- 82nd Session (2023)
Senate Bill No. 163–Senators Scheible, D. Harris and Spearman
Joint Sponsor: Assemblywoman González
CHAPTER..........
AN ACT relating to insurance; requiring certain health insurance to
include coverage for the treatment of conditions relating to
gender dysphoria and gender incongruence; prohibiting such
insurers from engaging in certain discrimination on the basis
of gender identity or expression; making appropriations and
authorizing certain expenditures; and providing other matters
properly relating thereto.
Legislative Counsel’s Digest:
Existing law requires public and private policies of health insurance regulated
under Nevada law to include certain coverage. (NRS 287.010, 287.04335,
422.2712-422.27241, 689A.04033-689A.0465, 689B.0303-689B.0379, 689C.1655-
689C.169, 689C.194, 689C.1945, 689C.195, 695A.184-695A.1875, 695B.1901-
695B.1948, 695C.1691-695C.176, 695G.162-695G.177) Existing law also requires
employers to provide certain benefits for health care to employees, including the
coverage required of health insurers, if the employer provides health benefits for its
employees. (NRS 608.1555) Sections 1.3, 3, 4, 6, 7, 8, 11, 13, 14 and 15 of this
bill: (1) require certain public and private policies of health insurance and health
care plans, including Medicaid, to cover the treatment of conditions relating to
gender dysphoria and gender incongruence; (2) authorize those policies and plans
to prescribe requirements that must be satisfied before the insurer will cover
surgical treatment for conditions relating to gender dysphoria or gender
incongruence for persons who are less than 18 years of age; and (3) require an
insurer to consult with a provider of health care with experience in prescribing or
delivering gender-affirming treatment when considering certain appeals of a denial
of coverage. Sections 1.6, 3.6, 4.6, 6.6, 7.6, 8.6, 11.6 and 15.6 of this bill prohibit
an insurer from engaging in certain discrimination on the basis of gender identity or
expression. Sections 2, 5, 9 and 12 of this bill make conforming changes to
indicate the proper placement of sections 1.3, 1.6, 4, 4.6, 8, 8.6, 15 and 15.6 in the
Nevada Revised Statutes.
Section 10 of this bill authorizes the Commissioner of Insurance to suspend or
revoke the certificate of a health maintenance organization that fails to comply with
the requirements of sections 8 and 8.6. The Commissioner would also be
authorized to take such action against other health insurers who fail to comply with
the requirements of sections 1.3, 1.6, 3, 3.6, 4, 4.6, 6, 6.6, 7, 7.6, 11 and 11.6.
(NRS 680A.200) Sections 16 and 17 of this bill make appropriations to the
Division of Health Care Financing and Policy of the Department of Health and
Human Services and authorize certain related expenditures for: (1) the costs of
providing the coverage under Medicaid required by section 15; and (2) certain
other costs associated with carrying out the provisions of this bill.
– 2 –
- 82nd Session (2023)
EXPLANATION – Matter in bolded italics is new; matter between brackets [omitted material] is material to be omitted.
THE PEOPLE OF THE STATE OF NEVADA, REPRESENTED IN
SENATE AND ASSEMBLY, DO ENACT AS FOLLOWS:
Section 1. Chapter 689A of NRS is hereby amended by
adding thereto the provisions set forth as sections 1.3 and 1.6 of this
act.
Sec. 1.3. 1. Except as otherwise provided in this section, an
insurer that issues a policy of health insurance shall include in the
policy coverage for the medically necessary treatment of
conditions relating to gender dysphoria and gender incongruence.
Such coverage must include coverage of medically necessary
psychosocial and surgical intervention and any other medically
necessary treatment for such disorders provided by:
(a) Endocrinologists;
(b) Pediatric endocrinologists;
(c) Social workers;
(d) Psychiatrists;
(e) Psychologists;
(f) Gynecologists;
(g) Speech-language pathologists;
(h) Primary care physicians;
(i) Advanced practice registered nurses;
(j) Physician assistants; and
(k) Any other providers of medically necessary services for the
treatment of gender dysphoria or gender incongruence.
2. This section does not require a policy of health insurance
to include coverage for cosmetic surgery performed by a plastic
surgeon or reconstructive surgeon that is not medically necessary.
3. An insurer that issues a policy of health insurance shall
not categorically refuse to cover medically necessary gender-
affirming treatments or procedures or revisions to prior treatments
if the policy provides coverage for any such services, procedures
or revisions for purposes other than gender transition or
affirmation.
4. An insurer that issues a policy of health insurance may
prescribe requirements that must be satisfied before the insurer
covers surgical treatment of conditions relating to gender
dysphoria or gender incongruence for an insured who is less than
18 years of age. Such requirements may include, without
limitation, requirements that:
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- 82nd Session (2023)
(a) The treatment must be recommended by a psychologist,
psychiatrist or other mental health professional;
(b) The treatment must be recommended by a physician;
(c) The insured must provide a written expression of the desire
of the insured to undergo the treatment;
(d) A written plan for treatment that covers at least 1 year must
be developed and approved by at least two providers of health
care; and
(e) Parental consent is provided for the insured unless the
insured is expressly authorized by law to consent on his or her
own behalf.
5. When determining whether treatment is medically
necessary for the purposes of this section, an insurer must
consider the most recent Standards of Care published by the
World Professional Association for Transgender Health, or its
successor organization.
6. An insurer shall make a reasonable effort to ensure that
the benefits required by subsection 1 are made available to an
insured through a provider of health care who participates in the
network plan of the insurer. If, after a reasonable effort, the
insurer is unable to make such benefits available through such a
provider of health care, the insurer may treat the treatment that
the insurer is unable to make available through such a provider of
health care in the same manner as other services provided by a
provider of health care who does not participate in the network
plan of the insurer.
7. If an insured appeals the denial of a claim or coverage
under this section on the grounds that the treatment requested by
the insured is not medically necessary, the insurer must consult
with a provider of health care who has experience in prescribing
or delivering gender-affirming treatment concerning the medical
necessity of the treatment requested by the insured when
considering the appeal.
8. A policy of health insurance subject to the provisions of
this chapter that is delivered, issued for delivery or renewed on or
after July 1, 2023, has the legal effect of including the coverage
required by subsection 1, and any provision of the policy or the
renewal which is in conflict with this section is void.
9. As used in this section:
(a) “Cosmetic surgery”:
(1) Means a surgical procedure that:
(I) Does not meaningfully promote the proper function
of the body;
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- 82nd Session (2023)
(II) Does not prevent or treat illness or disease; and
(III) Is primarily directed at improving the appearance
of a person.
(2) Includes, without limitation, cosmetic surgery directed
at preserving beauty.
(b) “Gender dysphoria” means distress or impairment in
social, occupational or other areas of functioning caused by a
marked difference between the gender identity or expression of a
person and the sex assigned to the person at birth which lasts at
least 6 months and is shown by at least two of the following:
(1) A marked difference between gender identity or
expression and primary or secondary sex characteristics or
anticipated secondary sex characteristics in young adolescents.
(2) A strong desire to be rid of primary or secondary sex
characteristics because of a marked difference between such sex
characteristics and gender identity or expression or a desire to
prevent the development of anticipated secondary sex
characteristics in young adolescents.
(3) A strong desire for the primary or secondary sex
characteristics of the gender opposite from the sex assigned at
birth.
(4) A strong desire to be of the opposite gender or a gender
different from the sex assigned at birth.
(5) A strong desire to be treated as the opposite gender or a
gender different from the sex assigned at birth.
(6) A strong conviction of experiencing typical feelings and
reactions of the opposite gender or a gender different from the sex
assigned at birth.
(c) “Medically necessary” means health care services or
products that a prudent provider of health care would provide to a
patient to prevent, diagnose or treat an illness, injury or disease, or
any symptoms thereof, that are necessary and:
(1) Provided in accordance with generally accepted
standards of medical practice;
(2) Clinically appropriate with regard to type, frequency,
extent, location and duration;
(3) Not provided primarily for the convenience of the
patient or provider of health care;
(4) Required to improve a specific health condition of a
patient or to preserve the existing state of health of the patient;
and
(5) The most clinically appropriate level of health care that
may be safely provided to the patient.
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- 82nd Session (2023)
A provider of health care prescribing, ordering, recommending
or approving a health care service or product does not, by itself,
make that health care service or product medically necessary.
(d) “Network plan” means a policy of health insurance offered
by an insurer under which the financing and delivery of medical
care, including items and services paid for as medical care, are
provided, in whole or in part, through a defined set of providers
under contract with the insurer. The term does not include an
arrangement for the financing of premiums.
(e) “Provider of health care” has the meaning ascribed to it in
NRS 629.031.
Sec. 1.6. An insurer that issues a policy of health insurance
shall not discriminate against any person with respect to
participation or coverage under the policy on the basis of actual or
perceived gender identity or expression. Prohibited discrimination
includes, without limitation:
1. Denying, cancelling, limiting or refusing to issue or renew
a policy of health insurance on the basis of the actual or perceived
gender identity or expression of a person or a family member of
the person;
2. Imposing a payment or premium that is based on the
actual or perceived gender identity or expression of an insured or
a family member of the insured;
3. Designating the actual or perceived gender identity or
expression of a person or a family member of the person as
grounds to deny, cancel or limit participation or coverage; and
4. Denying, cancelling or limiting participation or coverage
on the basis of actual or perceived gender identity or expression,
including, without limitation, by limiting or denying coverage for
health care services that are:
(a) Related to gender transition, provided that there is
coverage under the policy for the services when the services are
not related to gender transition; or
(b) Ordinarily or exclusively available to persons of any sex.
Sec. 2. NRS 689A.330 is hereby amended to read as follows:
689A.330 If any policy is issued by a domestic insurer for
delivery to a person residing in another state, and if the insurance
commissioner or corresponding public officer of that other state has
informed the Commissioner that the policy is not subject to approval
or disapproval by that officer, the Commissioner may by ruling
require that the policy meet the standards set forth in NRS 689A.030
to 689A.320, inclusive [.] , and sections 1.3 and 1.6 of this act.
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- 82nd Session (2023)
Sec. 2.8. Chapter 689B of NRS is hereby amended by adding
thereto the provisions set forth as sections 3 and 3.6 of this act.
Sec. 3. 1. Except as otherwise provided in this section, an
insurer that issues a policy of group health insurance shall
include in the policy coverage for the medically necessary
treatment of conditions relating to gender dysphoria and gender
incongruence. Such coverage must include coverage of medically
necessary psychosocial and surgical intervention and any other
medically necessary treatment for such disorders provided by:
(a) Endocrinologists;
(b) Pediatric endocrinologists;
(c) Social workers;
(d) Psychiatrists;
(e) Psychologists;
(f) Gynecologists;
(g) Speech-language pathologists;
(h) Primary care physicians;
(i) Advanced practice registered nurses;
(j) Physician assistants; and
(k) Any other providers of medically necessary services for the
treatment of gender dysphoria or gender incongruence.
2. This section does not require a policy of group health
insurance to include coverage for cosmetic surgery performed by a
plastic surgeon or reconstructive surgeon that is not medically
necessary.
3. An insurer that issues a policy of group health insurance
shall not categorically refuse to cover medically necessary gender-
affirming treatments or procedures or revisions to prior treatments
if the policy provides coverage for any such services, procedures
or revisions for purposes other than gender transition or
affirmation.
4. An insurer that issues a policy of group health insurance
may prescribe requirements that must be satisfied before the
insurer covers surgical treatment of conditions relating to gender
dysphoria or gender incongruence for an insured who is less than
18 years of age. Such requirements may include, without
limitation, requirements that:
(a) The treatment must be recommended by a psychologist,
psychiatrist or other mental health professional;
(b) The treatment must be recommended by a physician;
(c) The insured must provide a written expression of the desire
of the insured to undergo the treatment;
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- 82nd Session (2023)
(d) A written plan for treatment that covers at least 1 year must
be developed and approved by at least two providers of health
care; and
(e) Parental consent is provided for the insured unless the
insured is expressly authorized by law to consent on his or her
own behalf.
5. When determining whether treatment is medically
necessary for the purposes of this section, an insurer must
consider the most recent Standards of Care published by the
World Professional Association for Transgender Health, or its
successor organization.
6. An insurer shall make a reasonable effort to ensure that
the benefits required by subsection 1 are made available to an
insured through a provider of health care who participates in the
network plan of the insurer. If, after a reasonable effort, the
insurer is unable to make such benefits available through such a
provider of health care, the insurer may treat the treatment that
the insurer is unable to make available through such a provider of
health care in the same manner as other services provided by a
provider of health care who does not participate in the network
plan of the insurer.
7. If an insured appeals the denial of a claim or coverage
under this section on the grounds that the treatment requested by
the insured is not medically necessary, the insurer must consult
with a provider of health care who has experience in prescribing
or delivering gender-affirming treatment concerning the medical
necessity of the treatment requested by the insured when
considering the appeal.
8. A policy of group health insurance subject to the
provisions of this chapter that is delivered, issued for delivery or
renewed on or after July 1, 2023, has the legal effect of including
the coverage required by subsection 1, and any provision of the
policy or renewal which is in conflict with the provisions of this
section is void.
9. As used in this section:
(a) “Cosmetic surgery”:
(1) Means a surgical procedure that:
(I) Does not meaningfully promote the proper function
of the body;
(II) Does not prevent or treat illness or disease; and
(III) Is primarily directed at improving the appearance
of a person.
– 8 –
- 82nd Session (2023)
(2) Includes, without limitation, cosmetic surgery directed
at preserving beauty.
(b) “Gender dysphoria” means distress or impairment in
social, occupational or other areas of functioning caused by a
marked difference between the gender identity or expression of a
person and the sex assigned to the person at birth which lasts at
least 6 months and is shown by at least two of the following:
(1) A marked difference between gender identity or
expression and primary or secondary sex characteristics or
anticipated secondary sex characteristics in young adolescents.
(2) A strong desire to be rid of primary or secondary sex
characteristics because of a marked difference between such sex
characteristics and gender identity or expression or a desire to
prevent the development of anticipated secondary sex
characteristics in young adolescents.
(3) A strong desire for the primary or secondary sex
characteristics of the gender opposite from the sex assigned at
birth.
(4) A strong desire to be of the opposite gender or a gender
different from the sex assigned at birth.
(5) A strong desire to be treated as the opposite gender or a
gender different from the sex assigned at birth.
(6) A strong conviction of experiencing typical feelings and
reactions of the opposite gender or a gender different from the sex
assigned at birth.
(c) “Medically necessary” means health care services or
products that a prudent provider of health care would provide to a
patient to prevent, diagnose or treat an illness, injury or disease, or
any symptoms thereof, that are necessary and:
(1) Provided in accordance with generally accepted
standards of medical practice;
(2) Clinically appropriate with regard to type, frequency,
extent, location and duration;
(3) Not provided primarily for the convenience of the
patient or provider of health care;
(4) Required to improve a specific health condition of a
patient or to preserve the existing state of health of the patient;
and
(5) The most clinically appropriate level of health care that
may be safely provided to the patient.
A provider of health care prescribing, ordering, recommending
or approving a health care service or product does not, by itself,
make that health care service or product medically necessary.
– 9 –
- 82nd Session (2023)
(d) “Network plan” means a policy of group health insurance
offered by an insurer under which the financing and delivery of
medical care, including items and services paid for as medical
care, are provided, in whole or in part, through a defined set of
providers under contract with the insurer. The term does not
include an arrangement for the financing of premiums.
(e) “Provider of health care” has the meaning ascribed to it in
NRS 629.031.
Sec. 3.6. An insurer that issues a policy of group health
insurance shall not discriminate against any person with respect
to participation or coverage under the policy on the basis of actual
or perceived gender identity or expression. Prohibited
discrimination includes, without limitation:
1. Denying, cancelling, limiting or refusing to issue or renew
a policy of group health insurance on the basis of the actual or
perceived gender identity or expression of a person or a family
member of the person;
2. Imposing a payment or premium that is based on the
actual or perceived gender identity or expression of an insured or
a family member of the insured;
3. Designating the actual or perceived gender identity or
expression of a person or a family member of the person as
grounds to deny, cancel or limit participation or coverage; and
4. Denying, cancelling or limiting participation or coverage
on the basis of actual or perceived gender identity or expression,
including, without limitation, by limiting or denying coverage for
health care services that are:
(a) Related to gender transition, provided that there is
coverage under the policy for the services when the services are
not related to gender transition; or
(b) Ordinarily or exclusively available to persons of any sex.
Sec. 3.8. Chapter 689C of NRS is hereby amended by adding
thereto the provisions set forth as sections 4 and 4.6 of this act.
Sec. 4. 1. Except as otherwise provided in this section, a
carrier that issues a health benefit plan shall include in the health
benefit plan coverage for the medically necessary treatment of
conditions relating to gender dysphoria and gender incongruence.
Such coverage must include coverage of medically necessary
psychosocial and surgical intervention and any other medically
necessary treatment for such disorders provided by:
(a) Endocrinologists;
(b) Pediatric endocrinologists;
(c) Social workers;
– 10 –
- 82nd Session (2023)
(d) Psychiatrists;
(e) Psychologists;
(f) Gynecologists;
(g) Speech-language pathologists;
(h) Primary care physicians;
(i) Advanced practice registered nurses;
(j) Physician assistants; and
(k) Any other providers of medically necessary services for the
treatment of gender dysphoria or gender incongruence.
2. This section does not require a health benefit plan to
include coverage for cosmetic surgery performed by a plastic
surgeon or reconstructive surgeon that is not medically necessary.
3. A carrier that issues a health benefit plan shall not
categorically refuse to cover medically necessary gender-affirming
treatments or procedures or revisions to prior treatments if the
plan provides coverage for any such services, procedures or
revisions for purposes other than gender transition or affirmation.
4. A carrier that issues a health benefit plan may prescribe
requirements that must be satisfied before the carrier covers
surgical treatment of conditions relating to gender dysphoria or
gender incongruence for an insured who is less than 18 years of
age. Such requirements may include, without limitation,
requirements that:
(a) The treatment must be recommended by a psychologist,
psychiatrist or other mental health professional;
(b) The treatment must be recommended by a physician;
(c) The insured must provide a written expression of the desire
of the insured to undergo the treatment;
(d) A written plan for treatment that covers at least 1 year must
be developed and approved by at least two providers of health
care; and
(e) Parental consent is provided for the insured unless the
insured is expressly authorized by law to consent on his or her
own behalf.
5. When determining whether treatment is medically
necessary for the purposes of this section, a carrier must consider
the most recent Standards of Care published by the World
Professional Association for Transgender Health, or its successor
organization.
6. A carrier shall make a reasonable effort to ensure that the
benefits required by subsection 1 are made available to an insured
through a provider of health care who participates in the network
plan of the carrier. If, after a reasonable effort, the carrier is
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- 82nd Session (2023)
unable to make such benefits available through such a provider of
health care, the carrier may treat the treatment that the carrier is
unable to make available through such a provider of health care
in the same manner as other services provided by a provider of
health care who does not participate in the network plan of the
carrier.
7. If an insured appeals the denial of a claim or coverage
under this section on the grounds that the treatment requested by
the insured is not medically necessary, the carrier must consult
with a provider of health care who has experience in prescribing
or delivering gender-affirming treatment concerning the medical
necessity of the treatment requested by the insured when
considering the appeal
8. A health benefit plan subject to the provisions of this
chapter that is delivered, issued for delivery or renewed on or after
July 1, 2023, has the legal effect of including the coverage
required by subsection 1, and any provision of the plan or renewal
which is in conflict with the provisions of this section is void.
9. As used in this section:
(a) “Cosmetic surgery”:
(1) Means a surgical procedure that:
(I) Does not meaningfully promote the proper function
of the body;
(II) Does not prevent or treat illness or disease; and
(III) Is primarily directed at improving the appearance
of a person.
(2) Includes, without limitation, cosmetic surgery directed
at preserving beauty.
(b) “Gender dysphoria” means distress or impairment in
social, occupational or other areas of functioning caused by a
marked difference between the gender identity or expression of a
person and the sex assigned to the person at birth which lasts at
least 6 months and is shown by at least two of the following:
(1) A marked difference between gender identity or
expression and primary or secondary sex characteristics or
anticipated secondary sex characteristics in young adolescents.
(2) A strong desire to be rid of primary or secondary sex
characteristics because of a marked difference between such sex
characteristics and gender identity or expression or a desire to
prevent the development of anticipated secondary sex
characteristics in young adolescents.
– 12 –
- 82nd Session (2023)
(3) A strong desire for the primary or secondary sex
characteristics of the gender opposite from the sex assigned at
birth.
(4) A strong desire to be of the opposite gender or a gender
different from the sex assigned at birth.
(5) A strong desire to be treated as the opposite gender or a
gender different from the sex assigned at birth.
(6) A strong conviction of experiencing typical feelings and
reactions of the opposite gender or a gender different from the sex
assigned at birth.
(c) “Medically necessary” means health care services or
products that a prudent provider of health care would provide to a
patient to prevent, diagnose or treat an illness, injury or disease, or
any symptoms thereof, that are necessary and:
(1) Provided in accordance with generally accepted
standards of medical practice;
(2) Clinically appropriate with regard to type, frequency,
extent, location and duration;
(3) Not provided primarily for the convenience of the
patient or provider of health care;
(4) Required to improve a specific health condition of a
patient or to preserve the existing state of health of the patient;
and
(5) The most clinically appropriate level of health care that
may be safely provided to the patient.
A provider of health care prescribing, ordering, recommending
or approving a health care service or product does not, by itself,
make that health care service or product medically necessary.
(d) “Network plan” means a health benefit plan offered by a
carrier under which the financing and delivery of medical care,
including items and services paid for as medical care, are
provided, in whole or in part, through a defined set of providers
under contract with the carrier. The term does not include an
arrangement for the financing of premiums.
(e) “Provider of health care” has the meaning ascribed to it in
NRS 629.031.
Sec. 4.6. A carrier that issues a health benefit plan shall not
discriminate against any person with respect to participation or
coverage under the plan on the basis of actual or perceived gender
identity or expression. Prohibited discrimination includes, without
limitation:
1. Denying, cancelling, limiting or refusing to issue or renew
a health benefit plan on the basis of the actual or perceived gender
– 13 –
- 82nd Session (2023)
identity or expression of a person or a family member of the
person;
2. Imposing a payment or premium that is based on the
actual or perceived gender identity or expression of an insured or
a family member of the insured;
3. Designating the actual or perceived gender identity or
expression of a person or a family member of the person as
grounds to deny, cancel or limit participation or coverage; and
4. Denying, cancelling or limiting participation or coverage
on the basis of actual or perceived gender identity or expression,
including, without limitation, by limiting or denying coverage for
health care services that are:
(a) Related to gender transition, provided that there is
coverage under the plan for the services when the services are not
related to gender transition; or
(b) Ordinarily or exclusively available to persons of any sex.
Sec. 5. NRS 689C.425 is hereby amended to read as follows:
689C.425 A voluntary purchasing group and any contract
issued to such a group pursuant to NRS 689C.360 to 689C.600,
inclusive, are subject to the provisions of NRS 689C.015 to
689C.355, inclusive, and sections 4 and 4.6 of this act, to the extent
applicable and not in conflict with the express provisions of NRS
687B.408 and 689C.360 to 689C.600, inclusive.
Sec. 5.8. Chapter 695A of NRS is hereby amended by adding
thereto the provisions set forth as sections 6 and 6.6 of this act.
Sec. 6. 1. Except as otherwise provided in this section, a
society that issues a benefit contract shall include in the benefit
contract coverage for the medically necessary treatment of
conditions relating to gender dysphoria and gender incongruence.
Such coverage must include coverage of medically necessary
psychosocial and surgical intervention and any other medically
necessary treatment for such disorders provided by:
(a) Endocrinologists;
(b) Pediatric endocrinologists;
(c) Social workers;
(d) Psychiatrists;
(e) Psychologists;
(f) Gynecologists;
(g) Speech-language pathologists;
(h) Primary care physicians;
(i) Advanced practice registered nurses;
(j) Physician assistants; and
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- 82nd Session (2023)
(k) Any other providers of medically necessary services for the
treatment of gender dysphoria or gender incongruence.
2. This section does not require a benefit contract to include
coverage for cosmetic surgery performed by a plastic surgeon or
reconstructive surgeon that is not medically necessary.
3. A society that issues a benefit contract shall not
categorically refuse to cover medically necessary gender-affirming
treatments or procedures or revisions to prior treatments if the
contract provides coverage for any such services, procedures or
revisions for purposes other than gender transition or affirmation.
4. A society that issues a benefit contract may prescribe
requirements that must be satisfied before the society covers
surgical treatment of conditions relating to gender dysphoria or
gender incongruence for an insured who is less than 18 years of
age. Such requirements may include, without limitation,
requirements that:
(a) The treatment must be recommended by a psychologist,
psychiatrist or other mental health professional;
(b) The treatment must be recommended by a physician;
(c) The insured must provide a written expression of the desire
of the insured to undergo the treatment;
(d) A written plan for treatment that covers at least 1 year must
be developed and approved by at least two providers of health
care; and
(e) Parental consent is provided for the insured unless the
insured is expressly authorized by law to consent on his or her
own behalf.
5. When determining whether treatment is medically
necessary for the purposes of this section, a society must consider
the most recent Standards of Care published by the World
Professional Association for Transgender Health, or its successor
organization.
6. A society shall make a reasonable effort to ensure that the
benefits required by subsection 1 are made available to an insured
through a provider of health care who participates in the network
plan of the society. If, after a reasonable effort, the society is
unable to make such benefits available through such a provider of
health care, the society may treat the treatment that the society is
unable to make available through such a provider of health care
in the same manner as other services provided by a provider of
health care who does not participate in the network plan of the
society.
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- 82nd Session (2023)
7. If an insured appeals the denial of a claim or coverage
under this section on the grounds that the treatment requested by
the insured is not medically necessary, the society must consult
with a provider of health care who has experience in prescribing
or delivering gender-affirming treatment concerning the medical
necessity of the treatment requested by the insured when
considering the appeal.
8. A benefit contract subject to the provisions of this chapter
that is delivered, issued for delivery or renewed on or after July 1,
2023, has the legal effect of including the coverage required by
subsection 1, and any provision of the benefit contract or renewal
which is in conflict with the provisions of this section is void.
9. As used in this section:
(a) “Cosmetic surgery”:
(1) Means a surgical procedure that:
(I) Does not meaningfully promote the proper function
of the body;
(II) Does not prevent or treat illness or disease; and
(III) Is primarily directed at improving the appearance
of a person.
(2) Includes, without limitation, cosmetic surgery directed
at preserving beauty.
(b) “Gender dysphoria” means distress or impairment in
social, occupational or other areas of functioning caused by a
marked difference between the gender identity or expression of a
person and the sex assigned to the person at birth which lasts at
least 6 months and is shown by at least two of the following:
(1) A marked difference between gender identity or
expression and primary or secondary sex characteristics or
anticipated secondary sex characteristics in young adolescents.
(2) A strong desire to be rid of primary or secondary sex
characteristics because of a marked difference between such sex
characteristics and gender identity or expression or a desire to
prevent the development of anticipated secondary sex
characteristics in young adolescents.
(3) A strong desire for the primary or secondary sex
characteristics of the gender opposite from the sex assigned at
birth.
(4) A strong desire to be of the opposite gender or a gender
different from the sex assigned at birth.
(5) A strong desire to be treated as the opposite gender or a
gender different from the sex assigned at birth.
– 16 –
- 82nd Session (2023)
(6) A strong conviction of experiencing typical feelings and
reactions of the opposite gender or a gender different from the sex
assigned at birth.
(c) “Medically necessary” means health care services or
products that a prudent provider of health care would provide to a
patient to prevent, diagnose or treat an illness, injury or disease, or
any symptoms thereof, that are necessary and:
(1) Provided in accordance with generally accepted
standards of medical practice;
(2) Clinically appropriate with regard to type, frequency,
extent, location and duration;
(3) Not provided primarily for the convenience of the
patient or provider of health care;
(4) Required to improve a specific health condition of a
patient or to preserve the existing state of health of the patient;
and
(5) The most clinically appropriate level of health care that
may be safely provided to the patient.
A provider of health care prescribing, ordering, recommending
or approving a health care service or product does not, by itself,
make that health care service or product medically necessary.
(d) “Network plan” means a benefit contract offered by a
society under which the financing and delivery of medical care,
including items and services paid for as medical care, are
provided, in whole or in part, through a defined set of providers
under contract with the society. The term does not include an
arrangement for the financing of premiums.
(e) “Provider of health care” has the meaning ascribed to it in
NRS 629.031.
Sec. 6.6. A society that issues a benefit contract shall not
discriminate against any person with respect to participation or
coverage under the contract on the basis of actual or perceived
gender identity or expression. Prohibited discrimination includes,
without limitation:
1. Denying, cancelling, limiting or refusing to issue or renew
a benefit contract on the basis of the actual or perceived gender
identity or expression of a person or a family member of the
person;
2. Imposing a payment or premium that is based on the
actual or perceived gender identity or expression of an insured or
a family member of the insured;
– 17 –
- 82nd Session (2023)
3. Designating the actual or perceived gender identity or
expression of a person or a family member of the person as
grounds to deny, cancel or limit participation or coverage; and
4. Denying, cancelling or limiting participation or coverage
on the basis of actual or perceived gender identity or expression,
including, without limitation, by limiting or denying coverage for
health care services that are:
(a) Related to gender transition, provided that there is
coverage under the contract for the services when the services are
not related to gender transition; or
(b) Ordinarily or exclusively available to persons of any sex.
Sec. 6.8. Chapter 695B of NRS is hereby amended by adding
thereto the provisions set forth as sections 7 and 7.6 of this act.
Sec. 7. 1. Except as otherwise provided in this section, a
hospital or medical services corporation that issues a policy of
health insurance shall include in the policy coverage for the
medically necessary treatment of conditions relating to gender
dysphoria and gender incongruence. Such coverage must include
coverage of medically necessary psychosocial and surgical
intervention and any other medically necessary treatment for such
disorders provided by:
(a) Endocrinologists;
(b) Pediatric endocrinologists;
(c) Social workers;
(d) Psychiatrists;
(e) Psychologists;
(f) Gynecologists;
(g) Speech-language pathologists;
(h) Primary care physicians;
(i) Advanced practice registered nurses;
(j) Physician assistants; and
(k) Any other providers of medically necessary services for the
treatment of gender dysphoria or gender incongruence.
2. This section does not require a policy of health insurance
to include coverage for cosmetic surgery performed by a plastic
surgeon or reconstructive surgeon that is not medically necessary.
3. A hospital or medical services corporation that issues a
policy of health insurance shall not categorically refuse to cover
medically necessary gender-affirming treatments or procedures or
revisions to prior treatments if the policy provides coverage for any
such services, procedures or revisions for purposes other than
gender transition or affirmation.
– 18 –
- 82nd Session (2023)
4. A hospital or medical services corporation that issues a
policy of health insurance may prescribe requirements that must
be satisfied before the hospital or medical services corporation
covers surgical treatment of conditions relating to gender
dysphoria or gender incongruence for an insured who is less than
18 years of age. Such requirements may include, without
limitation, requirements that:
(a) The treatment must be recommended by a psychologist,
psychiatrist or other mental health professional;
(b) The treatment must be recommended by a physician;
(c) The insured must provide a written expression of the desire
of the insured to undergo the treatment;
(d) A written plan for treatment that covers at least 1 year must
be developed and approved by at least two providers of health
care; and
(e) Parental consent is provided for the insured unless the
insured is expressly authorized by law to consent on his or her
own behalf.
5. When determining whether treatment is medically
necessary for the purposes of this section, a hospital or medical
services corporation must consider the most recent Standards of
Care published by the World Professional Association for
Transgender Health, or its successor organization.
6. A hospital or medical services corporation shall make a
reasonable effort to ensure that the benefits required by subsection
1 are made available to an insured through a provider of health
care who participates in the network plan of the hospital or
medical services corporation. If, after a reasonable effort, the
hospital or medical services corporation is unable to make such
benefits available through such a provider of health care, the
hospital or medical services corporation may treat the treatment
that the hospital or medical services corporation is unable to make
available through such a provider of health care in the same
manner as other services provided by a provider of health care
who does not participate in the network plan of the hospital or
medical services corporation.
7. If an insured appeals the denial of a claim or coverage
under this section on the grounds that the treatment requested by
the insured is not medically necessary, the hospital or medical
services corporation must consult with a provider of health care
who has experience in prescribing or delivering gender-affirming
treatment concerning the medical necessity of the treatment
requested by the insured when considering the appeal.
– 19 –
- 82nd Session (2023)
8. A policy of health insurance subject to the provisions of
this chapter that is delivered, issued for delivery or renewed on or
after July 1, 2023, has the legal effect of including the coverage
required by subsection 1, and any provision of the policy or
renewal which is in conflict with the provisions of this section is
void.
9. As used in this section:
(a) “Cosmetic surgery”:
(1) Means a surgical procedure that:
(I) Does not meaningfully promote the proper function
of the body;
(II) Does not prevent or treat illness or disease; and
(III) Is primarily directed at improving the appearance
of a person.
(2) Includes, without limitation, cosmetic surgery directed
at preserving beauty.
(b) “Gender dysphoria” means distress or impairment in
social, occupational or other areas of functioning caused by a
marked difference between the gender identity or expression of a
person and the sex assigned to the person at birth which lasts at
least 6 months and is shown by at least two of the following:
(1) A marked difference between gender identity or
expression and primary or secondary sex characteristics or
anticipated secondary sex characteristics in young adolescents.
(2) A strong desire to be rid of primary or secondary sex
characteristics because of a marked difference between such sex
characteristics and gender identity or expression or a desire to
prevent the development of anticipated secondary sex
characteristics in young adolescents.
(3) A strong desire for the primary or secondary sex
characteristics of the gender opposite from the sex assigned at
birth.
(4) A strong desire to be of the opposite gender or a gender
different from the sex assigned at birth.
(5) A strong desire to be treated as the opposite gender or a
gender different from the sex assigned at birth.
(6) A strong conviction of experiencing typical feelings and
reactions of the opposite gender or a gender different from the sex
assigned at birth.
(c) “Medically necessary” means health care services or
products that a prudent provider of health care would provide to a
patient to prevent, diagnose or treat an illness, injury or disease, or
any symptoms thereof, that are necessary and:
– 20 –
- 82nd Session (2023)
(1) Provided in accordance with generally accepted
standards of medical practice;
(2) Clinically appropriate with regard to type, frequency,
extent, location and duration;
(3) Not provided primarily for the convenience of the
patient or provider of health care;
(4) Required to improve a specific health condition of a
patient or to preserve the existing state of health of the patient;
and
(5) The most clinically appropriate level of health care that
may be safely provided to the patient.
A provider of health care prescribing, ordering, recommending
or approving a health care service or product does not, by itself,
make that health care service or product medically necessary.
(d) “Network plan” means a policy of health insurance offered
by a hospital or medical services corporation under which the
financing and delivery of medical care, including items and
services paid for as medical care, are provided, in whole or in part,
through a defined set of providers under contract with the hospital
or medical services corporation. The term does not include an
arrangement for the financing of premiums.
(e) “Provider of health care” has the meaning ascribed to it in
NRS 629.031.
Sec. 7.6. A hospital or medical services corporation that
issues a policy of health insurance shall not discriminate against
any person with respect to participation or coverage under the
policy on the basis of actual or perceived gender identity or
expression. Prohibited discrimination includes, without limitation:
1. Denying, cancelling, limiting or refusing to issue or renew
a policy of health insurance on the basis of the actual or perceived
gender identity or expression of a person or a family member of
the person;
2. Imposing a payment or premium that is based on the
actual or perceived gender identity or expression of an insured or
a family member of the insured;
3. Designating the actual or perceived gender identity or
expression of a person or a family member of the person as
grounds to deny, cancel or limit participation or coverage; and
4. Denying, cancelling or limiting participation or coverage
on the basis of actual or perceived gender identity or expression,
including, without limitation, by limiting or denying coverage for
health care services that are:
– 21 –
- 82nd Session (2023)
(a) Related to gender transition, provided that there is
coverage under the policy for the services when the services are
not related to gender transition; or
(b) Ordinarily or exclusively available to persons of any sex.
Sec. 7.8. Chapter 695C of NRS is hereby amended by adding
thereto the provisions set forth as sections 8 and 8.6 of this act.
Sec. 8. 1. Except as otherwise provided in this section, a
health maintenance organization that issues a health care plan
shall include in the health care plan coverage for the medically
necessary treatment of conditions relating to gender dysphoria and
gender incongruence. Such coverage must include coverage of
medically necessary psychosocial and surgical intervention and
any other medically necessary treatment for such disorders
provided by:
(a) Endocrinologists;
(b) Pediatric endocrinologists;
(c) Social workers;
(d) Psychiatrists;
(e) Psychologists;
(f) Gynecologists;
(g) Speech-language pathologists;
(h) Primary care physicians;
(i) Advanced practice registered nurses;
(j) Physician assistants; and
(k) Any other providers of medically necessary services for the
treatment of gender dysphoria or gender incongruence.
2. This section does not require a health care plan to include
coverage for cosmetic surgery performed by a plastic surgeon or
reconstructive surgeon that is not medically necessary.
3. A health maintenance organization that issues a health
care plan shall not categorically refuse to cover medically
necessary gender-affirming treatments or procedures or revisions
to prior treatments if the plan provides coverage for any such
services, procedures or revisions for purposes other than gender
transition or affirmation.
4. A health maintenance organization that issues a health
care plan may prescribe requirements that must be satisfied before
the health maintenance organization covers surgical treatment of
conditions relating to gender dysphoria or gender incongruence
for an enrollee who is less than 18 years of age. Such
requirements may include, without limitation, requirements that:
(a) The treatment must be recommended by a psychologist,
psychiatrist or other mental health professional;
– 22 –
- 82nd Session (2023)
(b) The treatment must be recommended by a physician;
(c) The enrollee must provide a written expression of the desire
of the enrollee to undergo the treatment;
(d) A written plan for treatment that covers at least 1 year must
be developed and approved by at least two providers of health
care; and
(e) Parental consent is provided for the enrollee unless the
enrollee is expressly authorized by law to consent on his or her
own behalf.
5. When determining whether treatment is medically
necessary for the purposes of this section, a health maintenance
organization must consider the most recent Standards of Care
prescribed by the World Professional Association for Transgender
Health, or its successor organization.
6. A health maintenance organization shall make a
reasonable effort to ensure that the benefits required by subsection
1 are made available to an enrollee through a provider of
health care who participates in the network plan of the health
maintenance organization. If, after a reasonable effort, the health
maintenance organization is unable to make such benefits
available through such a provider of health care, the health
maintenance organization may treat the treatment that the health
maintenance organization is unable to make available through
such a provider of health care in the same manner as other
services provided by a provider of health care who does not
participate in the network plan of the health maintenance
organization.
7. If an enrollee appeals the denial of a claim or coverage
under this section on the grounds that the treatment requested by
the enrollee is not medically necessary, the health maintenance
organization must consult with a provider of health care who has
experience in prescribing or delivering gender-affirming treatment
concerning the medical necessity of the treatment requested by the
enrollee when considering the appeal.
8. A health care plan subject to the provisions of this chapter
that is delivered, issued for delivery or renewed on or after July 1,
2023, has the legal effect of including the coverage required by
subsection 1, and any provision of the plan or renewal which is in
conflict with the provisions of this section is void.
9. As used in this section:
(a) “Cosmetic surgery”:
(1) Means a surgical procedure that:
– 23 –
- 82nd Session (2023)
(I) Does not meaningfully promote the proper function
of the body;
(II) Does not prevent or treat illness or disease; and
(III) Is primarily directed at improving the appearance
of a person.
(2) Includes, without limitation, cosmetic surgery directed
at preserving beauty.
(b) “Gender dysphoria” means distress or impairment in
social, occupational or other areas of functioning caused by a
marked difference between the gender identity or expression of a
person and the sex assigned to the person at birth which lasts at
least 6 months and is shown by at least two of the following:
(1) A marked difference between gender identity or
expression and primary or secondary sex characteristics or
anticipated secondary sex characteristics in young adolescents.
(2) A strong desire to be rid of primary or secondary sex
characteristics because of a marked difference between such sex
characteristics and gender identity or expression or a desire to
prevent the development of anticipated secondary sex
characteristics in young adolescents.
(3) A strong desire for the primary or secondary sex
characteristics of the gender opposite from the sex assigned at
birth.
(4) A strong desire to be of the opposite gender or a gender
different from the sex assigned at birth.
(5) A strong desire to be treated as the opposite gender or a
gender different from the sex assigned at birth.
(6) A strong conviction of experiencing typical feelings and
reactions of the opposite gender or a gender different from the sex
assigned at birth.
(c) “Medically necessary” means health care services or
products that a prudent provider of health care would provide to a
patient to prevent, diagnose or treat an illness, injury or disease, or
any symptoms thereof, that are necessary and:
(1) Provided in accordance with generally accepted
standards of medical practice;
(2) Clinically appropriate with regard to type, frequency,
extent, location and duration;
(3) Not provided primarily for the convenience of the
patient or provider of health care;
(4) Required to improve a specific health condition of a
patient or to preserve the existing state of health of the patient;
and
– 24 –
- 82nd Session (2023)
(5) The most clinically appropriate level of health care that
may be safely provided to the patient.
A provider of health care prescribing, ordering, recommending
or approving a health care service or product does not, by itself,
make that health care service or product medically necessary.
(d) “Network plan” means a health care plan offered by a
health maintenance organization under which the financing and
delivery of medical care, including items and services paid for as
medical care, are provided, in whole or in part, through a defined
set of providers under contract with the health maintenance
organization. The term does not include an arrangement for the
financing of premiums.
(e) “Provider of health care” has the meaning ascribed to it in
NRS 629.031.
Sec. 8.6. A health maintenance organization that issues a
health care plan shall not discriminate against any person with
respect to participation or coverage under the plan on the basis of
actual or perceived gender identity or expression. Prohibited
discrimination includes, without limitation:
1. Denying, cancelling, limiting or refusing to issue or renew
a health care plan on the basis of the actual or perceived gender
identity or expression of a person or a family member of the
person;
2. Imposing a payment or premium that is based on the
actual or perceived gender identity or expression of an enrollee or
a family member of the enrollee;
3. Designating the actual or perceived gender identity or
expression of a person or a family member of the person as
grounds to deny, cancel or limit participation or coverage; and
4. Denying, cancelling or limiting participation or coverage
on the basis of actual or perceived gender identity or expression,
including, without limitation, by limiting or denying coverage for
health care services that are:
(a) Related to gender transition, provided that there is
coverage under the plan for the services when the services are not
related to gender transition; or
(b) Ordinarily or exclusively available to persons of any sex.
Sec. 9. NRS 695C.050 is hereby amended to read as follows:
695C.050 1. Except as otherwise provided in this chapter or
in specific provisions of this title, the provisions of this title are not
applicable to any health maintenance organization granted a
certificate of authority under this chapter. This provision does not
apply to an insurer licensed and regulated pursuant to this title
– 25 –
- 82nd Session (2023)
except with respect to its activities as a health maintenance
organization authorized and regulated pursuant to this chapter.
2. Solicitation of enrollees by a health maintenance
organization granted a certificate of authority, or its representatives,
must not be construed to violate any provision of law relating to
solicitation or advertising by practitioners of a healing art.
3. Any health maintenance organization authorized under this
chapter shall not be deemed to be practicing medicine and is exempt
from the provisions of chapter 630 of NRS.
4. The provisions of NRS 695C.110, 695C.125, 695C.1691,
695C.1693, 695C.170, 695C.1703, 695C.1705, 695C.1709 to
695C.173, inclusive, 695C.1733, 695C.17335, 695C.1734,
695C.1751, 695C.1755, 695C.1759, 695C.176 to 695C.200,
inclusive, and 695C.265 do not apply to a health maintenance
organization that provides health care services through managed
care to recipients of Medicaid under the State Plan for Medicaid or
insurance pursuant to the Children’s Health Insurance Program
pursuant to a contract with the Division of Health Care Financing
and Policy of the Department of Health and Human Services. This
subsection does not exempt a health maintenance organization from
any provision of this chapter for services provided pursuant to any
other contract.
5. The provisions of NRS 695C.1694 to 695C.1698, inclusive,
695C.1701, 695C.1708, 695C.1728, 695C.1731, 695C.17333,
695C.17345, 695C.17347, 695C.1735, 695C.1737, 695C.1743,
695C.1745 and 695C.1757 and sections 8 and 8.6 of this act apply
to a health maintenance organization that provides health care
services through managed care to recipients of Medicaid under the
State Plan for Medicaid.
Sec. 10. NRS 695C.330 is hereby amended to read as follows:
695C.330 1. The Commissioner may suspend or revoke any
certificate of authority issued to a health maintenance organization
pursuant to the provisions of this chapter if the Commissioner finds
that any of the following conditions exist:
(a) The health maintenance organization is operating
significantly in contravention of its basic organizational document,
its health care plan or in a manner contrary to that described in and
reasonably inferred from any other information submitted pursuant
to NRS 695C.060, 695C.070 and 695C.140, unless any amendments
to those submissions have been filed with and approved by the
Commissioner;
(b) The health maintenance organization issues evidence of
coverage or uses a schedule of charges for health care services
– 26 –
- 82nd Session (2023)
which do not comply with the requirements of NRS 695C.1691 to
695C.200, inclusive, or 695C.207 [;] or sections 8 and 8.6 of this
act;
(c) The health care plan does not furnish comprehensive health
care services as provided for in NRS 695C.060;
(d) The Commissioner certifies that the health maintenance
organization:
(1) Does not meet the requirements of subsection 1 of NRS
695C.080; or
(2) Is unable to fulfill its obligations to furnish health care
services as required under its health care plan;
(e) The health maintenance organization is no longer financially
responsible and may reasonably be expected to be unable to meet its
obligations to enrollees or prospective enrollees;
(f) The health maintenance organization has failed to put into
effect a mechanism affording the enrollees an opportunity to
participate in matters relating to the content of programs pursuant to
NRS 695C.110;
(g) The health maintenance organization has failed to put into
effect the system required by NRS 695C.260 for:
(1) Resolving complaints in a manner reasonably to dispose
of valid complaints; and
(2) Conducting external reviews of adverse determinations
that comply with the provisions of NRS 695G.241 to 695G.310,
inclusive;
(h) The health maintenance organization or any person on its
behalf has advertised or merchandised its services in an untrue,
misrepresentative, misleading, deceptive or unfair manner;
(i) The continued operation of the health maintenance
organization would be hazardous to its enrollees or creditors or to
the general public;
(j) The health maintenance organization fails to provide the
coverage required by NRS 695C.1691; or
(k) The health maintenance organization has otherwise failed to
comply substantially with the provisions of this chapter.
2. A certificate of authority must be suspended or revoked only
after compliance with the requirements of NRS 695C.340.
3. If the certificate of authority of a health maintenance
organization is suspended, the health maintenance organization shall
not, during the period of that suspension, enroll any additional
groups or new individual contracts, unless those groups or persons
were contracted for before the date of suspension.
– 27 –
- 82nd Session (2023)
4. If the certificate of authority of a health maintenance
organization is revoked, the organization shall proceed, immediately
following the effective date of the order of revocation, to wind up its
affairs and shall conduct no further business except as may be
essential to the orderly conclusion of the affairs of the organization.
It shall engage in no further advertising or solicitation of any kind.
The Commissioner may, by written order, permit such further
operation of the organization as the Commissioner may find to be in
the best interest of enrollees to the end that enrollees are afforded
the greatest practical opportunity to obtain continuing coverage for
health care.
Sec. 10.8. Chapter 695G of NRS is hereby amended by adding
thereto the provisions set forth as sections 11 and 11.6 of this act.
Sec. 11. 1. Except as otherwise provided in this section, a
managed care organization that issues a health care plan shall
include in the health care plan coverage for the medically
necessary treatment of conditions relating to gender dysphoria and
gender incongruence. Such coverage must include coverage of
medically necessary psychosocial and surgical intervention and
any other medically necessary treatment for such disorders
provided by:
(a) Endocrinologists;
(b) Pediatric endocrinologists;
(c) Social workers;
(d) Psychiatrists;
(e) Psychologists;
(f) Gynecologists;
(g) Speech-language pathologists;
(h) Primary care physicians;
(i) Advanced practice registered nurses;
(j) Physician assistants; and
(k) Any other providers of medically necessary services for the
treatment of gender dysphoria or gender incongruence.
2. This section does not require a health care plan to include
coverage for cosmetic surgery performed by a plastic surgeon or
reconstructive surgeon that is not medically necessary.
3. A managed care organization that issues a health care
plan shall not categorically refuse to cover medically necessary
gender-affirming treatments or procedures or revisions to prior
treatments if the plan provides coverage for any such services,
procedures or revisions for purposes other than gender transition
or affirmation.
– 28 –
- 82nd Session (2023)
4. A managed care organization that issues a health care
plan may prescribe requirements that must be satisfied before the
managed care organization covers surgical treatment of
conditions relating to gender dysphoria or gender incongruence
for an insured who is less than 18 years of age. Such requirements
may include, without limitation, requirements that:
(a) The treatment must be recommended by a psychologist,
psychiatrist or other mental health professional;
(b) The treatment must be recommended by a physician;
(c) The insured must provide a written expression of the desire
of the insured to undergo the treatment;
(d) A written plan for treatment that covers at least 1 year must
be developed and approved by at least two providers of health
care; and
(e) Parental consent is provided for the insured unless the
insured is expressly authorized by law to consent on his or her
own behalf.
5. When determining whether treatment is medically
necessary for the purposes of this section, a managed care
organization must consider the most recent Standards of Care
prescribed by the World Professional Association for Transgender
Health, or its successor organization.
6. A managed care organization shall make a reasonable
effort to ensure that the benefits required by subsection 1 are
made available to an insured through a provider of health care
who participates in the network plan of the managed
care organization. If, after a reasonable effort, the managed care
organization is unable to make such benefits available through
such a provider of health care, the managed care organization
may treat the treatment that the managed care organization is
unable to make available through such a provider of health care
in the same manner as other services provided by a provider of
health care who does not participate in the network plan of the
managed care organization.
7. If an insured appeals the denial of a claim or coverage
under this section on the grounds that the treatment requested by
the insured is not medically necessary, the managed care
organization must consult with a provider of health care who has
experience in prescribing or delivering gender-affirming treatment
concerning the medical necessity of the treatment requested by the
insured when considering the appeal.
8. Evidence of coverage subject to the provisions of this
chapter that is delivered, issued for delivery or renewed on or after
– 29 –
- 82nd Session (2023)
July 1, 2023, has the legal effect of including the coverage
required by subsection 1, and any provision of the plan or renewal
which is in conflict with the provisions of this section is void.
9. As used in this section:
(a) “Cosmetic surgery”:
(1) Means a surgical procedure that:
(I) Does not meaningfully promote the proper function
of the body;
(II) Does not prevent or treat illness or disease; and
(III) Is primarily directed at improving the appearance
of a person.
(2) Includes, without limitation, cosmetic surgery directed
at preserving beauty.
(b) “Gender dysphoria” means distress or impairment in
social, occupational or other areas of functioning caused by a
marked difference between the gender identity or expression of a
person and the sex assigned to the person at birth which lasts at
least 6 months and is shown by at least two of the following:
(1) A marked difference between gender identity or
expression and primary or secondary sex characteristics or
anticipated secondary sex characteristics in young adolescents.
(2) A strong desire to be rid of primary or secondary sex
characteristics because of a marked difference between such sex
characteristics and gender identity or expression or a desire to
prevent the development of anticipated secondary sex
characteristics in young adolescents.
(3) A strong desire for the primary or secondary sex
characteristics of the gender opposite from the sex assigned at
birth.
(4) A strong desire to be of the opposite gender or a gender
different from the sex assigned at birth.
(5) A strong desire to be treated as the opposite gender or a
gender different from the sex assigned at birth.
(6) A strong conviction of experiencing typical feelings and
reactions of the opposite gender or a gender different from the sex
assigned at birth.
(c) “Medically necessary” means health care services or
products that a prudent provider of health care would provide to a
patient to prevent, diagnose or treat an illness, injury or disease, or
any symptoms thereof, that are necessary and:
(1) Provided in accordance with generally accepted
standards of medical practice;
– 30 –
- 82nd Session (2023)
(2) Clinically appropriate with regard to type, frequency,
extent, location and duration;
(3) Not provided primarily for the convenience of the
patient or provider of health care;
(4) Required to improve a specific health condition of a
patient or to preserve the existing state of health of the patient;
and
(5) The most clinically appropriate level of health care that
may be safely provided to the patient.
A provider of health care prescribing, ordering, recommending
or approving a health care service or product does not, by itself,
make that health care service or product medically necessary.
(d) “Network plan” means a health care plan offered by a
managed care organization under which the financing and
delivery of medical care, including items and services paid for as
medical care, are provided, in whole or in part, through a defined
set of providers under contract with the managed care
organization. The term does not include an arrangement for the
financing of premiums.
(e) “Provider of health care” has the meaning ascribed to it in
NRS 629.031.
Sec. 11.6. A managed care organization that issues a health
care plan shall not discriminate against any person with respect to
participation or coverage under the plan on the basis of actual or
perceived gender identity or expression. Prohibited discrimination
includes, without limitation:
1. Denying, cancelling, limiting or refusing to issue or renew
a health care plan on the basis of the actual or perceived gender
identity or expression of a person or a family member of the
person;
2. Imposing a payment or premium that is based on the
actual or perceived gender identity or expression of an insured or
a family member of the insured;
3. Designating the actual or perceived gender identity or
expression of a person or a family member of the person as
grounds to deny, cancel or limit participation or coverage; and
4. Denying, cancelling or limiting participation or coverage
on the basis of actual or perceived gender identity or expression,
including, without limitation, by limiting or denying coverage for
health care services that are:
(a) Related to gender transition, provided that there is
coverage under the plan for the services when the services are not
related to gender transition; or
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(b) Ordinarily or exclusively available to persons of any sex.
Sec. 12. NRS 232.320 is hereby amended to read as follows:
232.320 1. The Director:
(a) Shall appoint, with the consent of the Governor,
administrators of the divisions of the Department, who are
respectively designated as follows:
(1) The Administrator of the Aging and Disability Services
Division;
(2) The Administrator of the Division of Welfare and
Supportive Services;
(3) The Administrator of the Division of Child and Family
Services;
(4) The Administrator of the Division of Health Care
Financing and Policy; and
(5) The Administrator of the Division of Public and
Behavioral Health.
(b) Shall administer, through the divisions of the Department,
the provisions of chapters 63, 424, 425, 427A, 432A to 442,
inclusive, 446 to 450, inclusive, 458A and 656A of NRS, NRS
127.220 to 127.310, inclusive, 422.001 to 422.410, inclusive, and
sections 15 and 15.6 of this act, 422.580, 432.010 to 432.133,
inclusive, 432B.6201 to 432B.626, inclusive, 444.002 to 444.430,
inclusive, and 445A.010 to 445A.055, inclusive, and all other
provisions of law relating to the functions of the divisions of the
Department, but is not responsible for the clinical activities of the
Division of Public and Behavioral Health or the professional line
activities of the other divisions.
(c) Shall administer any state program for persons with
developmental disabilities established pursuant to the
Developmental Disabilities Assistance and Bill of Rights Act of
2000, 42 U.S.C. §§ 15001 et seq.
(d) Shall, after considering advice from agencies of local
governments and nonprofit organizations which provide social
services, adopt a master plan for the provision of human services in
this State. The Director shall revise the plan biennially and deliver a
copy of the plan to the Governor and the Legislature at the
beginning of each regular session. The plan must:
(1) Identify and assess the plans and programs of the
Department for the provision of human services, and any
duplication of those services by federal, state and local agencies;
(2) Set forth priorities for the provision of those services;
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(3) Provide for communication and the coordination of those
services among nonprofit organizations, agencies of local
government, the State and the Federal Government;
(4) Identify the sources of funding for services provided by
the Department and the allocation of that funding;
(5) Set forth sufficient information to assist the Department
in providing those services and in the planning and budgeting for the
future provision of those services; and
(6) Contain any other information necessary for the
Department to communicate effectively with the Federal
Government concerning demographic trends, formulas for the
distribution of federal money and any need for the modification of
programs administered by the Department.
(e) May, by regulation, require nonprofit organizations and state
and local governmental agencies to provide information regarding
the programs of those organizations and agencies, excluding
detailed information relating to their budgets and payrolls, which the
Director deems necessary for the performance of the duties imposed
upon him or her pursuant to this section.
(f) Has such other powers and duties as are provided by law.
2. Notwithstanding any other provision of law, the Director, or
the Director’s designee, is responsible for appointing and removing
subordinate officers and employees of the Department.
Sec. 13. NRS 287.010 is hereby amended to read as follows:
287.010 1. The governing body of any county, school
district, municipal corporation, political subdivision, public
corporation or other local governmental agency of the State of
Nevada may:
(a) Adopt and carry into effect a system of group life, accident
or health insurance, or any combination thereof, for the benefit of its
officers and employees, and the dependents of officers and
employees who elect to accept the insurance and who, where
necessary, have authorized the governing body to make deductions
from their compensation for the payment of premiums on the
insurance.
(b) Purchase group policies of life, accident or health insurance,
or any combination thereof, for the benefit of such officers and
employees, and the dependents of such officers and employees, as
have authorized the purchase, from insurance companies authorized
to transact the business of such insurance in the State of Nevada,
and, where necessary, deduct from the compensation of officers and
employees the premiums upon insurance and pay the deductions
upon the premiums.
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(c) Provide group life, accident or health coverage through a
self-insurance reserve fund and, where necessary, deduct
contributions to the maintenance of the fund from the compensation
of officers and employees and pay the deductions into the fund. The
money accumulated for this purpose through deductions from
the compensation of officers and employees and contributions of the
governing body must be maintained as an internal service fund as
defined by NRS 354.543. The money must be deposited in a state or
national bank or credit union authorized to transact business in the
State of Nevada. Any independent administrator of a fund created
under this section is subject to the licensing requirements of chapter
683A of NRS, and must be a resident of this State. Any contract
with an independent administrator must be approved by the
Commissioner of Insurance as to the reasonableness of
administrative charges in relation to contributions collected and
benefits provided. The provisions of NRS 686A.135, 687B.352,
687B.408, 687B.723, 687B.725, 689B.030 to 689B.050, inclusive,
and sections 3 and 3.6 of this act, 689B.265, 689B.287 and
689B.500 apply to coverage provided pursuant to this paragraph,
except that the provisions of NRS 689B.0378, 689B.03785 and
689B.500 only apply to coverage for active officers and employees
of the governing body, or the dependents of such officers and
employees.
(d) Defray part or all of the cost of maintenance of a self-
insurance fund or of the premiums upon insurance. The money for
contributions must be budgeted for in accordance with the laws
governing the county, school district, municipal corporation,
political subdivision, public corporation or other local governmental
agency of the State of Nevada.
2. If a school district offers group insurance to its officers and
employees pursuant to this section, members of the board of trustees
of the school district must not be excluded from participating in the
group insurance. If the amount of the deductions from compensation
required to pay for the group insurance exceeds the compensation to
which a trustee is entitled, the difference must be paid by the trustee.
3. In any county in which a legal services organization exists,
the governing body of the county, or of any school district,
municipal corporation, political subdivision, public corporation or
other local governmental agency of the State of Nevada in the
county, may enter into a contract with the legal services
organization pursuant to which the officers and employees of the
legal services organization, and the dependents of those officers and
employees, are eligible for any life, accident or health insurance
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provided pursuant to this section to the officers and employees, and
the dependents of the officers and employees, of the county, school
district, municipal corporation, political subdivision, public
corporation or other local governmental agency.
4. If a contract is entered into pursuant to subsection 3, the
officers and employees of the legal services organization:
(a) Shall be deemed, solely for the purposes of this section, to be
officers and employees of the county, school district, municipal
corporation, political subdivision, public corporation or other local
governmental agency with which the legal services organization has
contracted; and
(b) Must be required by the contract to pay the premiums or
contributions for all insurance which they elect to accept or of which
they authorize the purchase.
5. A contract that is entered into pursuant to subsection 3:
(a) Must be submitted to the Commissioner of Insurance for
approval not less than 30 days before the date on which the contract
is to become effective.
(b) Does not become effective unless approved by the
Commissioner.
(c) Shall be deemed to be approved if not disapproved by the
Commissioner within 30 days after its submission.
6. As used in this section, “legal services organization” means
an organization that operates a program for legal aid and receives
money pursuant to NRS 19.031.
Sec. 14. NRS 287.04335 is hereby amended to read as
follows:
287.04335 If the Board provides health insurance through a
plan of self-insurance, it shall comply with the provisions of NRS
686A.135, 687B.352, 687B.409, 687B.723, 687B.725, 689B.0353,
689B.255, 695C.1723, 695G.150, 695G.155, 695G.160, 695G.162,
695G.1635, 695G.164, 695G.1645, 695G.1665, 695G.167,
695G.1675, 695G.170 to 695G.174, inclusive, and sections 11 and
11.6 of this act, 695G.176, 695G.177, 695G.200 to 695G.230,
inclusive, 695G.241 to 695G.310, inclusive, and 695G.405, in the
same manner as an insurer that is licensed pursuant to title 57 of
NRS is required to comply with those provisions.
Sec. 14.8. Chapter 422 of NRS is hereby amended by adding
thereto the provisions set forth as sections 15 and 15.6 of this act.
Sec. 15. 1. Except as otherwise provided in this section, the
Director shall include in the State Plan for Medicaid a
requirement that the State, to the extent authorized by federal law,
must pay the nonfederal share of expenditures incurred for the
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medically necessary treatment of conditions relating to gender
dysphoria and gender incongruence. Such treatment includes
medically necessary psychosocial and surgical intervention and
any other medically necessary treatment for such disorders
provided by:
(a) Endocrinologists;
(b) Pediatric endocrinologists;
(c) Social workers;
(d) Psychiatrists;
(e) Psychologists;
(f) Gynecologists;
(g) Speech-language pathologists;
(h) Primary care physicians;
(i) Advanced practice registered nurses;
(j) Physician assistants; and
(k) Any other providers of medically necessary services for the
treatment of gender dysphoria or gender incongruence.
2. This section does not require the Director to include in the
State Plan for Medicaid coverage for cosmetic surgery performed
by a plastic surgeon or reconstructive surgeon that is not
medically necessary.
3. The Department shall not categorically refuse to cover any
medically necessary gender-affirming treatments or procedures or
revisions to prior treatments if the State Plan for Medicaid
provides coverage for any such services, procedures or revisions
for purposes other than gender transition or affirmation.
4. When determining whether treatment is medically
necessary for the purposes of this section, the Department must
consider the most recent Standards of Care published by the
World Professional Association for Transgender Health, or its
successor organization.
5. If a person appeals the denial of a payment or coverage
under this section on the grounds that the treatment requested by
the person is not medically necessary, the Division must consult
with a provider of health care who has experience in prescribing
or delivering gender-affirming treatment concerning the medical
necessity of the treatment requested by the person when
considering the appeal.
6. As used in this section:
(a) “Cosmetic surgery”:
(1) Means a surgical procedure that:
(I) Does not meaningfully promote the proper function
of the body;
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(II) Does not prevent or treat illness or disease; and
(III) Is primarily directed at improving the appearance
of a person.
(2) Includes, without limitation, cosmetic surgery directed
at preserving beauty.
(b) “Gender dysphoria” means distress or impairment in
social, occupational or other areas of functioning caused by a
marked difference between the gender identity or expression of a
person and the sex assigned to the person at birth which lasts at
least 6 months and is shown by at least two of the following:
(1) A marked difference between gender identity or
expression and primary or secondary sex characteristics or
anticipated secondary sex characteristics in young adolescents.
(2) A strong desire to be rid of primary or secondary sex
characteristics because of a marked difference between such sex
characteristics and gender identity or expression or a desire to
prevent the development of anticipated secondary sex
characteristics in young adolescents.
(3) A strong desire for the primary or secondary sex
characteristics of the gender opposite from the sex assigned at
birth.
(4) A strong desire to be of the opposite gender or a gender
different from the sex assigned at birth.
(5) A strong desire to be treated as the opposite gender or a
gender different from the sex assigned at birth.
(6) A strong conviction of experiencing typical feelings and
reactions of the opposite gender or a gender different from the sex
assigned at birth.
(c) “Medically necessary” means health care services or
products that a prudent provider of health care would provide to a
patient to prevent, diagnose or treat an illness, injury or disease, or
any symptoms thereof, that are necessary and:
(1) Provided in accordance with generally accepted
standards of medical practice;
(2) Clinically appropriate with regard to type, frequency,
extent, location and duration;
(3) Not provided primarily for the convenience of the
patient or provider of health care;
(4) Required to improve a specific health condition of a
patient or to preserve the existing state of health of the patient;
and
(5) The most clinically appropriate level of health care that
may be safely provided to the patient.
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A provider of health care prescribing, ordering, recommending
or approving a health care service or product does not, by itself,
make that health care service or product medically necessary.
(d) “Provider of health care” has the meaning ascribed to it in
NRS 629.031.
Sec. 15.6. The Department shall not discriminate against any
person with respect to participation or coverage under Medicaid
on the basis of actual or perceived gender identity or expression.
Prohibited discrimination includes, without limitation:
1. Denying, cancelling, limiting or refusing to issue a
payment or coverage on the basis of the actual or perceived gender
identity or expression of a person or a family member of the
person;
2. Imposing a payment that is based on the actual or
perceived gender identity or expression of a recipient of Medicaid
or a family member of the recipient;
3. Designating the actual or perceived gender identity or
expression of a person or a family member of the person as
grounds to deny, cancel or limit participation or coverage; and
4. Denying, cancelling or limiting participation or coverage
on the basis of actual or perceived gender identity or expression,
including, without limitation, by limiting or denying payment or
coverage for health care services that are:
(a) Related to gender transition, provided that there is
coverage under Medicaid for the services when the services are
not related to gender transition; or
(b) Ordinarily or exclusively available to persons of any sex.
Sec. 16. 1. There is hereby appropriated from the State
General Fund to the Division of Health Care Financing and Policy
of the Department of Health and Human Services for the costs of
providing coverage under Medicaid for the treatment of conditions
relating to gender dysphoria and gender incongruence required by
section 15 of this act the following sums:
For the Fiscal Year 2023-2024 .................................. $162,926
For the Fiscal Year 2024-2025 .................................. $182,654
2. Any balance of the sums appropriated by subsection 1
remaining at the end of the respective fiscal years must not be
committed for expenditure after June 30 of the respective fiscal
years by the entity to which the appropriation is made or any entity
to which money from the appropriation is granted or otherwise
transferred in any manner, and any portion of the appropriated
money remaining must not be spent for any purpose after
September 20, 2024, and September 19, 2025, respectively, by
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either the entity to which the money was appropriated or the entity
to which the money was subsequently granted or transferred, and
must be reverted to the State General Fund on or before
September 20, 2024, and September 19, 2025, respectively.
3. Expenditure of $1,239,172 not appropriated from the State
General Fund or the State Highway Fund is hereby authorized
during Fiscal Year 2023-2024 by the Division of Health Care
Financing and Policy of the Department of Health and Human
Services for the same purposes as set forth in subsection 1.
4. Expenditure of $1,076,246 not appropriated from the State
General Fund or the State Highway Fund is hereby authorized
during Fiscal Year 2024-2025 by the Division of Health Care
Financing and Policy of the Department of Health and Human
Services for the same purposes as set forth in subsection 1.
Sec. 17. 1. There is hereby appropriated from the State
General Fund to the Division of Health Care Financing and Policy
of the Department of Health and Human Services the sum of
$19,500 for the costs of information system upgrades and actuarial
rate setting associated with carrying out the provisions of this act.
2. Any remaining balance of the appropriation made by
subsection 1 must not be committed for expenditure after June 30,
2024, by the entity to which the appropriation is made or any entity
to which money from the appropriation is granted or otherwise
transferred in any manner, and any portion of the appropriated
money remaining must not be spent for any purpose after
September 20, 2024, by either the entity to which the money was
appropriated or the entity to which the money was subsequently
granted or transferred, and must be reverted to the State General
Fund on or before September 20, 2024.
3. Expenditure of $48,000 not appropriated from the State
General Fund or the State Highway Fund is hereby authorized
during Fiscal Year 2023-2024 by the Division of Health Care
Financing and Policy of the Department of Health and Human
Services for the same purposes as set forth in subsection 1.
Sec. 18. The provisions of NRS 354.599 do not apply to any
additional expenses of a local government that are related to the
provisions of this act.
Sec. 19. This act becomes effective on July 1, 2023.
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