintenance organization that has:
(a) Negotiated in good faith with a federally-qualified health center to provide health care services for the health maintenance organization;
(b) Negotiated in good faith with the University Medical Center of Southern Nevada to provide inpatient and ambulatory services to recipients of Medicaid; and
(c) Negotiated in good faith with the University of Nevada School of Medicine to provide health care services to recipients of Medicaid.
FLUSH
Nothing in this section shall be construed as exempting a
federally-qualified health center, the University Medical Center of Southern
Nevada or the University of Nevada School of Medicine from the requirements for
contracting with the health maintenance organization.
2. During the development and implementation of any Medicaid managed care program, the Department shall cooperate with the University of Nevada School of Medicine by assisting in the provision of an adequate and diverse group of patients upon which the school may base its educational programs.
3. The University of Nevada School of Medicine may establish a nonprofit organization to assist in any research necessary for the development of a Medicaid managed care program, receive and accept gifts, grants and donations to support such a program and assist in establishing educational services about the program for recipients of Medicaid.
4. For the purpose of contracting with a Medicaid managed care program pursuant to this section, a health maintenance organization is exempt from the provisions of NRS 695C.123.
5. The provisions of this section apply to any managed care organization, including a health maintenance organization, that provides health care services to recipients of Medicaid under the State Plan for Medicaid or the Children’s Health Insurance Program pursuant to a contract with the Division of Health Care Financing and Policy of the Department of Human Resources. Such a managed care organization or health maintenance organization is not required to establish a system for conducting external reviews of final adverse determinations in accordance with chapter 695B, 695C or 695G of NRS. This subsection does not exempt such a managed care organization or health maintenance organization for services provided pursuant to any other contract.
6. As used in this section, unless the context otherwise requires:
(a) “Federally-qualified health center” has the meaning ascribed to it in 42 U.S.C. § 1396d(l)(2)(B).
(b) “Health maintenance organization” has the meaning ascribed to it in NRS 695C.030.
(c) “Managed care organization” has the meaning ascribed to it in NRS 695G.050.”.
Amend sec. 22, page 13, by deleting lines 31 through 35 and inserting:
“2. Sections 1 to 36, inclusive, of this act become”.
Amend sec. 22, page 13, line 41, by deleting “1” and inserting “2”.
Amend the title of the bill to read as follows:
“AN ACT relating to health care; requiring an external review organization to be certified by the Commissioner of Insurance before conducting an external review of a final adverse determination of a managed care organization, health maintenance organization or certain insurers; authorizing an insured under certain health care plans to submit to a managed care organization, health maintenance organization or certain insurers a request for such a review under certain circumstances; requiring an external review organization to approve, modify or reverse a final adverse determination within a certain period; providing that an external review organization is not liable in a civil action for damages relating to a determination issued by the external review organization under certain circumstances; and providing other matters properly relating thereto.”.
Amend the summary of the bill to read as follows: