A.B. 290
- *AB290*
ASSEMBLY BILL NO. 290–ASSEMBLYMEMBERS NGUYEN,
CONSIDINE, NADEEM; AND EDGEWORTH
FEBRUARY 25, 2025
____________
JOINT SPONSORS: SENATORS FLORES AND NGUYEN
____________
Referred to Committee on Commerce and Labor
SUMMARY—Revises provisions relating to prior authorization for
medical or dental care under health insurance plans.
(BDR 57-861)
FISCAL NOTE: Effect on Local Government: May have Fiscal Impact.
Effect on the State: Yes.
CONTAINS UNFUNDED MANDATE (§ 22)
(NOT REQUESTED BY AFFECTED LOCAL GOVERNMENT)
~
EXPLANATION – Matter in bolded italics is new; matter between brackets [omitted material] is material to be omitted.
AN ACT relating to insurance; imposing requirements governing
prior authorization for medical or dental care; prohibiting
an insurer from requiring prior authorization for covered
emergency services or denying coverage for covered,
medically necessary emergency services; requiring an
insurer to publish certain information relating to requests
for prior authorization on the Internet; requiring an insurer
and the Commissioner of Insurance to compile certain
reports; and providing other matters properly relating
thereto.
Legislative Counsel’s Digest:
Existing law authorizes certain health insurers to require prior authorization 1
before an insured may receive coverage for health and dental care in certain 2
circumstances. If an insurer requires prior authorization, existing law requires the 3
insurer to: (1) file its procedure for obtaining prior authorization with the 4
Commissioner of Insurance for approval; and (2) respond to a request for prior 5
authorization within 20 days after receiving the request. (NRS 687B.225) This bill 6
establishes additional requirements relating to the use of prior authorization for 7
health and dental care by health insurers, including Medicaid, the Children’s Health 8
Insurance Program and insurance for public employees. 9
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Specifically, sections 19 and 34 of this bill require that a procedure for 10
obtaining prior authorization includes: (1) a list of the specific goods and services 11
for which the insurer requires prior authorization; and (2) the clinical review 12
criteria used by the insurer to evaluate requests for prior authorization. Sections 19 13
and 34 also require an insurer to publish its procedure for obtaining prior 14
authorization on its Internet website and update that website as necessary to 15
account for any changes in the procedure. Sections 19 and 34 prohibit an insurer 16
from denying a claim for payment for medical or dental care because of the failure 17
to obtain prior authorization if the insurer’s procedures for obtaining prior 18
authorization in effect on the date that the care was provided did not require prior 19
authorization for that care. 20
Sections 19 and 35 of this bill revise the period for insurers to take action on a 21
request for prior authorization by requiring an insurer to approve or make an 22
adverse determination on such a request, or request additional, medically relevant 23
information within: (1) five days after receiving the request, for medical or dental 24
care that is not urgent; or (2) twenty-four hours after receiving the request, for care 25
that is urgent. Sections 13 and 36 of this bill require any adverse determination on 26
a request for prior authorization to be made by a licensed physician or, for a request 27
relating to dental care, a dentist, who has certain qualifications. Sections 13 and 36 28
require an insurer, in certain circumstances, to allow the provider of health care 29
who requested the prior authorization to discuss the issues involved in the request 30
with the physician or dentist who is responsible for making a determination on the 31
request. Sections 13 and 36 require an insurer, upon making an adverse 32
determination on a request for prior authorization, to transmit certain information to 33
the insured to whom the request pertains, including information relating to the right 34
of the insured to appeal the adverse determination. Sections 13 and 36 further 35
require: (1) an insurer to establish a process for appeals that provides for the timely 36
resolution of appeals submitted by insureds; and (2) a decision upholding an 37
adverse determination on an appeal submitted by an insured to be made by a 38
physician or dentist who has qualifications beyond those required of a physician or 39
dentist who evaluates initial requests for prior authorization. 40
Sections 14 and 37 of this bill: (1) provide that a request for prior authorization 41
that has been approved by the insurer remains valid for 12 months; and (2) require 42
an insurer, for the first 90 days of the coverage period for a new insured, to honor a 43
request for prior authorization that has been approved by the previous insurer of the 44
new insured, under certain circumstances. Sections 14 and 37 prohibit an insurer 45
from denying or imposing additional limits on a request for prior authorization that 46
the insurer has previously approved if the care at issue in the request is provided 47
within 90 business days after the date on which the insurer receives the request and 48
certain other requirements are met. 49
Sections 15 and 38 of this bill prohibit an insurer from requiring prior 50
authorization for covered emergency services. Sections 15 and 38 also prohibit an 51
insurer from requiring that an insured or provider of health care notify the insurer 52
earlier than the end of the business day following the date of admission or the date 53
on which the emergency services are provided. Finally, sections 15 and 38: (1) 54
prohibit an insurer from denying coverage for covered medically necessary 55
emergency services; and (2) establish a presumption of medical necessity under 56
certain conditions. 57
Sections 3-12 and 27-33 of this bill define certain terms relating to the process 58
of obtaining and processing requests for prior authorization, and sections 2 and 26 59
of this bill establish the applicability of those definitions. Sections 16 and 39 of 60
this bill provide that if an insurer violates any provision of section 13-15, 19 or 34-61
38 with respect to a particular request for prior authorization, that the request is 62
deemed approved. Sections 16 and 39 also clarify that nothing in any provision of 63
section 13-15, 19 or 34-38 require an insurer to provide coverage: (1) for care that 64
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the insurer does not cover, regardless of the medical necessity of the care; or (2) to 65
persons to whom the insured is not obligated to provide coverage. 66
Sections 17 and 40 of this bill require an insurer to annually publish on its 67
Internet website certain information relating to requests for prior authorization that 68
have been processed by the insurer during the immediately preceding year. 69
Sections 18 and 41 of this bill additionally require an insurer to publish an annual 70
report of certain information relating to requests for prior authorization processed 71
by the insurer during the immediately preceding year. 72
Section 20 of this bill requires a nonprofit hospital and medical or dental 73
service corporation to comply with sections 2-18. Section 21 of this bill requires 74
the Director of the Department of Health and Human Services to administer the 75
provisions of sections 25-41 of this bill in the same manner as other provisions 76
governing Medicaid. Sections 22, 23 and 44 of this bill require plans of self-77
insurance for employees of local governments, the Public Employees’ Benefits 78
Program and plans of self-insurance for private employers, respectively, to comply 79
with the requirements of sections 2-19 of this bill to the extent applicable. Section 80
25 provides that a managed care organization that provides services to recipients of 81
Medicaid or the Children’s Health Insurance Program is not subject to sections 26-82
41, but must comply with sections 2-19. Section 42 of this bill requires the policies 83
and procedures for coverage for prescription drugs under Medicaid to comply with 84
sections 26-41. 85
THE PEOPLE OF THE STATE OF NEVADA, REPRESENTED IN
SENATE AND ASSEMBLY, DO ENACT AS FOLLOWS:
Section 1. Chapter 687B of NRS is hereby amended by adding 1
thereto the provisions set forth as sections 2 to 18, inclusive, of this 2
act. 3
Sec. 2. As used in NRS 687B.225 and sections 2 to 18, 4
inclusive, of this act, unless the context otherwise requires, the 5
words and terms defined in sections 3 to 12, inclusive, of this act 6
have the meanings ascribed to them in those sections. 7
Sec. 3. “Adverse determination” means a determination by a 8
health carrier that an admission, availability of care, continued 9
stay or other medical care or dental care that is a covered benefit 10
has been reviewed and, based upon the information provided, does 11
not meet the health carrier’s requirements for medical necessity, 12
