EXEMPT
(Reprinted with amendments adopted on April 21, 2025)
FIRST REPRINT A.B. 463
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ASSEMBLY BILL NO. 463–ASSEMBLYMEMBER BACKUS
MARCH 17, 2025
____________
Referred to Committee on Commerce and Labor
SUMMARY—Revises provisions relating to prior authorization.
(BDR 57-825)
FISCAL NOTE: Effect on Local Government: May have Fiscal Impact.
Effect on the State: Yes.
CONTAINS UNFUNDED MANDATE (§ 30)
(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; prohibiting an
insurer from requiring prior authorization for certain other
medical care; 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 medical 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
medical and dental care by health insurers, including Medicaid, the Children’s 8
Health Insurance Program and insurance for public employees. 9
Section 44 of this bill requires that the procedure for obtaining prior 10
authorization for services reimbursable through Medicaid or the Children’s Health 11
Insurance Program on a fee-for-service basis includes: (1) a list of the specific 12
goods and services for which the Department of Health and Human Services 13
requires prior authorization; and (2) the clinical review criteria used by the 14
Department to evaluate requests for prior authorization. Section 44 also requires 15
the Department to publish its procedure for obtaining prior authorization on its 16
Internet website and update that website as necessary to account for any changes in 17
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the procedure. Section 44 prohibits the Department from denying a claim for 18
payment for medical or dental care because of the failure to obtain prior 19
authorization if the Department’s procedures for obtaining prior authorization in 20
effect on the date on which the care was provided did not require prior 21
authorization for that care. 22
Section 45 of this bill requires the Department to approve or deny such a 23
request, or request additional, medically relevant information within 48 hours after 24
receiving the request. Section 46 of this bill requires any adverse determination on 25
a request for prior authorization for services reimbursable through Medicaid or the 26
Children’s Health Insurance Program on a fee-for-service basis to be made by a 27
physician or, for a request relating to dental care, a dentist, who is licensed in this 28
State and possesses certain other qualifications. Section 46 requires the 29
Department, in certain circumstances, to allow the provider of health care who 30
requested the prior authorization to discuss the issues involved in the request with 31
the physician or dentist who is responsible for making a determination on the 32
request. Section 46 requires the Department, upon making an adverse 33
determination on a request for prior authorization, to transmit certain information to 34
the recipient of benefits under Medicaid or the Children’s Health Insurance 35
Program to whom the request pertains, including information relating to the right of 36
the recipient to appeal the adverse determination. Section 46 further requires: (1) 37
the Department to establish a process for appeals that provides for the timely 38
resolution of appeals submitted by recipients; and (2) a decision upholding an 39
adverse determination on an appeal submitted by a recipient to be made by a 40
physician or dentist who has qualifications beyond those required of a physician or 41
dentist who evaluates initial requests for prior authorization. If the Department 42
approves a request for prior authorization, section 47 of this bill requires the 43
Department to pay the provider of health care the full applicable rate for the 44
relevant care, except in certain circumstances. 45
Sections 18 and 47 of this bill provide that a request for prior authorization that 46
has been approved by a public or private insurer, including Medicaid and the 47
Children’s Health Insurance Program, remains valid for: (1) 12 months; or (2) 48
treatment related to a chronic condition, until the standard of treatment for that 49
condition changes. 50
Sections 19 and 48 of this bill prohibit an insurer from requiring an insured to 51
obtain prior authorization for certain medical care, including certain preventive care 52
services. Sections 20 and 49 of this bill prohibit an insurer from requiring prior 53
authorization for covered emergency services. Sections 20 and 49 prohibit an 54
insurer from requiring that an insured or provider of health care notify the insurer 55
earlier than the end of the business day immediately following the date of 56
admission or the date on which the emergency services are provided. Sections 20 57
and 49 also require an insurer to respond to a request for prior authorization for 58
certain follow-up care relating to the emergency care received by an insured within 59
60 minutes after receiving the request. Finally, Sections 20 and 49: (1) prohibit an 60
insurer from denying coverage for covered medically necessary emergency 61
services; and (2) establish a presumption of medical necessity under certain 62
conditions. 63
Section 18 prohibits an insurer other than Medicaid from denying or imposing 64
additional limits on a request for prior authorization that the insurer has previously 65
approved if the care at issue in the request is provided within 45 business days after 66
the date on which the insurer receives the request and certain other requirements are 67
met. Section 21 of this bill requires such an insurer to exempt providers of health 68
care from the requirement to obtain prior authorization for specific goods and 69
services if the insurer has granted requests for prior authorization for those goods or 70
services submitted by the provider at a rate of 80 percent or more during the 71
previous year. Section 21 requires such an insurer to annually conduct reviews of 72
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each provider of health care in the network of the insurer to determine whether each 73
such provider qualifies for an exemption. If the provider qualifies for an exemption, 74
section 21 requires the insurer to automatically grant the exemption for the 75
applicable goods and services, without requiring the provider to affirmatively 76
request an exemption. Section 22 of this bill prescribes the requirements and 77
procedure for such an insurer to revoke an exemption granted to a provider of 78
health care. Section 22 also requires such an insurer to establish a procedure by 79
which a provider of health care may appeal a revocation of an exemption. Section 80
27 of this bill makes conforming changes to clarify that an insurer may not require 81
prior authorization where prohibited by sections 19-21. 82
Sections 4-15 and 35-42 of this bill define certain terms relating to the process 83
of obtaining and processing requests for prior authorization, and sections 2 and 34 84
of this bill establish the applicability of those definitions. Sections 23 and 52 of 85
this bill provide that if a private insurer or the Department violates any provision of 86
section 18-20 or 44-49 with respect to a particular request for prior authorization, 87
that the request is deemed approved. 88
Section 28 of this bill requires a nonprofit hospital and medical or dental 89
service corporation to comply with sections 2-23. Section 29 of this bill requires 90
the Director of the Department to administer the provisions of sections 33-52 of 91
this bill in the same manner as other provisions governing Medicaid. Sections 30, 92
31 and 56 of this bill require plans of self-insurance for employees of local 93
governments, the Public Employees’ Benefits Program and plans of self-insurance 94
for private employers, respectively, to comply with the requirements of sections 2-95
27 to the extent applicable. Section 33 provides that a managed care organization 96
that provides services to recipients of Medicaid or the Children’s Health Insurance 97
Program is not subject to sections 34-52, but must comply with sections 2-27. 98
Section 55 requires the policies and procedures for coverage for prescription drugs 99
under Medicaid to comply with sections 34-52. 100
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 26, inclusive, of this 2
act. 3
Sec. 2. As used in NRS 687B.225 and sections 2 to 26, 4
inclusive, of this act, unless the context otherwise requires, the 5
words and terms defined in sections 3 to 16, inclusive, of this act 6
have the meanings ascribed to them in those sections. 7
Sec. 3. (Deleted by amendment.) 8
Sec. 4. “Approval” means a determination by a health 9
carrier or a utilization review organization that the medical care 10
or dental care furnished or proposed to be furnished to an insured 11
has been reviewed and, based on the information provided to the 12
health carrier, satisfies the health carrier’s criteria for medical 13
necessity or appropriateness and the requested care or payment 14
for the care is therefore approved. 15
Sec. 5. (Deleted by amendment.) 16
Sec. 6. (Deleted by amendment.) 17
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Sec. 7. “Health carrier” has the meaning ascribed to it in 1
NRS 695G.024, and includes, without limitation, an organization 2
for dental care. The term additionally includes a utilization review 3
organization, as defined in NRS 695G.085. 4
Sec. 8. (Deleted by amendment.) 5
Sec. 9. “Insured” means a policyholder, subscriber, enrollee 6
or other person covered by a health carrier. 7
Sec. 10. (Deleted by amendment.) 8
Sec. 11. “Medically necessary” has the meaning ascribed to 9
it in NRS 695G.055. 10
Sec. 12. “Network” means a defined set of providers of 11
health care who are under contract with a health carrier to 12
provide health care services pursuant to a network plan offered or 13
issued by the health carrier. 14
Sec. 13. “Network plan” means a contract or policy of 15
insurance offered by a health carrier under which the financing 16
and delivery of medical or dental care is provided, in whole or in 17
part, through a defined set of providers under contract with the 18
health carrier. 19
Sec. 14. “Prior authorization” means: 20
1. Any process by which a health carrier determines, before 21
medical care or dental care that is otherwise covered by the health 22
carrier is provided to an insured, that the medical care or dental 23
care is medically necessary or medically appropriate with respect 24
to the particular insured; or 25
2. Any requirement that an insured or a provider of health 26
care of the insured notify the health carrier before medical or 27
dental care is provided to the insured. 28
Sec. 15. “Provider of health care” has the meaning ascribed 29
to it in NRS 695G.070. 30
Sec. 16. (Deleted by amendment.) 31
Sec. 17. (Deleted by amendment.) 32
Sec. 18. 1. If a health carrier approves a request for prior 33
authorization, the approval remains valid until: 34
(a) Twelve months after the date on which the request is 35
approved; or 36
(b) If the approval relates to the treatment of a chronic 37
condition, until the standard of treatment for that condition 38
changes. 39
2. A health carrier shall not revoke or impose an additional 40
limit, condition or restriction on a request for prior authorization 41
that the health carrier has previously approved unless: 42
(a) The care at issue in the request is not provided to the 43
insured within 45 business days after the date on which the health 44
carrier received the request; or 45
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(b) The health carrier determines that an insured or provider 1
of health care procured the approval by fraud or material 2
misrepresentation. 3
3. As used in this section, “chronic condition” means a 4
condition that is expected to last 1 year or more and: 5
(a) Requires ongoing medical attention to effectively manage 6
the condition or prevent an event that adversely affects the health 7
of the person; or 8
(b) Limits one or more activities of daily living. 9
Sec. 19. 1. A health carrier shall not require prior 10
authorization for: 11
(a) Outpatient services for the treatment of a substance use 12
disorder. 13
(b) Antineoplastic treatment for cancer, other than 14
prescription drugs, that is consistent with the guidelines 15
established by the National Comprehensive Cancer Network, or its 16
successor organization. 17
(c) Evidence-based goods or services for preventive care that 18
have in effect a grade of “A” or “B” identified by the United 19
States Preventive Services Task Force. 20
(d) Preventive care for women described in 45 C.F.R. § 21
147.130(a)(1)(iv). 22
(e) Hospice care provided to pediatric patients in a facility for 23
hospice care licensed pursuant to chapter 449 of NRS. 24
(f) Care provided to treat neonatal abstinence syndrome 25
provided by a provider of health care who specializes in pain 26
management for pediatric patients or palliative care provided to 27
pediatric patients. 28
(g) The prescription of test strips for measuring blood glucose 29
in persons with diabetes. 30
(h) Psychiatric care provided by a psychiatrist licensed to 31
practice medicine in this State and certified by the American 32
Board of Psychiatry and Neurology, Inc. 33
2. As used in this section: 34
(a) “Facility for hospice care” has the meaning ascribed to it 35
in NRS 449.0033. 36
(b) “Hospice care” has the meaning ascribed to it in 37
NRS 449.0115. 38
Sec. 20. 1. A health carrier shall not require prior 39
authorization for emergency medical services covered by the 40
health carrier, including, where applicable, transportation by 41
ambulance to a hospital or other medical facility. 42
2. If a health carrier requires an insured or his or her 43
provider of health care to notify the health carrier that the insured 44
has been admitted to a hospital to receive emergency medical 45
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services or has received emergency medical services, the health 1
carrier shall not require an insured or a provider of health care to 2
transmit such a notice earlier than the end of the business day 3
immediately following the date on which the insured was admitted 4
or the emergency medical services were provided, as applicable. 5
3. A health carrier shall not deny coverage for emergency 6
medical services covered by the health carrier that are medically 7
necessary. Emergency medical services are presumed to be 8
medically necessary if, within 72 hours after an insured is 9
admitted to receive emergency medical services, the provider of 10
health care of the insured transmits to the health carrier a 11
certification, in writing, that the condition of the insured required 12
emergency medical services. The health carrier may rebut that 13
presumption by establishing, by clear and convincing evidence, 14
that the emergency medical services were not medically necessary. 15
4. If an insured receives emergency medical services and 16
must additionally receive post-evaluation or post-stabilization 17
medical care, and a health carrier requires prior authorization for 18
the post-evaluation or post-stabilization care, the health carrier 19
shall approve or deny a request for prior authorization for such 20
care within 60 minutes after receiving the request. 21
5. A health carrier shall make all determinations for whether 22
emergency medical services are medically necessary without 23
regard to whether a provider of health care that provided or billed 24
for those services participates in the network of the health carrier. 25
6. As used in this section: 26
(a) “Emergency medical services” means health care services 27
that are provided in a medical facility by a provider of health care 28
to screen and to stabilize an insured after the sudden onset of a 29
medical condition that manifests itself by symptoms of such 30
sufficient severity that a prudent layperson who possesses average 31
knowledge of health and medicine would believe that the absence 32
of immediate medical attention could result in: 33
(1) Placing the health of the insured in serious jeopardy; 34
(2) Placing the health of an unborn child of the insured in 35
serious jeopardy; 36
(3) A serious impairment of a bodily function of the 37
insured; or 38
(4) A serious dysfunction of any bodily organ or part of the 39
insured. 40
(b) “Medical facility” has the meaning ascribed to it in 41
NRS 449.0151. 42
Sec. 21. 1. A health carrier shall exempt a provider of 43
health care who participates in the network of the health carrier 44
from the requirement to obtain prior authorization for a specific 45
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good or service if, within the immediately preceding 12 months, 1
the health carrier approved 80 percent or more of the requests for 2
prior authorization for that specific good or service submitted by 3
the provider of health care. If a provider of health care qualifies 4
for an exemption pursuant to this section, a health carrier shall: 5
(a) Automatically grant the exemption without requiring the 6
provider of health care to submit a request for the exemption; and 7
(b) Transmit to the provider of health care after granting the 8
exemption a notice that includes: 9
(1) A statement that the provider of health care has been 10
granted an exemption from the requirement to obtain prior 11
authorization from the health carrier for the specific goods and 12
services listed pursuant to subparagraph (2); 13
(2) A list of goods and services to which the exemption 14
applies; and 15
(3) The date on which the exemption expires, which must 16
not be earlier than 12 months after the date on which the health 17
carrier granted the exemption. 18
2. A health carrier shall provide for an annual review of the 19
requests for prior authorization submitted by providers of health 20
care who participate in the network of the health carrier to 21
determine whether those providers meet the criteria prescribed by 22
subsection 1 for an exemption from the requirement to obtain 23
prior authorization. If a provider of health care is initially 24
determined to be ineligible for an exemption based on such a 25
review, the eligibility of the provider of health care to receive an 26
exemption must be independently determined by a provider of 27
health care who: 28
(a) Is licensed in this State; 29
(b) Is of the same or similar specialty as the provider of health 30
care who is being evaluated for an exemption; and 31
(c) Has experience providing the good or service for which the 32
exemption has been initially denied. 33
3. A provider of health care who is not granted an exemption 34
from the requirement to obtain prior authorization for a particular 35
good or service may, for that specific good or service, request from 36
the health carrier any evidence that supported the decision of the 37
health carrier to not grant the exemption for that good or service. 38
A provider of health care may submit a request for supporting 39
evidence pursuant to this subsection not more than once during a 40
single 12-month period for each good or service for which the 41
provider of health care has not been granted an exemption. 42
4. An exemption from the requirement to obtain prior 43
authorization pursuant to this section applies to the provision of 44
any good or service covered by the exemption which is provided or 45
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ordered by the provider of health care to whom the exception 1
applies. 2
5. A health carrier shall not deny a claim or reduce the 3
amount of payment paid under a claim for a good or service that is 4
subject to an exemption pursuant to this section unless: 5
(a) The provider of health care who submitted the claim 6
knowingly and materially misrepresented the goods or services 7
actually provided to an insured, and the provider of health care 8
made the misrepresentation with the specific intent to obtain a 9
payment from the health carrier to which the provider of health 10
care is not legally or contractually entitled; or 11
(b) The service or good for which payment is sought was not 12
substantially performed or provided, as applicable. 13
Sec. 22. 1. Not more than once during a single 12-month 14
period, a health carrier may reevaluate the eligibility of a provider 15
of health care to receive an exemption from the requirement to 16
obtain prior authorization pursuant to section 21 of this act. 17
2. A health carrier may, pursuant to subsection 1, revoke an 18
exemption from the requirement to obtain prior authorization 19
granted to a provider of health care only if the health carrier 20
determines that the provider of health care would not have met the 21
criteria prescribed in subsection 1 of section 21 of this act for the 22
good or service to which the exemption applies based on: 23
(a) A retrospective review of claims submitted by the provider 24
of health care for that good or service during the immediately 25
preceding 3 months; or 26
(b) If the provider of health care did not submit at least 10 27
claims for that good or service during the immediately preceding 3 28
months, a retrospective review of at least the last 10 claims 29
submitted by the provider of health care for that good or service. 30
3. If it is initially determined that a provider of health care 31
meets the criteria prescribed in subsection 2 for the revocation of 32
an exemption based on a review conducted pursuant to that 33
subsection, the satisfaction of those criteria must be independently 34
determined by a provider of health care described in subsection 2 35
of section 21 of this act before the health carrier may revoke the 36
exemption. 37
4. A health carrier that revokes an exemption from the 38
requirement to obtain prior authorization pursuant to subsection 2 39
shall transmit to the provider of health care to which the 40
revocation pertains a notice that includes: 41
(a) The information that the health carrier relied upon when 42
making the determination described in subsection 2; 43
(b) An identification of each good or service to which the 44
revoked exemption applies; 45
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(c) The date on which the revocation takes effect, which must 1
not be earlier than 30 days after the date on which the health 2
carrier transmits the notice; and 3
(d) A description, written in easily comprehensible language, 4
of how the provider of health care may appeal the revocation 5
pursuant to subsection 5. 6
5. A health carrier shall adopt a procedure by which a 7
provider of health care may appeal the revocation of an exemption 8
from the requirement to obtain prior authorization. If a provider 9
of health care appeals a revocation of such exemption, the 10
exemption must remain in effect: 11
(a) If the revocation is reversed on appeal, until the next 12
reevaluation pursuant to subsection 1 of the eligibility of the 13
provider of health care to continue receiving the exemption. 14
(b) If the revocation is upheld on appeal, until the later of the 15
5th calendar day after the revocation is upheld or the date 16
contained within the notice sent to the provider of health care 17
pursuant to subsection 4. 18
Sec. 23. If a health carrier violates NRS 687B.225 or 19
sections 17 to 20, inclusive, of this act with respect to a particular 20
request for prior authorization, the request shall be deemed 21
approved. 22
Sec. 24. (Deleted by amendment.) 23
Sec. 25. (Deleted by amendment.) 24
Sec. 26. (Deleted by amendment.) 25
Sec. 27. NRS 687B.225 is hereby amended to read as follows: 26
687B.225 1. Except as otherwise provided in NRS 27
689A.0405, 689A.0412, 689A.0413, 689A.0418, 689A.0437, 28
689A.044, 689A.0445, 689A.0459, 689B.031, 689B.0312, 29
689B.0313, 689B.0315, 689B.0317, 689B.0319, 689B.0374, 30
689B.0378, 689C.1665, 689C.1671, 689C.1675, 689C.1676, 31
695A.1843, 695A.1856, 695A.1865, 695A.1874, 695B.1912, 32
695B.1913, 695B.1914, 695B.1919, 695B.19197, 695B.1924, 33
695B.1925, 695B.1942, 695C.1696, 695C.1699, 695C.1713, 34
695C.1735, 695C.1737, 695C.1743, 695C.1745, 695C.1751, 35
695G.170, 695G.1705, 695G.171, 695G.1714, 695G.1715, 36
695G.1719 and 695G.177, and sections 19, 20 and 21 of this act, 37
any contract [for group, blanket or individual health] or policy of 38
insurance [or any contract by a nonprofit hospital, medical or dental 39
service corporation or organization for dental care] issued by a 40
health carrier which provides for payment of a certain part of 41
medical or dental care may require the insured [or member] to 42
obtain prior authorization for that care from the [insurer or 43
organization. The insurer or organization] health carrier. The 44
health carrier shall: 45
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(a) File its procedure for obtaining [approval of care] prior 1
authorization pursuant to this section for approval by the 2
Commissioner; and 3
(b) Unless a shorter time period is prescribed by a specific 4
statute, including, without limitation, NRS 689A.0446, 689B.0361, 5
689C.1688, 695A.1859, 695B.19087, 695C.16932 and 695G.1703, 6
respond to any request for approval by the insured [or member] 7
pursuant to this section within 20 days after it receives the request. 8
2. The procedure for prior authorization may not discriminate 9
among persons licensed to provide the covered care. 10
Sec. 28. NRS 695B.320 is hereby amended to read as follows: 11
695B.320 1. Nonprofit hospital and medical or dental service 12
corporations are subject to the provisions of this chapter, and to the 13
provisions of chapters 679A and 679B of NRS, subsections 2, 4, 17, 14
18 and 30 of NRS 680B.010, NRS 680B.025 to 680B.060, 15
inclusive, chapter 681B of NRS, NRS 686A.010 to 686A.315, 16
inclusive, 686B.010 to 686B.175, inclusive, 687B.010 to 17
687B.040, inclusive, 687B.070 to 687B.140, inclusive, 687B.150, 18
687B.160, 687B.180, 687B.200 to 687B.255, inclusive, and 19
sections 2 to 26, inclusive, of this act, 687B.270, 687B.310 to 20
687B.380, inclusive, 687B.410, 687B.420, 687B.430, 687B.500 and 21
chapters 692B, 692C, 693A and 696B of NRS, to the extent 22
applicable and not in conflict with the express provisions of this 23
chapter. 24
2. For the purposes of this section and the provisions set forth 25
in subsection 1, a nonprofit hospital and medical or dental service 26
corporation is included in the meaning of the term “insurer.” 27
Sec. 29. NRS 232.320 is hereby amended to read as follows: 28
232.320 1. The Director: 29
(a) Shall appoint, with the consent of the Governor, 30
administrators of the divisions of the Department, who are 31
respectively designated as follows: 32
(1) The Administrator of the Aging and Disability Services 33
Division; 34
(2) The Administrator of the Division of Welfare and 35
Supportive Services; 36
(3) The Administrator of the Division of Child and Family 37
Services; 38
(4) The Administrator of the Division of Health Care 39
Financing and Policy; and 40
(5) The Administrator of the Division of Public and 41
Behavioral Health. 42
(b) Shall administer, through the divisions of the Department, 43
the provisions of chapters 63, 424, 425, 427A, 432A to 442, 44
inclusive, 446 to 450, inclusive, 458A and 656A of NRS, 45
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NRS 127.220 to 127.310, inclusive, 422.001 to 422.410, inclusive, 1
and sections 33 to 54, inclusive, of this act, 422.580, 432.010 to 2
432.133, inclusive, 432B.6201 to 432B.626, inclusive, 444.002 to 3
444.430, inclusive, and 445A.010 to 445A.055, inclusive, and all 4
other provisions of law relating to the functions of the divisions of 5
the Department, but is not responsible for the clinical activities of 6
the Division of Public and Behavioral Health or the professional line 7
activities of the other divisions. 8
(c) Shall administer any state program for persons with 9
developmental disabilities established pursuant to the 10
Developmental Disabilities Assistance and Bill of Rights Act of 11
2000, 42 U.S.C. §§ 15001 et seq. 12
(d) Shall, after considering advice from agencies of local 13
governments and nonprofit organizations which provide social 14
services, adopt a master plan for the provision of human services in 15
this State. The Director shall revise the plan biennially and deliver a 16
copy of the plan to the Governor and the Legislature at the 17
beginning of each regular session. The plan must: 18
(1) Identify and assess the plans and programs of the 19
Department for the provision of human services, and any 20
duplication of those services by federal, state and local agencies; 21
(2) Set forth priorities for the provision of those services; 22
(3) Provide for communication and the coordination of those 23
services among nonprofit organizations, agencies of local 24
government, the State and the Federal Government; 25
(4) Identify the sources of funding for services provided by 26
the Department and the allocation of that funding; 27
(5) Set forth sufficient information to assist the Department 28
in providing those services and in the planning and budgeting for the 29
future provision of those services; and 30
(6) Contain any other information necessary for the 31
Department to communicate effectively with the Federal 32
Government concerning demographic trends, formulas for the 33
distribution of federal money and any need for the modification of 34
programs administered by the Department. 35
(e) May, by regulation, require nonprofit organizations and state 36
and local governmental agencies to provide information regarding 37
the programs of those organizations and agencies, excluding 38
detailed information relating to their budgets and payrolls, which the 39
Director deems necessary for the performance of the duties imposed 40
upon him or her pursuant to this section. 41
(f) Has such other powers and duties as are provided by law. 42
2. Notwithstanding any other provision of law, the Director, or 43
the Director’s designee, is responsible for appointing and removing 44
subordinate officers and employees of the Department. 45
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Sec. 30. NRS 287.010 is hereby amended to read as follows: 1
287.010 1. The governing body of any county, school 2
district, municipal corporation, political subdivision, public 3
corporation or other local governmental agency of the State of 4
Nevada may: 5
(a) Adopt and carry into effect a system of group life, accident 6
or health insurance, or any combination thereof, for the benefit of its 7
officers and employees, and the dependents of officers and 8
employees who elect to accept the insurance and who, where 9
necessary, have authorized the governing body to make deductions 10
from their compensation for the payment of premiums on the 11
insurance. 12
(b) Purchase group policies of life, accident or health insurance, 13
or any combination thereof, for the benefit of such officers and 14
employees, and the dependents of such officers and employees, as 15
have authorized the purchase, from insurance companies authorized 16
to transact the business of such insurance in the State of Nevada, 17
and, where necessary, deduct from the compensation of officers and 18
employees the premiums upon insurance and pay the deductions 19
upon the premiums. 20
(c) Provide group life, accident or health coverage through a 21
self-insurance reserve fund and, where necessary, deduct 22
contributions to the maintenance of the fund from the compensation 23
of officers and employees and pay the deductions into the fund. The 24
money accumulated for this purpose through deductions from the 25
compensation of officers and employees and contributions of the 26
governing body must be maintained as an internal service fund as 27
defined by NRS 354.543. The money must be deposited in a state or 28
national bank or credit union authorized to transact business in the 29
State of Nevada. Any independent administrator of a fund created 30
under this section is subject to the licensing requirements of chapter 31
683A of NRS, and must be a resident of this State. Any contract 32
with an independent administrator must be approved by the 33
Commissioner of Insurance as to the reasonableness of 34
administrative charges in relation to contributions collected and 35
benefits provided. The provisions of NRS 439.581 to 439.597, 36
inclusive, 686A.135, paragraph (b) of subsection 1 of NRS 37
687B.225, subsection 2 of NRS 687B.225, 687B.352, 687B.408, 38
687B.692, 687B.723, 687B.725, 687B.805, 689B.030 to 39
689B.0317, inclusive, paragraphs (b) and (c) of subsection 1 of NRS 40
689B.0319, subsections 2, 4, 6 and 7 of NRS 689B.0319, 689B.033 41
to 689B.0369, inclusive, 689B.0375 to 689B.050, inclusive, 42
689B.0675, 689B.265, 689B.287 and 689B.500 and sections 2 to 43
26, inclusive, of this act apply to coverage provided pursuant to this 44
paragraph, except that the provisions of NRS 689B.0378, 45
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- *AB463_R1*
689B.03785 and 689B.500 only apply to coverage for active officers 1
and employees of the governing body, or the dependents of such 2
officers and employees. 3
(d) Defray part or all of the cost of maintenance of a self-4
insurance fund or of the premiums upon insurance. The money for 5
contributions must be budgeted for in accordance with the laws 6
governing the county, school district, municipal corporation, 7
political subdivision, public corporation or other local governmental 8
agency of the State of Nevada. 9
2. If a school district offers group insurance to its officers and 10
employees pursuant to this section, members of the board of trustees 11
of the school district must not be excluded from participating in the 12
group insurance. If the amount of the deductions from compensation 13
required to pay for the group insurance exceeds the compensation to 14
which a trustee is entitled, the difference must be paid by the trustee. 15
3. In any county in which a legal services organization exists, 16
the governing body of the county, or of any school district, 17
municipal corporation, political subdivision, public corporation or 18
other local governmental agency of the State of Nevada in the 19
county, may enter into a contract with the legal services 20
organization pursuant to which the officers and employees of the 21
legal services organization, and the dependents of those officers and 22
employees, are eligible for any life, accident or health insurance 23
provided pursuant to this section to the officers and employees, and 24
the dependents of the officers and employees, of the county, school 25
district, municipal corporation, political subdivision, public 26
corporation or other local governmental agency. 27
4. If a contract is entered into pursuant to subsection 3, the 28
officers and employees of the legal services organization: 29
(a) Shall be deemed, solely for the purposes of this section, to be 30
officers and employees of the county, school district, municipal 31
corporation, political subdivision, public corporation or other local 32
governmental agency with which the legal services organization has 33
contracted; and 34
(b) Must be required by the contract to pay the premiums or 35
contributions for all insurance which they elect to accept or of which 36
they authorize the purchase. 37
5. A contract that is entered into pursuant to subsection 3: 38
(a) Must be submitted to the Commissioner of Insurance for 39
approval not less than 30 days before the date on which the contract 40
is to become effective. 41
(b) Does not become effective unless approved by the 42
Commissioner. 43
(c) Shall be deemed to be approved if not disapproved by the 44
Commissioner within 30 days after its submission. 45
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6. As used in this section, “legal services organization” means 1
an organization that operates a program for legal aid and receives 2
money pursuant to NRS 19.031. 3
Sec. 31. NRS 287.04335 is hereby amended to read as 4
follows: 5
287.04335 If the Board provides health insurance through a 6
plan of self-insurance, it shall comply with the provisions of NRS 7
439.581 to 439.597, inclusive, 686A.135, paragraph (b) of 8
subsection 1 of NRS 687B.225, subsection 2 of NRS 687B.225, 9
687B.352, 687B.409, 687B.692, 687B.723, 687B.725, 687B.805, 10
689B.0353, 689B.255, 695C.1723, 695G.150, 695G.155, 695G.160, 11
695G.162, 695G.1635, 695G.164, 695G.1645, 695G.1665, 12
695G.167, 695G.1675, 695G.170 to 695G.1712, inclusive, 13
695G.1714 to 695G.174, inclusive, 695G.176, 695G.177, 695G.200 14
to 695G.230, inclusive, 695G.241 to 695G.310, inclusive, 695G.405 15
and 695G.415, and sections 2 to 26, inclusive, of this act in the 16
same manner as an insurer that is licensed pursuant to title 57 of 17
NRS is required to comply with those provisions. 18
Sec. 32. Chapter 422 of NRS is hereby amended by adding 19
thereto the provisions set forth as sections 33 to 54, inclusive, of this 20
act. 21
Sec. 33. 1. The provisions of sections 34 to 54, inclusive, of 22
this act and any policies developed pursuant thereto do not apply 23
to the delivery of services to recipients of Medicaid or the 24
Children’s Health Insurance Program through managed care in 25
accordance with NRS 422.273. 26
2. A health maintenance organization or other managed care 27
organization that enters into a contract with the Department or the 28
Division pursuant to NRS 422.273 to provide health care services 29
to recipients of Medicaid under the State Plan for Medicaid or the 30
Children’s Health Insurance Program shall comply with NRS 31
687B.225 and sections 2 to 26, inclusive, of this act. 32
Sec. 34. As used in sections 34 to 54, inclusive, of this act, 33
unless the context otherwise requires, the words and terms defined 34
in sections 35 to 43, inclusive, of this act have the meanings 35
ascribed to them in those sections. 36
Sec. 35. “Adverse determination”: 37
1. Means a determination by the Department that the medical 38
care or dental care furnished or proposed to be furnished to a 39
recipient is not medically necessary, or is experimental or 40
investigational, and the requested care or payment for the care is 41
therefore denied, reduced or terminated. 42
2. Does not include the denial, reduction or termination of 43
coverage or payment for medical care or dental care for a reason 44
other than the medical necessity or experimental or investigational 45
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nature of the medical care or dental care at issue in a request for 1
prior authorization, including, without limitation, the denial of 2
coverage for medical care or dental care that is not covered under 3
Medicaid or the Children’s Health Insurance Program. 4
Sec. 36. “Approval” means a determination by the 5
Department that the medical care or dental care furnished or 6
proposed to be furnished to a recipient has been reviewed and, 7
based on the information provided to the Department, satisfies the 8
Department’s criteria for medical necessity or appropriateness and 9
the requested care or payment for the care is therefore approved. 10
Sec. 37. (Deleted by amendment.) 11
Sec. 38. (Deleted by amendment.) 12
Sec. 39. (Deleted by amendment.) 13