appropriateness, health care setting, level of care or effectiveness, 13
and the requested care or service or payment for the care or 14
service is therefore denied, reduced or terminated. 15
Sec. 4. “Emergency services” means health care services 16
that are provided by a provider of health care to screen and to 17
stabilize an insured after the sudden onset of a medical condition 18
that manifests itself by symptoms of such sufficient severity that a 19
prudent person would believe that the absence of immediate 20
medical attention could result in: 21
1. Serious jeopardy to the health of the insured; 22
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2. Serious jeopardy to the health of an unborn child of the 1
insured; 2
3. Serious impairment of a bodily function of the insured; or 3
4. Serious dysfunction of any bodily organ or part of the 4
insured. 5
Sec. 5. “Health carrier” has the meaning ascribed to it in 6
NRS 695G.024, and includes, without limitation, an organization 7
for dental care. 8
Sec. 6. “Individually identifiable health information” means 9
information relating to the provision of health care to an insured: 10
1. That specifically identifies the insured; or 11
2. For which there is a reasonable basis to believe that the 12
information can be used to identify the insured. 13
Sec. 7. “Insured” means a policyholder, subscriber, enrollee 14
or other person covered by a health carrier. 15
Sec. 8. “Medically necessary” has the meaning ascribed to it 16
in NRS 695G.055. 17
Sec. 9. “Network” means a defined set of providers of health 18
care who are under contract with a health carrier to provide 19
health care services pursuant to a network plan offered or issued 20
by the health carrier. 21
Sec. 10. “Network plan” means a contract or policy of 22
insurance offered by a health carrier under which the financing 23
and delivery of medical or dental care is provided, in whole or in 24
part, through a defined set of providers under contract with the 25
health carrier. 26
Sec. 11. “Provider of health care” has the meaning ascribed 27
to it in NRS 695G.070. 28
Sec. 12. “Urgent health care”: 29
1. Means health care that, in the opinion of a provider of 30
health care with knowledge of an insured’s medical condition, if 31
not rendered to the insured within 48 hours could: 32
(a) Seriously jeopardize the life or health of the insured or the 33
ability of the insured to regain maximum function; or 34
(b) Subject the insured to severe pain that cannot be 35
adequately managed without receiving such care. 36
2. Does not include emergency services. 37
Sec. 13. 1. A health carrier shall not make an adverse 38
determination on a request for prior authorization unless: 39
(a) The adverse determination is made by a physician or, for 40
dental care, a dentist, who: 41
(1) Holds an unrestricted license to practice medicine or 42
dentistry, as applicable, in any state or territory of the United 43
States; 44
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(2) Is of the same or similar specialty as a physician or 1
dentist, as applicable, who typically manages or treats the medical 2
or dental condition or provides the health or dental care involved 3
in the request; and 4
(3) Has experience treating or managing the medical or 5
dental condition involved in the request; and 6
(b) The adverse determination is reviewed and affirmed by: 7
(1) The medical director of the health carrier or a similar 8
employee who is in charge of the medical operations of the health 9
carrier; or 10
(2) A physician or, for dental care, a dentist, who: 11
(I) Has been designated by the medical director or 12
similar employee to review the adverse determination; and 13
(II) Is employed by or contracted with the health carrier 14
specifically to perform reviews or appeals of adverse 15
determinations. 16
2. If a physician or dentist described in paragraph (a) of 17
subsection 1 is considering making an adverse determination on a 18
request for prior authorization on the basis that the medical or 19
dental care involved in the request is not medically necessary, the 20
health carrier that received the request shall: 21
(a) Immediately notify the provider of health care who 22
submitted the request that the medical necessity of the requested 23
care is being questioned by the health carrier; and 24
(b) Offer the provider of health care an opportunity to speak 25
with the physician or dentist, as applicable, over the telephone or 26
by videoconference to discuss the clinical issues involved in the 27
request before the physician or dentist renders an initial 28
determination on the request. 29
3. Upon rendering an adverse determination on a request for 30
prior authorization, a health carrier shall immediately transmit to 31
the insured to whom the request pertains a written notice that 32
contains: 33
(a) A specific description of all reasons that the health carrier 34
made the adverse determination; 35
(b) A description of any documentation that the health carrier 36
requested from the insured or a provider of health care of the 37
insured and did not receive or deemed insufficient, if the failure to 38
receive sufficient documentation contributed to the adverse 39
determination; 40
(c) A statement that the insured has the right to appeal the 41
adverse determination; 42
(d) Instructions, written in clear language that is 43
understandable to an ordinary layperson, describing how the 44
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insured can appeal the adverse determination through the process 1
established pursuant to subsection 4; and 2
(e) A description of any documentation that may be necessary 3
or pertinent to a potential appeal. 4
4. A health carrier shall establish a process that allows an 5
insured to appeal an adverse determination on a request for prior 6
authorization. The process must allow for the clear resolution of 7
each appeal within a reasonable time. 8
5. A health carrier shall not uphold on appeal an adverse 9
determination pertaining to a request for prior authorization 10
unless the decision on the appeal is made by a physician or, for 11
dental care, a dentist, who: 12
(a) Holds an unrestricted license to practice medicine or 13
dentistry, as applicable, in any state or territory of the United 14
States; 15
(b) Evaluates and treats patients in his or her capacity as an 16
actively practicing physician or dentist, as applicable; 17
(c) Is of the same or similar specialty as a physician or dentist, 18
as applicable, who typically manages or treats the medical or 19
dental condition or provides the medical or dental care involved in 20
the request; 21
(d) Has experience treating or managing the medical or dental 22
condition involved in the request; 23
(e) Was not involved in making the adverse determination that 24
is the subject of the appeal; 25
(f) Considers all known clinical aspects of the medical or 26
dental care involved in the request; and 27
(g) Is employed by or contracted with the health carrier to: 28
(1) Participate in the network of the health carrier in his or 29
her capacity as a practicing physician or dentist, as applicable; or 30
(2) Solely make determinations on reviews or appeals of 31
adverse determinations. 32
Sec. 14. 1. If a health carrier approves a request for prior 33
authorization, the approval remains valid until 12 months after the 34
date on which the request is approved. 35
2. A health carrier shall not revoke or impose an additional 36
limit, condition or restriction on a request for prior authorization 37
that the health carrier has previously approved unless: 38
(a) The care at issue in the request was not provided to the 39
insured within 90 business days after the health carrier received 40
the request; 41
(b) The health carrier determines that an insured or a provider 42
of health care procured the approval by fraud or material 43
misrepresentation; or 44
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(c) The health carrier determines that the care at issue in the 1
request was not covered by the health carrier at the time the care 2
was provided. 3
3. A health carrier that has approved a request for prior 4
authorization shall not deny or refuse to promptly pay a claim for 5
the approved medical or dental care unless the health carrier 6
determines that the insured or provider of health care procured 7
the prior authorization by fraud or material misrepresentation. 8
The claim must be paid at the same rate that the health carrier is 9
contractually obligated to or would ordinarily pay a provider of 10
health care for providing the specific type of care that was 11
approved and provided to the insured. 12
4. Within the first 90 days of the coverage period for an 13
insured, a health carrier shall honor a request for prior 14
authorization that has been approved by a health carrier or other 15
entity that previously provided the insured with coverage for 16
medical or dental care if: 17
(a) The approval was issued within the 12 months immediately 18
preceding the first day of the coverage period under the current 19
contract or policy of insurance; and 20
(b) The specific medical or dental care included within the 21
request is not affirmatively excluded under the terms and 22
conditions of the contract or policy of insurance issued by the 23
health carrier. 24
5. As used in this section, “coverage period” means the 25
current term of a contract or policy of insurance issued by a 26
health carrier. 27
Sec. 15. 1. A health carrier shall not require prior 28
authorization for emergency services covered by the health 29
carrier, including, where applicable, transportation by ambulance 30
to a hospital or other medical facility. 31
2. If a health carrier requires an insured or his or her 32
provider of health care to notify the health carrier that the insured 33
has been admitted to a hospital to receive emergency services or 34
has received emergency services, the health carrier shall not 35
require an insured or a provider of health care to transmit such a 36
notice earlier than the end of the business day immediately 37
following the day after the date on which the insured was admitted 38
or the emergency services were provided, as applicable. 39
3. A health carrier shall not deny coverage for emergency 40
services covered by the health carrier that are medically necessary. 41
Emergency services are presumed to be medically necessary if, 42
within 72 hours after an insured is admitted to receive emergency 43
services, the insured’s provider of health care transmits to the 44
health carrier a certification, in writing, that the condition of the 45
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insured required emergency services. The health carrier may rebut 1
that presumption by establishing, by clear and convincing 2
evidence, that the emergency services were not medically 3
necessary. 4
4. A health carrier shall make all determinations for whether 5
emergency services are medically necessary without regard to 6
whether a provider of health care that provided or billed for those 7
services participates in the network of the health carrier. 8
Sec. 16. 1. If a health carrier violates NRS 687B.225 or 9
section 13, 14 or 15 of this act with respect to a particular request 10
for prior authorization, the request shall be deemed approved. 11
2. Nothing in NRS 687B.225 or section 13, 14 or 15 of this 12
act shall be construed to require a health carrier to provide 13
coverage: 14
(a) For medical or dental care that, regardless of whether such 15
care is medically necessary, would not be a covered benefit under 16
the terms and conditions of the contract or policy of insurance; 17
(b) To a person who is not insured by the health carrier on the 18
date on which medical or dental care is provided to the person; or 19
(c) To an insured who, as a result of his or her failure to pay 20
the applicable premiums required under the terms and conditions 21
of a contract or policy of insurance, has no coverage under the 22
contract or policy on the date on which medical or dental care is 23
provided to the insured. 24
Sec. 17. 1. On or before March 1 of each calendar year, a 25
health carrier shall publish on an Internet website maintained by 26
the health carrier in an easily accessible format the following 27
information for the immediately preceding calendar year, in 28
aggregated form for all requests for prior authorization received 29
by the insurer during the immediately preceding year and 30
disaggregated in accordance with subsection 2: 31
(a) The percentage of requests for prior authorization for 32
medical or dental care in this State that were approved upon initial 33
review; 34
(b) The percentage of requests for prior authorization for 35
medical or dental care in this State that resulted in an adverse 36
determination upon initial review; 37
(c) The percentage of the adverse determinations described in 38
paragraph (b) that were appealed; 39
(d) The percentage of appeals of adverse determinations 40
described in paragraph (c) that resulted in a reversal of the 41
adverse determination; 42
(e) The five most common reasons for the adverse 43
determinations described in paragraph (b); and 44
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(f) The average time between a request for prior authorization 1
for medical or dental care in this State and the resolution of the 2
request. 3
2. The information described in subsection 1 must be 4
disaggregated for the following categories: 5
(a) The specialty of the provider of health care who submitted 6
a request for prior authorization; and 7
(b) The types of health or dental care at issue in the request for 8
prior authorization, including the specific types of prescription 9
drugs, procedures or diagnostic tests involved in the requests. 10
3. A health carrier shall not include individually identifiable 11
health information in the information published pursuant to 12
subsection 1. 13
Sec. 18. 1. On or before March 1 of each calendar year, a 14
health carrier shall compile and transmit to the Commissioner, in 15
a form prescribed by the Commissioner, and publish on an 16
Internet website maintained by the health carrier a report 17
containing the following information: 18
(a) The specific goods and services for which the health 19
carrier requires prior authorization and, for each good or service: 20
(1) The date on which prior authorization for that good or 21
service became required for contracts or policies issued or 22
delivered in this State and the date on which that requirement was 23
listed on the Internet website of the health carrier pursuant to 24
subsection 6 of NRS 687B.225; 25
(2) The number of requests for prior authorization received 26
by the health carrier during the immediately preceding calendar 27
year for the provision of the good or service to insureds in this 28
State; 29
(3) The number and percentage of the requests listed 30
pursuant to subparagraph (2) that were approved; 31
(4) The number and percentage of the requests listed 32
pursuant to subparagraph (2) that resulted in adverse 33
determinations; and 34
(5) The number of appeals from adverse determinations 35
during the immediately preceding calendar year and the 36
percentage of those appeals that were reversed on appeal by the 37
health carrier. 38
(b) For all requests for prior authorization for non-urgent 39
health or dental care received by the health carrier during the 40
immediately preceding calendar year, the average and median 41
time between: 42
(1) The health carrier receiving a request for prior 43
authorization and the health carrier approving or making an 44
adverse determination on the request; and 45
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(2) The submission of an appeal of an adverse 1
determination on a request for prior authorization and the 2
resolution of the appeal. 3
(c) For all requests for prior authorization for urgent health 4
care received by the health carrier during the immediately 5
preceding calendar year, the average and median time between: 6
(1) The health carrier receiving a request for prior 7
authorization and the health carrier approving or making an 8
adverse determination on the request; and 9
(2) The submission of an appeal of an adverse 10
determination on a request for prior authorization and the 11
resolution of the appeal. 12
2. On or before May 1 of each even-numbered year, the 13
Commissioner shall: 14
(a) Compile a report summarizing the information submitted 15
to the Commissioner pursuant to subsection 1 during the 16
immediately preceding biennium and providing recommendations 17
for legislation to improve the process for obtaining prior 18
authorization; and 19
(b) Submit the report and all information provided to the 20
Commissioner pursuant to subsection 1 to the Director of the 21
Legislative Counsel Bureau for transmittal to the Joint Interim 22
Standing Committee on Health and Human Services and the Joint 23
Interim Standing Committee on Commerce and Labor. 24
3. A health carrier shall not include individually identifiable 25
health information in a report published pursuant to subsection 1. 26
Sec. 19. NRS 687B.225 is hereby amended to read as follows: 27
687B.225 1. Except as otherwise provided in NRS 28
689A.0405, 689A.0412, 689A.0413, 689A.0418, 689A.0437, 29
689A.044, 689A.0445, 689A.0459, 689B.031, 689B.0312, 30
689B.0313, 689B.0315, 689B.0317, 689B.0319, 689B.0374, 31
689B.0378, 689C.1665, 689C.1671, 689C.1675, 689C.1676, 32
695A.1843, 695A.1856, 695A.1865, 695A.1874, 695B.1912, 33
695B.1913, 695B.1914, 695B.1919, 695B.19197, 695B.1924, 34
695B.1925, 695B.1942, 695C.1696, 695C.1699, 695C.1713, 35
695C.1735, 695C.1737, 695C.1743, 695C.1745, 695C.1751, 36
695G.170, 695G.1705, 695G.171, 695G.1714, 695G.1715, 37
695G.1719 and 695G.177, and section 15 of this act, any contract 38
[for group, blanket or individual health] or policy of insurance [or 39
any contract by a nonprofit hospital, medical or dental service 40
corporation or organization for dental care] issued by a health 41
carrier which provides for payment of a certain part of medical or 42
dental care may require the insured [or member] to obtain prior 43
authorization for that care from the [insurer or organization. The 44
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insurer or organization] health carrier in a manner consistent with 1
this section and sections 2 to 18, inclusive, of this act. 2
2. A health carrier that requires an insured to obtain prior 3
authorization shall: 4
(a) File its procedure for obtaining [approval of care] prior 5
authorization pursuant to this section , including, without 6
limitation, a list of the specific goods and services for which the 7
health carrier requires prior authorization and the clinical review 8
criteria used by the health carrier to evaluate requests for prior 9
authorization, for approval by the Commissioner . [; and] 10
(b) Unless a shorter time period is prescribed by a specific 11
statute, including, without limitation, NRS 689A.0446, 689B.0361, 12
689C.1688, 695A.1859, 695B.19087, 695C.16932 and 695G.1703, 13
[respond to] and except as otherwise provided by paragraph (c), 14
approve or make an adverse determination on any request for 15
[approval by the insured or member] prior authorization submitted 16
by or on behalf of the insured pursuant to this section [within 20 17
days after it receives the request.] and notify the insured and his or 18
her provider of health care of the approval or adverse 19
determination: 20
(1) For non-urgent medical or dental care, within 5 days 21
after receiving the request. 22
(2) For urgent health care, within 24 hours after receiving 23
the request. 24
(c) If the health carrier requires additional, medically relevant 25
information or documentation in order to adequately evaluate a 26
request for prior authorization: 27
(1) Notify the insured and the provider of health care who 28
submitted the request within the applicable amount of time 29
described in paragraph (b) that additional information is required 30
to evaluate the request; 31
(2) Include within the notification sent pursuant to 32
subparagraph (1) a description, with reasonable specificity, of the 33
information that the health carrier requires to make a 34
determination on the request for prior authorization; and 35
(3) Approve or make an adverse determination on the 36
request: 37
(I) For non-urgent medical or dental care, within 5 days 38
after receiving the information. 39
(II) For urgent health care, within 24 hours after 40
receiving the information. 41
[2.] 3. The procedure for prior authorization may not 42
discriminate among persons licensed to provide the covered care. 43
4. If a health carrier seeks to amend its procedure for 44
obtaining prior authorization, including, without limitation, 45
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changing the goods and services for which the health carrier 1
requires prior authorization or changing the clinical review 2
criteria used by the health carrier, the health carrier: 3
(a) Must file a request to amend the procedure for approval by 4
the Commissioner. 5
(b) May not allow the amended procedure to take effect until: 6
(1) The Commissioner notifies the health carrier that the 7
request is approved; and 8
(2) The health carrier satisfies the requirements of 9
subsection 5 after the health carrier receives a notice of approval 10
from the Commissioner. 11
5. A change to a health carrier’s procedure for obtaining 12
prior authorization may not take effect until: 13
(a) The health carrier transmits a notice that contains a 14
summary of the changes to the procedure to each of its insureds 15
and providers of health care who participate in the network of the 16
health carrier; 17
(b) The health carrier updates the information published on its 18
Internet website pursuant to subsection 6 to reflect the amended 19
procedure for obtaining prior authorization and the date on which 20
the amended procedure takes effect; and 21
(c) At least 60 days have passed after the later of: 22
(1) The date on which the health carrier transmitted the 23
notice to its insureds and providers of health care who participate 24
in the network of the health carrier pursuant to paragraph (a); or 25
(2) The date on which the health carrier updated the 26
information published on its Internet website pursuant to 27
paragraph (b). 28
6. A health carrier shall publish its procedures for obtaining 29
prior authorization, including, without limitation, the clinical 30
review criteria, on its Internet website: 31
(a) Using clear language that is understandable to an ordinary 32
layperson, where practicable; and 33
(b) In a place that is readily accessible and conspicuous to 34
insureds and the public. 35
7. A health carrier shall not deny a claim based on the failure 36
of an insured to obtain prior authorization for medical or dental 37
care if the procedure for obtaining prior authorization established 38
by the health carrier did not require the insured to obtain prior 39
authorization for that medical or dental care on the date that the 40
medical or dental care was provided to the insured. 41
8. As used in this section, “clinical review criteria” means 42
any written screening procedure, decision abstract, clinical 43
protocol or practice guideline used by the health carrier to 44
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determine the necessity and appropriateness of medical or dental 1
care. 2
Sec. 20. NRS 695B.320 is hereby amended to read as follows: 3
695B.320 1. Nonprofit hospital and medical or dental service 4
corporations are subject to the provisions of this chapter, and to the 5
provisions of chapters 679A and 679B of NRS, subsections 2, 4, 17, 6
18 and 30 of NRS 680B.010, NRS 680B.025 to 680B.060, 7
inclusive, chapter 681B of NRS, NRS 686A.010 to 686A.315, 8
inclusive, 686B.010 to 686B.175, inclusive, 687B.010 to 9
687B.040, inclusive, 687B.070 to 687B.140, inclusive, 687B.150, 10
687B.160, 687B.180, 687B.200 to 687B.255, inclusive, and 11
sections 2 to 18, inclusive, of this act, 687B.270, 687B.310 to 12
687B.380, inclusive, 687B.410, 687B.420, 687B.430, 687B.500 and 13
chapters 692B, 692C, 693A and 696B of NRS, to the extent 14
applicable and not in conflict with the express provisions of this 15
chapter. 16
2. For the purposes of this section and the provisions set forth 17
in subsection 1, a nonprofit hospital and medical or dental service 18
corporation is included in the meaning of the term “insurer.” 19
Sec. 21. NRS 232.320 is hereby amended to read as follows: 20
232.320 1. The Director: 21
(a) Shall appoint, with the consent of the Governor, 22
administrators of the divisions of the Department, who are 23
respectively designated as follows: 24
(1) The Administrator of the Aging and Disability Services 25
Division; 26
(2) The Administrator of the Division of Welfare and 27
Supportive Services; 28
(3) The Administrator of the Division of Child and Family 29
Services; 30
(4) The Administrator of the Division of Health Care 31
Financing and Policy; and 32
(5) The Administrator of the Division of Public and 33
Behavioral Health. 34
(b) Shall administer, through the divisions of the Department, 35
the provisions of chapters 63, 424, 425, 427A, 432A to 442, 36
inclusive, 446 to 450, inclusive, 458A and 656A of NRS, NRS 37
127.220 to 127.310, inclusive, 422.001 to 422.410, inclusive, and 38
sections 25 to 41, inclusive, of this act, 422.580, 432.010 to 39
432.133, inclusive, 432B.6201 to 432B.626, inclusive, 444.002 to 40
444.430, inclusive, and 445A.010 to 445A.055, inclusive, and all 41
other provisions of law relating to the functions of the divisions of 42
the Department, but is not responsible for the clinical activities of 43
the Division of Public and Behavioral Health or the professional line 44
activities of the other divisions. 45
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(c) Shall administer any state program for persons with 1
developmental disabilities established pursuant to the 2
Developmental Disabilities Assistance and Bill of Rights Act of 3
2000, 42 U.S.C. §§ 15001 et seq. 4
(d) Shall, after considering advice from agencies of local 5
governments and nonprofit organizations which provide social 6
services, adopt a master plan for the provision of human services in 7
this State. The Director shall revise the plan biennially and deliver a 8
copy of the plan to the Governor and the Legislature at the 9
beginning of each regular session. The plan must: 10
(1) Identify and assess the plans and programs of the 11
Department for the provision of human services, and any 12
duplication of those services by federal, state and local agencies; 13
(2) Set forth priorities for the provision of those services; 14
(3) Provide for communication and the coordination of those 15
services among nonprofit organizations, agencies of local 16
government, the State and the Federal Government; 17
(4) Identify the sources of funding for services provided by 18
the Department and the allocation of that funding; 19
(5) Set forth sufficient information to assist the Department 20
in providing those services and in the planning and budgeting for the 21
future provision of those services; and 22
(6) Contain any other information necessary for the 23
Department to communicate effectively with the Federal 24
Government concerning demographic trends, formulas for the 25
distribution of federal money and any need for the modification of 26
programs administered by the Department. 27
(e) May, by regulation, require nonprofit organizations and state 28
and local governmental agencies to provide information regarding 29
the programs of those organizations and agencies, excluding 30
detailed information relating to their budgets and payrolls, which the 31
Director deems necessary for the performance of the duties imposed 32
upon him or her pursuant to this section. 33
(f) Has such other powers and duties as are provided by law. 34
2. Notwithstanding any other provision of law, the Director, or 35
the Director’s designee, is responsible for appointing and removing 36
subordinate officers and employees of the Department. 37
Sec. 22. NRS 287.010 is hereby amended to read as follows: 38
287.010 1. The governing body of any county, school 39
district, municipal corporation, political subdivision, public 40
corporation or other local governmental agency of the State of 41
Nevada may: 42
(a) Adopt and carry into effect a system of group life, accident 43
or health insurance, or any combination thereof, for the benefit of its 44
officers and employees, and the dependents of officers and 45
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employees who elect to accept the insurance and who, where 1
necessary, have authorized the governing body to make deductions 2
from their compensation for the payment of premiums on the 3
insurance. 4
(b) Purchase group policies of life, accident or health insurance, 5
or any combination thereof, for the benefit of such officers and 6
employees, and the dependents of such officers and employees, as 7
have authorized the purchase, from insurance companies authorized 8
to transact the business of such insurance in the State of Nevada, 9
and, where necessary, deduct from the compensation of officers and 10
employees the premiums upon insurance and pay the deductions 11
upon the premiums. 12
(c) Provide group life, accident or health coverage through a 13
self-insurance reserve fund and, where necessary, deduct 14
contributions to the maintenance of the fund from the compensation 15
of officers and employees and pay the deductions into the fund. The 16
money accumulated for this purpose through deductions from the 17
compensation of officers and employees and contributions of the 18
governing body must be maintained as an internal service fund as 19
defined by NRS 354.543. The money must be deposited in a state or 20
national bank or credit union authorized to transact business in the 21
State of Nevada. Any independent administrator of a fund created 22
under this section is subject to the licensing requirements of chapter 23
683A of NRS, and must be a resident of this State. Any contract 24
with an independent administrator must be approved by the 25
Commissioner of Insurance as to the reasonableness of 26
administrative charges in relation to contributions collected and 27
benefits provided. The provisions of NRS 439.581 to 439.597, 28
inclusive, 686A.135, paragraphs (b) and (c) of subsection 2 and 29
subsections 1, 3, 5, 6 and 7 of NRS 687B.225, 687B.352, 30
687B.408, 687B.692, 687B.723, 687B.725, 687B.805, 689B.030 to 31
689B.0317, inclusive, paragraphs (b) and (c) of subsection 1 of NRS 32
689B.0319, subsections 2, 4, 6 and 7 of NRS 689B.0319, 689B.033 33
to 689B.0369, inclusive, 689B.0375 to 689B.050, inclusive, 34
689B.0675, 689B.265, 689B.287 and 689B.500 and sections 2 to 35
18, inclusive, of this act apply to coverage provided pursuant to this 36
paragraph, except that the provisions of NRS 689B.0378, 37
689B.03785 and 689B.500 only apply to coverage for active officers 38
and employees of the governing body, or the dependents of such 39
officers and employees. 40
(d) Defray part or all of the cost of maintenance of a self-41
insurance fund or of the premiums upon insurance. The money for 42
contributions must be budgeted for in accordance with the laws 43
governing the county, school district, municipal corporation, 44
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political subdivision, public corporation or other local governmental 1
agency of the State of Nevada. 2
2. If a school district offers group insurance to its officers and 3
employees pursuant to this section, members of the board of trustees 4
of the school district must not be excluded from participating in the 5
group insurance. If the amount of the deductions from compensation 6
required to pay for the group insurance exceeds the compensation to 7
which a trustee is entitled, the difference must be paid by the trustee. 8
3. In any county in which a legal services organization exists, 9
the governing body of the county, or of any school district, 10
municipal corporation, political subdivision, public corporation or 11
other local governmental agency of the State of Nevada in the 12
county, may enter into a contract with the legal services 13
organization pursuant to which the officers and employees of the 14
legal services organization, and the dependents of those officers and 15
employees, are eligible for any life, accident or health insurance 16
provided pursuant to this section to the officers and employees, and 17
the dependents of the officers and employees, of the county, school 18
district, municipal corporation, political subdivision, public 19
corporation or other local governmental agency. 20
4. If a contract is entered into pursuant to subsection 3, the 21
officers and employees of the legal services organization: 22
(a) Shall be deemed, solely for the purposes of this section, to be 23
officers and employees of the county, school district, municipal 24
corporation, political subdivision, public corporation or other local 25
governmental agency with which the legal services organization has 26
contracted; and 27
(b) Must be required by the contract to pay the premiums or 28
contributions for all insurance which they elect to accept or of which 29
they authorize the purchase. 30
5. A contract that is entered into pursuant to subsection 3: 31
(a) Must be submitted to the Commissioner of Insurance for 32
approval not less than 30 days before the date on which the contract 33
is to become effective. 34
(b) Does not become effective unless approved by the 35
Commissioner. 36
(c) Shall be deemed to be approved if not disapproved by the 37
Commissioner within 30 days after its submission. 38
6. As used in this section, “legal services organization” means 39
an organization that operates a program for legal aid and receives 40
money pursuant to NRS 19.031. 41
Sec. 23. NRS 287.04335 is hereby amended to read as 42
follows: 43
287.04335 If the Board provides health insurance through a 44
plan of self-insurance, it shall comply with the provisions of 45
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NRS 439.581 to 439.597, inclusive, 686A.135, paragraphs (b) and 1
(c) of subsection 2 and subsections 1, 3, 5, 6 and 7 of NRS 2
687B.225, 687B.352, 687B.409, 687B.692, 687B.723, 687B.725, 3
687B.805, 689B.0353, 689B.255, 695C.1723, 695G.150, 695G.155, 4
695G.160, 695G.162, 695G.1635, 695G.164, 695G.1645, 5
695G.1665, 695G.167, 695G.1675, 695G.170 to 695G.1712, 6
inclusive, 695G.1714 to 695G.174, inclusive, 695G.176, 695G.177, 7
695G.200 to 695G.230, inclusive, 695G.241 to 695G.310, inclusive, 8
695G.405 and 695G.415, and sections 2 to 18, inclusive, of this act 9
in the same manner as an insurer that is licensed pursuant to title 57 10
of NRS is required to comply with those provisions. 11
Sec. 24. Chapter 422 of NRS is hereby amended by adding 12
thereto the provisions set forth as sections 25 to 41, inclusive, of this 13
act. 14
Sec. 25. 1. The provisions of sections 26 to 41, inclusive, of 15
this act and any policies developed pursuant thereto do not apply 16
to the delivery of services to recipients of Medicaid or the 17
Children’s Health Insurance Program through managed care in 18
accordance with NRS 422.273. 19
2. A health maintenance organization or other managed care 20
organization that enters into a contract with the Department or the 21
Division pursuant to NRS 422.273 to provide health care services 22
to recipients of Medicaid under the State Plan for Medicaid or the 23
Children’s Health Insurance Program shall comply with NRS 24
687B.225 and sections 2 to 18, inclusive, of this act. 25
Sec. 26. As used in sections 26 to 41, inclusive, of this act, 26
unless the context otherwise requires, the words and terms defined 27
in sections 27 to 33, inclusive, of this act have the meanings 28
ascribed to them in those sections. 29
Sec. 27. “Adverse determination” means a determination by 30
the Department that an admission, availability of care, continued 31
stay or other medical care or dental care that is a covered benefit 32
has been reviewed and, based upon the information provided, does 33
not meet the Department’s requirements for medical necessity, 34
appropriateness, health care setting, level of care or effectiveness, 35
and the requested care or service or payment for the care or 36
service is therefore denied, reduced or terminated. 37
Sec. 28. “Emergency services” means health care services 38
that are provided by a provider of health care to screen and to 39
stabilize a recipient after the sudden onset of a medical condition 40
that manifests itself by symptoms of such sufficient severity that a 41
prudent person would believe that the absence of immediate 42
medical attention could result in: 43
1. Serious jeopardy to the health of the recipient; 44
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2. Serious jeopardy to the health of an unborn child of the 1
recipient; 2
3. Serious impairment of a bodily function of the recipient; or 3
4. Serious dysfunction of any bodily organ or part of the 4
recipient. 5
Sec. 29. “Individually identifiable health information” 6
means information relating to the provision of health care to a 7
recipient: 8
1. That specifically identifies the recipient; or 9
2. For which there is a reasonable basis to believe that the 10
information can be used to identify the recipient. 11
Sec. 30. “Medically necessary” has the meaning ascribed to 12
it in NRS 695G.055. 13
Sec. 31. “Provider of health care” has the meaning ascribed 14
to it in NRS 695G.070. 15
Sec. 32. “Recipient” means a natural person who receives 16
benefits through Medicaid or the Children’s Health Insurance 17
Program, as applicable. 18
Sec. 33. “Urgent health care”: 19
1. Means health care that, in the opinion of a provider of 20
health care with knowledge of a recipient’s medical condition, if 21
not rendered to the recipient within 48 hours could: 22
(a) Seriously jeopardize the life or health of the recipient or 23
the ability of the recipient to regain maximum function; or 24
(b) Subject the recipient to severe pain that cannot be 25
adequately managed without receiving such care. 26
2. Does not include emergency services. 27
Sec. 34. 1. The Department, with respect to Medicaid and 28
the Children’s Health Insurance Program, shall establish written 29
procedures for obtaining prior authorization for medical or dental 30
care which must include, without limitation: 31
(a) A list of the specific goods and services for which the 32
Department requires prior authorization; and 33
(b) A description of the clinical review criteria used by the 34
Department. 35
2. The Department shall publish the written procedures for 36
obtaining prior authorization established by the Department 37
pursuant to subsection 1, including, without limitation, the clinical 38
review criteria, on an Internet website maintained by the 39
Department: 40
(a) Using clear language that is understandable to an ordinary 41
layperson, where practicable; and 42
(b) In a place that is readily accessible and conspicuous to 43
recipients and the public. 44
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3. If the Department amends the procedure for obtaining 1
prior authorization adopted pursuant to subsection 1, including, 2
without limitation, changing the goods and services for which the 3
Department requires prior authorization or changing the clinical 4
review criteria used by the Department, the Department shall: 5
(a) Transmit a notice containing a summary of the changes 6
made to the procedure to each recipient and each provider of 7
goods or services under Medicaid or the Children’s Health 8
Insurance Program, as applicable; and 9
(b) Update the information published on its Internet website 10
pursuant to subsection 2 to reflect the amended procedure for 11
obtaining prior authorization and the date on which the amended 12
procedure takes effect. 13
4. A change to the Department’s procedure for obtaining 14
prior authorization may not take effect until 60 days have passed 15
after the later of: 16
(a) The date on which the Department transmitted the notice to 17
recipients and providers of goods or services under Medicaid or 18
the Children’s Health Insurance Program, as applicable, pursuant 19
to paragraph (a) of subsection 3; or 20
(b) The date on which the Department updated the 21
information published on its Internet website pursuant to 22
paragraph (b) of subsection 3. 23
5. The Department shall not deny a claim based on the 24
failure of a recipient to obtain prior authorization for medical or 25
dental care if the procedure for obtaining prior authorization 26
established by the Department pursuant to this section did not 27
require the recipient to obtain prior authorization for that medical 28
or dental care on the date that the medical or dental care was 29
provided to the recipient. 30
6. As used in this section, “clinical review criteria” means 31
any written screening procedure, decision abstract, clinical 32
protocol or practice guideline used by the Department to 33
determine the necessity and appropriateness of medical or dental 34
care. 35
Sec. 35. 1. Unless a shorter time period is prescribed by a 36
specific statute, and except as otherwise provided in subsection 2, 37
the Department, with respect to Medicaid and the Children’s 38
Health Insurance Program, shall approve or make an adverse 39
determination on a request for prior authorization submitted by or 40
on behalf of a recipient and notify the recipient and his or her 41
provider of health care of the approval or adverse determination: 42
(a) For non-urgent medical or dental care, within 5 days after 43
receiving the request. 44
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(b) For urgent health care, within 24 hours after receiving the 1
request. 2
2. If the Department requires additional, medically relevant 3
information or documentation in order to adequately evaluate a 4
request for prior authorization, the Department shall: 5
(a) Notify the recipient and the provider of health care who 6
submitted the request within the applicable amount of time 7
described in subsection 1 that additional information is required to 8
evaluate the request; 9
(b) Include within the notification sent pursuant to paragraph 10
(a) a description, with reasonable specificity, of the information 11
that the Department requires to make a determination on the 12
request for prior authorization; and 13
(c) Approve or make an adverse determination on the request: 14
(1) For non-urgent medical or dental care, within 5 days 15
after receiving the information. 16
(2) For urgent health care, within 24 hours after receiving 17
the information. 18
Sec. 36. 1. The Department, with respect to Medicaid and 19
the Children’s Health Insurance Program, shall not make an 20
adverse determination on a request for prior authorization unless 21
the adverse determination is made by a physician or, for a request 22
relating to dental care, a dentist, who: 23
(a) Holds an unrestricted license to practice medicine or 24
dentistry, as applicable, in any state or territory of the United 25
States; 26
(b) Is of the same or similar specialty as a physician or dentist, 27
as applicable, who typically manages or treats the medical or 28
dental condition or provides the medical or dental care involved in 29
the request; and 30
(c) Has experience treating or managing the medical or dental 31
condition involved in the request. 32
2. If a physician or dentist described in subsection 1 is 33
considering making an adverse determination on a request for 34
prior authorization on the basis that the medical or dental care 35
involved in the request is not medically necessary, the Department 36
shall: 37
(a) Immediately notify the provider of health care who 38
submitted the request that the medical necessity of the requested 39
care is being questioned by the Department; and 40
(b) Offer the provider of health care an opportunity to speak 41
with the physician or dentist, as applicable, over the telephone or 42
by videoconference to discuss the clinical issues involved in the 43
request before the physician or dentist renders an initial 44
determination on the request. 45
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3. Upon rendering an adverse determination on a request for 1
prior authorization, the Department shall immediately transmit to 2
the recipient to whom the request pertains a written notice that 3
contains: 4
(a) A specific description of all reasons that the Department 5
made the adverse determination; 6
(b) A description of any documentation that the Department 7
requested from the recipient or a provider of health care of the 8
recipient and did not receive or deemed insufficient, if the failure 9
to receive sufficient documentation contributed to the adverse 10
determination; 11
(c) A statement that the recipient has the right to appeal the 12
adverse determination; 13
(d) Instructions, written in clear language that is 14
understandable to an ordinary layperson, describing how the 15
recipient can appeal the adverse determination through the 16
process established pursuant to subsection 4; and 17
(e) A description of any documentation that may be necessary 18
or pertinent to a potential appeal. 19
4. The Department shall establish a process that allows a 20
recipient to appeal an adverse determination on a request for prior 21
authorization. The process must allow for the clear resolution of 22
each appeal within a reasonable time. 23
5. The Department shall not uphold on appeal an adverse 24
determination pertaining to a request for prior authorization 25
unless the decision on the appeal is made by a physician, or, for 26
an appeal relating to dental care, a dentist, who: 27
(a) Holds an unrestricted license to practice medicine or 28
dentistry, as applicable, in any state or territory of the United 29
States; 30
(b) Evaluates and treats patients in his or her capacity as an 31
actively practicing physician or dentist, as applicable; 32
(c) Is of the same or similar specialty as a physician or dentist, 33
as applicable, who typically manages or treats the medical or 34
dental condition or provides the medical or dental care involved in 35
the request; 36
(d) Has experience treating or managing the medical or dental 37
condition involved in the request; 38
(e) Was not involved in making the adverse determination that 39
is the subject of the appeal; 40
(f) Considers all known clinical aspects of the medical or 41
dental care involved in the request; and 42
(g) Is employed by or contracted with the Department solely to 43
make determinations on appeals of adverse determinations. 44
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Sec. 37. 1. If the Department approves a request for prior 1
authorization, the approval remains valid until 12 months after the 2
date on which the request is approved. 3
2. The Department shall not revoke or impose an additional 4
limit, condition or restriction on a request for prior authorization 5
that the Department has previously approved unless: 6
(a) The care at issue in the request was not provided to the 7
recipient within 90 business days after the Department received 8
the request; 9
(b) The Department determines that a recipient or a provider 10
of health care procured the approval by fraud or material 11
misrepresentation; or 12
(c) The Department determines that the care at issue in the 13
request was not covered by Medicaid or the Children’s Health 14
Insurance Program, as applicable, at the time the care was 15
provided. 16
3. If the Department has approved a request for prior 17
authorization, the Department shall not deny or refuse to promptly 18
pay a claim for the approved medical or dental care unless the 19
Department determines that the recipient or provider of health 20
care procured the prior authorization by fraud or material 21
misrepresentation. The claim must be paid at the same rate that 22
the Department is contractually obligated to or would ordinarily 23
pay a provider of health care for providing the specific type of care 24
that was approved and provided to the recipient. 25
4. Within the first 90 days that a recipient is enrolled in 26
Medicaid or the Children’s Health Insurance Program, as 27
applicable, the Department shall honor a request for prior 28
authorization that has been approved by a health carrier or other 29
entity that previously provided the recipient with coverage for 30
medical or dental care if: 31
(a) The approval was issued within the 12 months immediately 32
preceding the first day of the enrollment of the recipient; and 33
(b) The specific medical or dental care included within the 34
request is not affirmatively excluded under the terms and 35
conditions of Medicaid or the Children’s Health Insurance 36
Program, as applicable. 37
5. As used in this section, “health carrier” has the meaning 38
ascribed to it in NRS 695G.024 and includes, without limitation, 39
an organization for dental care. 40
Sec. 38. 1. The Department, with respect to Medicaid and 41
the Children’s Health Insurance Program, shall not require prior 42
authorization for covered emergency services, including, where 43
applicable, transportation by ambulance to a hospital or other 44
medical facility. 45
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2. If the Department requires a recipient or his or her 1
provider of health care to notify the Department that the recipient 2
has been admitted to a hospital to receive emergency services or 3
has received emergency services, the Department shall not require 4
a recipient or a provider of health care to transmit such a notice 5
earlier than the end of the business day immediately following the 6
day after the date on which the recipient was admitted or the 7
emergency services were provided, as applicable. 8
3. The Department shall not deny coverage for emergency 9
services covered by Medicaid or the Children’s Health Insurance 10
Program that are medically necessary. Emergency services are 11
presumed to be medically necessary if, within 72 hours after a 12
recipient is admitted to receive emergency services, the recipient’s 13
provider of health care transmits to the Department a certification, 14
in writing, that the condition of the recipient required emergency 15
services. The Department may rebut that presumption by 16
establishing, by clear and convincing evidence, that the emergency 17
services were not medically necessary. 18
Sec. 39. 1. If the Department violates sections 34 to 38, 19
inclusive, of this act with respect to a particular request for prior 20
authorization, the request shall be deemed approved. 21
2. Nothing in sections 34 to 38, inclusive, of this act shall be 22
construed to require the Department to provide coverage: 23
(a) For medical or dental care that, regardless of whether such 24
care is medically necessary, would not be a covered benefit under 25
the terms and conditions of Medicaid or the Children’s Health 26
Insurance Program, as applicable; or 27
(b) To a person who is not a recipient or is not otherwise 28
eligible to receive coverage under Medicaid or the Children’s 29
Health Insurance Program, as applicable, on the date on which 30
medical or dental care is provided to the person. 31
Sec. 40. 1. On or before March 1 of each calendar year, the 32
Department shall publish on an Internet website maintained by 33
the Department in an easily accessible format the following 34
information for the immediately preceding calendar year, in 35
aggregated form for all requests for prior authorization received 36
by the insurer during the immediately preceding year and 37
disaggregated in accordance with subsection 2: 38
(a) The percentage of requests for prior authorization for 39
medical or dental care that were approved upon initial review; 40
(b) The percentage of requests for prior authorization for 41
medical or dental care that resulted in an adverse determination 42
upon initial review; 43
(c) The percentage of the adverse determinations described in 44
paragraph (b) that were appealed; 45
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(d) The percentage of appeals of adverse determinations 1
described in paragraph (c) that resulted in a reversal of the 2
adverse determination; 3
(e) The five most common reasons for the adverse 4
determinations described in paragraph (b); and 5
(f) The average time between a request for prior authorization 6
for medical or dental care in this State and the resolution of the 7
request. 8
2. The information described in subsection 1 must be 9
disaggregated for the following categories: 10
(a) The specialty of the provider of health care who submitted 11
a request for prior authorization; and 12
(b) The types of health or dental care at issue in the request for 13
prior authorization, including the specific types of prescription 14
drugs, procedures or diagnostic tests involved in the requests. 15
3. The Department shall not include individually identifiable 16
health information in the information published pursuant to 17
subsection 1. 18
Sec. 41. 1. On or before March 1 of each calendar year, the 19
Department shall: 20
(a) Compile a report containing the following information for 21
Medicaid and the Children’s Health Insurance Program: 22
(1) The specific goods and services for which the 23
Department requires prior authorization and, for each good or 24
service: 25
(I) The date on which the Department began requiring 26
prior authorization for that good or service and the date on which 27
that requirement was listed on the Internet website of the 28
Department pursuant to section 34 of this act; 29
(II) The number of requests for prior authorization 30
received by the Department during the immediately preceding 31
calendar year for the provision of the good or service; 32
(III) The number and percentage of the requests listed 33