Sec. 40. “Medically necessary” has the meaning ascribed to 14
it in NRS 695G.055. 15
Sec. 41. “Provider of health care” means a person who 16
participates in the State Plan for Medicaid or the Children’s 17
Health Insurance Program as a provider of goods or services. 18
Sec. 42. “Recipient” means a natural person who receives 19
benefits through Medicaid or the Children’s Health Insurance 20
Program, as applicable. 21
Sec. 43. (Deleted by amendment.) 22
Sec. 44. 1. The Department, with respect to Medicaid and 23
the Children’s Health Insurance Program, shall establish written 24
procedures for obtaining prior authorization for medical or dental 25
care which must include, without limitation: 26
(a) Specific goods and services for which the Department 27
requires prior authorization; and 28
(b) Clinical review criteria used by the Department. 29
2. The Department shall publish the written procedures for 30
obtaining prior authorization established by the Department 31
pursuant to subsection 1, including, without limitation, the clinical 32
review criteria, on an Internet website maintained by the 33
Department: 34
(a) Using clear language that is understandable to an ordinary 35
layperson, where practicable; and 36
(b) In a place that is readily accessible and conspicuous to 37
recipients and the public. 38
3. If the Department amends the procedure for obtaining 39
prior authorization established pursuant to subsection 1, 40
including, without limitation, changing the goods and services for 41
which the Department requires prior authorization or changing 42
the clinical review criteria used by the Department, the 43
Department shall: 44
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(a) Transmit a notice containing a summary of the changes 1
made to the procedure to each recipient and each provider of 2
goods or services under Medicaid or the Children’s Health 3
Insurance Program, as applicable; and 4
(b) Update the information published on its Internet website 5
pursuant to subsection 2 to reflect the amended procedure for 6
obtaining prior authorization and the date on which the amended 7
procedure takes effect. 8
4. A change to the Department’s procedure for obtaining 9
prior authorization may not take effect until 60 days have passed 10
after the later of: 11
(a) The date on which the Department transmitted the notice to 12
recipients and providers of goods or services under Medicaid or 13
the Children’s Health Insurance Program, as applicable, pursuant 14
to paragraph (a) of subsection 3; or 15
(b) The date on which the Department updated the 16
information published on its Internet website pursuant to 17
paragraph (b) of subsection 3. 18
5. The Department shall not deny a claim based on the 19
failure of a recipient to obtain prior authorization for medical or 20
dental care if the procedure for obtaining prior authorization 21
established by the Department pursuant to this section did not 22
require the recipient to obtain prior authorization for that medical 23
or dental care on the date on which the medical or dental care was 24
provided to the recipient. 25
6. As used in this section, “clinical review criteria” means 26
any written screening procedure, formulary decision abstract, 27
clinical protocol, practice guideline or other criteria used by the 28
Department to determine the necessity and appropriateness of 29
medical or dental care. 30
Sec. 45. 1. Unless a shorter time period is prescribed by a 31
specific statute, and except as otherwise provided in subsection 2, 32
the Department, with respect to Medicaid and the Children’s 33
Health Insurance Program, shall approve or deny a request for 34
prior authorization submitted by or on behalf of a recipient and 35
notify the recipient and his or her provider of health care of the 36
approval or denial within 48 hours after receiving the request. 37
2. If the Department requires additional, medically relevant 38
information or documentation in order to adequately evaluate a 39
request for prior authorization, the Department shall: 40
(a) Notify the recipient and the provider of health care who 41
submitted the request within the applicable amount of time 42
described in subsection 1 that additional information is required to 43
evaluate the request; 44
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- *AB463_R1*
(b) Include within the notification sent pursuant to paragraph 1
(a) a description, with reasonable specificity, of the information 2
that the Department requires to make a determination on the 3
request for prior authorization; and 4
(c) Approve or deny the request within 48 hours after receiving 5
the information. 6
Sec. 46. 1. The Department, with respect to Medicaid and 7
the Children’s Health Insurance Program, shall not make an 8
adverse determination on a request for prior authorization unless 9
the adverse determination is made by a physician licensed 10
pursuant to chapter 630 or 633 of NRS or, for dental care, a 11
dentist licensed in this State who: 12
(a) Is of the same or similar specialty as a physician or dentist, 13
as applicable, who typically manages or treats the medical or 14
dental condition or provides the medical or dental care involved in 15
the request; and 16
(b) Has experience treating or managing the medical or dental 17
condition involved in the request. 18
2. If a physician or dentist described in subsection 1 is 19
considering making an adverse determination on a request for 20
prior authorization on the basis that the medical or dental care 21
involved in the request is not medically necessary, the Department 22
shall: 23
(a) Immediately notify the provider of health care who 24
submitted the request that the medical necessity of the requested 25
care is being questioned by the Department; and 26
(b) Offer the provider of health care an opportunity to speak 27
with the physician or dentist, as applicable, over the telephone or 28
by videoconference to discuss the clinical issues involved in the 29
request before the physician or dentist renders an initial 30
determination on the request. 31
3. Upon rendering an adverse determination on a request for 32
prior authorization, the Department shall immediately transmit to 33
the recipient to whom the request pertains a written notice that 34
contains: 35
(a) A specific description of all reasons that the Department 36
made the adverse determination; 37
(b) A description of any documentation that the Department 38
requested from the recipient or a provider of health care of the 39
recipient and did not receive or deemed insufficient, if the failure 40