pursuant to sub-subparagraph (II) that were approved; 34
(IV) The number and percentage of the requests listed 35
pursuant to sub-subparagraph (II) that resulted in adverse 36
determinations; and 37
(V) The number of appeals from adverse determinations 38
during the immediately preceding calendar year and the 39
percentage of those appeals that were reversed on appeal by the 40
Department; 41
(2) For all requests for prior authorization for non-urgent 42
health or dental care received by the Department during the 43
immediately preceding calendar year, the average and median 44
time between: 45
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(I) The Department receiving a request for prior 1
authorization and the Department approving or making an 2
adverse determination on the request; and 3
(II) The submission of an appeal of an adverse 4
determination on a request for prior authorization and the 5
resolution of the appeal; and 6
(3) For all requests for prior authorization for urgent 7
health care received by the Department during the immediately 8
preceding calendar year, the average and median time between: 9
(I) The Department receiving a request for prior 10
authorization and the Department approving or making an 11
adverse determination on the request; and 12
(II) The submission of an appeal of an adverse 13
determination on a request for prior authorization and the 14
resolution of the appeal; 15
(b) Post the report on the Internet website maintained by the 16
Department; and 17
(c) Submit the report to the Director of the Legislative Counsel 18
Bureau for transmittal to the Joint Interim Standing Committee 19
on Health and Human Services. 20
2. The Department shall not include individually identifiable 21
health information in a report published pursuant to subsection 1. 22
Sec. 42. NRS 422.403 is hereby amended to read as follows: 23
422.403 1. The Department shall, by regulation, establish and 24
manage the use by the Medicaid program of step therapy and prior 25
authorization for prescription drugs. 26
2. The Drug Use Review Board shall: 27
(a) Advise the Department concerning the use by the Medicaid 28
program of step therapy and prior authorization for prescription 29
drugs; 30
(b) Develop step therapy protocols and prior authorization 31
policies and procedures that comply with the provisions of sections 32
26 to 41, inclusive, of this act for use by the Medicaid program for 33
prescription drugs; and 34
(c) Review and approve, based on clinical evidence and best 35
clinical practice guidelines and without consideration of the cost of 36
the prescription drugs being considered, step therapy protocols used 37
by the Medicaid program for prescription drugs. 38
3. The step therapy protocol established pursuant to this section 39
must not apply to a drug approved by the Food and Drug 40
Administration that is prescribed to treat a psychiatric condition of a 41
recipient of Medicaid, if: 42
(a) The drug has been approved by the Food and Drug 43
Administration with indications for the psychiatric condition of the 44
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insured or the use of the drug to treat that psychiatric condition is 1
otherwise supported by medical or scientific evidence; 2
(b) The drug is prescribed by: 3
(1) A psychiatrist; 4
(2) A physician assistant under the supervision of a 5
psychiatrist; 6
(3) An advanced practice registered nurse who has the 7
psychiatric training and experience prescribed by the State Board of 8
Nursing pursuant to NRS 632.120; or 9
(4) A primary care provider that is providing care to an 10
insured in consultation with a practitioner listed in subparagraph (1), 11
(2) or (3), if the closest practitioner listed in subparagraph (1), (2) or 12
(3) who participates in Medicaid is located 60 miles or more from 13
the residence of the recipient; and 14
(c) The practitioner listed in paragraph (b) who prescribed the 15
drug knows, based on the medical history of the recipient, or 16
reasonably expects each alternative drug that is required to be used 17
earlier in the step therapy protocol to be ineffective at treating the 18
psychiatric condition. 19
4. The Department shall not require the Drug Use Review 20
Board to develop, review or approve prior authorization policies or 21
procedures necessary for the operation of the list of preferred 22
prescription drugs developed pursuant to NRS 422.4025. 23
5. The Department shall accept recommendations from the 24
Drug Use Review Board as the basis for developing or revising step 25
therapy protocols and prior authorization policies and procedures 26
used by the Medicaid program for prescription drugs. 27
6. As used in this section: 28
(a) “Medical or scientific evidence” has the meaning ascribed to 29
it in NRS 695G.053. 30
(b) “Step therapy protocol” means a procedure that requires a 31
recipient of Medicaid to use a prescription drug or sequence of 32
prescription drugs other than a drug that a practitioner recommends 33
for treatment of a psychiatric condition of the recipient before 34
Medicaid provides coverage for the recommended drug. 35
Sec. 43. NRS 439B.736 is hereby amended to read as follows: 36
439B.736 1. “Third party” includes, without limitation: 37
(a) The issuer of a health benefit plan, as defined in NRS 38
695G.019 ; [, which provides coverage for medically necessary 39
emergency services;] 40
(b) The Public Employees’ Benefits Program established 41
pursuant to subsection 1 of NRS 287.043; 42
(c) The Public Option established pursuant to NRS 695K.200; 43
and 44
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(d) Any other entity or organization that elects pursuant to NRS 1
439B.757 for the provisions of NRS 439B.700 to 439B.760, 2
inclusive, to apply to the provision of medically necessary 3
emergency services by out-of-network providers to covered persons. 4
2. The term does not include the State Plan for Medicaid, the 5
Children’s Health Insurance Program or a health maintenance 6
organization, as defined in NRS 695C.030, or managed care 7
organization, as defined in NRS 695G.050, when providing health 8
care services through managed care to recipients of Medicaid under 9
the State Plan for Medicaid or insurance pursuant to the Children’s 10
Health Insurance Program pursuant to a contract with the Division 11
of Health Care Financing and Policy of the Department. 12
Sec. 44. NRS 608.1555 is hereby amended to read as follows: 13
608.1555 Any employer who provides benefits for health care 14
to his or her employees shall provide the same benefits and pay 15
providers of health care in the same manner as a policy of insurance 16
pursuant to chapters 689A and 689B of NRS, including, without 17
limitation, as required by paragraphs (b) and (c) of subsection 2 18
and subsections 1, 3, 5, 6 and 7 of NRS 687B.225, NRS 687B.409, 19
687B.723 and 687B.725 [.] and sections 2 to 18, inclusive, of this 20
act. 21
Sec. 45. 1. The amendatory provisions of this act do not 22
apply to a request for prior authorization submitted: 23
(a) Under a contract or policy of health insurance issued before 24
January 1, 2026, but apply to any request for prior authorization 25
submitted under any renewal of such a contract or policy. 26
(b) To the Department of Health and Human Services before 27
January 1, 2026, for medical or dental care provided to a recipient of 28
Medicaid. 29
2. A health carrier must, in order to continue requiring prior 30
authorization in contracts or policies of health insurance issued or 31
renewed after January 1, 2026: 32
(a) Develop a procedure for obtaining prior authorization that 33
complies with NRS 687B.225, as amended by section 19 of this act, 34
and sections 2 to 18, inclusive, of this act; and 35
(b) Obtain the approval of the Commissioner of Insurance 36
pursuant to NRS 687B.225, as amended by section 19 of this act, for 37
the procedure developed pursuant to paragraph (a). 38
3. As used in this section, “health carrier” has the meaning 39
ascribed to it in section 5 of this act. 40
Sec. 46. The provisions of NRS 218D.380 do not apply to any 41
provision of this act which adds or revises a requirement to submit a 42
report to the Legislature. 43
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Sec. 47. The provisions of NRS 354.599 do not apply to any 1
additional expenses of a local government that are related to the 2
provisions of this act. 3
Sec. 48. 1. This section and section 45 of this act become 4
effective upon passage and approval. 5
2. Sections 1 to 44, inclusive, 46 and 47 of this act become 6
effective: 7
(a) Upon passage and approval for the purpose of adopting any 8
regulations, performing any other preparatory administrative tasks 9
that are necessary to carry out the provisions of this act and 10
approving procedures for obtaining prior authorization pursuant to 11
NRS 687B.225, as amended by section 19 of this act, and section 45 12
of this act; and 13
(b) On January 1, 2026, for all other purposes. 14
H