to receive sufficient documentation contributed to the adverse 41
determination; 42
(c) A statement that the recipient has the right to appeal the 43
adverse determination; 44
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(d) Instructions, written in clear language that is 1
understandable to an ordinary layperson, describing how the 2
recipient can appeal the adverse determination through the 3
process established pursuant to subsection 4; and 4
(e) A description of any documentation that may be necessary 5
or pertinent to a potential appeal. 6
4. The Department shall establish a process that allows a 7
recipient to appeal an adverse determination on a request for prior 8
authorization. The process must allow for the clear resolution of 9
each appeal within a reasonable time. 10
5. The Department shall not uphold on appeal an adverse 11
determination pertaining to a request for prior authorization 12
unless the decision on the appeal is made by a physician licensed 13
pursuant to chapter 630 or 633 of NRS or, for dental care, a 14
dentist licensed in this State, who: 15
(a) Is actively practicing medicine or dentistry, as applicable, 16
within the same or similar specialty as a physician or dentist, as 17
applicable, who typically manages or treats the medical or dental 18
condition or provides the medical or dental care involved in the 19
request and has been actively practicing in that specialty for at 20
least 5 consecutive years preceding the date on which the 21
physician or dentist, as applicable, makes the determination on the 22
appeal; 23
(b) Is knowledgeable of and has experience treating or 24
managing the medical or dental condition involved in the request; 25
(c) Was not involved in making the adverse determination that 26
is the subject of the appeal; 27
(d) Has no financial interest in the outcome of the request for 28
prior authorization that is the subject of the appeal; 29
(e) Is not employed by or contracted with the Department or 30
any administrator contracted by the Department except: 31
(1) To participate in Medicaid or the Children’s Health 32
Insurance Program as a provider of services; 33
(2) To make determinations on appeals of adverse 34
determinations; or 35
(3) For the purposes described in both subparagraphs (1) 36
and (2); and 37
(f) Considers all known clinical aspects of the medical or 38
dental care involved in the request, including, without limitation: 39
(1) The medical records of the recipient that are provided 40
or accessible to the Department, including those records provided 41
to the Department by the recipient or a provider of health care of 42
the recipient; 43
(2) The clinical review criteria adopted by the Department 44
pursuant to section 44 of this act; and 45
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(3) Medical or scientific evidence provided to the 1
Department by the provider of health care who requested prior 2
authorization for the care at issue. 3
6. As used in this section: 4
(a) “Administrator” has the meaning ascribed to it in 5
NRS 683A.025. 6
(b) “Medical or scientific evidence” has the meaning ascribed 7
to it in NRS 695G.053. 8
Sec. 47. 1. If the Department approves a request for prior 9
authorization, the approval remains valid until the later of: 10
(a) Twelve months after the date on which the request is 11
approved; or 12
(b) If the approval relates to the treatment of a chronic 13
condition, until the standard of treatment for that condition 14
changes. 15
2. If the Department approves a request for prior 16
authorization, the Department shall promptly pay a provider of 17
health care for a claim for the approved medical or dental care at 18
the full rate of reimbursement provided under Medicaid or the 19
Children’s Health Insurance Program, as applicable, unless: 20
(a) The provider of health care knowingly and materially 21
misrepresented the medical care or dental care contained in the 22
request with the specific intent to deceive and obtain a payment 23
from the Department to which the provider of health care was not 24
entitled; or 25
(b) The provider of health care was not a participating 26
provider of services under Medicaid or the Children’s Health 27
Insurance Program, as applicable, on the date that the care was 28
provided. 29
3. As used in this section, “chronic condition” means a 30
condition that is expected to last 1 year or more and: 31
(a) Requires ongoing medical attention to effectively manage 32
the condition or prevent an event that adversely affects the health 33
of the person; or 34
(b) Limits one or more activities of daily living. 35
Sec. 48. 1. The Department, with respect to Medicaid and 36
the Children’s Health Insurance Program, shall not require prior 37
authorization for: 38
(a) Outpatient services for the treatment of a mental health 39
condition or substance use disorder. 40
(b) Antineoplastic treatment for cancer, other than 41
prescription drugs, that is consistent with the guidelines 42
established by the National Comprehensive Cancer Network, or its 43
successor organization. 44
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(c) Evidence-based goods or services for preventive care that 1
have in effect a grade of “A” or “B” identified by the United 2
States Preventive Services Task Force. 3
(d) Preventive care for women described in 45 C.F.R. § 4
147.130(a)(iv). 5
(e) Hospice care provided to pediatric patients in a facility for 6
hospice care licensed pursuant to chapter 449 of NRS. 7
(f) Care provided to treat neonatal abstinence syndrome 8
provided by a provider of health care who specializes in pain 9
management for pediatric patients or palliative care provided to 10
pediatric patients. 11
(g) The prescription of test strips for measuring blood glucose 12
in persons with diabetes. 13
(h) Psychiatric care provided by a psychiatrist licensed to 14
practice medicine in this State and certified by the American 15
Board of Psychiatry and Neurology, Inc. 16
2. As used in this section: 17
(a) “Facility for hospice care” has the meaning ascribed to it 18
in NRS 449.0033. 19
(b) “Hospice care” has the meaning ascribed to it in 20
NRS 449.0115. 21
Sec. 49. 1. The Department, with respect to Medicaid and 22
the Children’s Health Insurance Program, shall not require prior 23
authorization for covered emergency services, including, where 24
applicable, transportation by ambulance to a hospital or other 25
medical facility. 26
2. If the Department requires a recipient or his or her 27
provider of health care to notify the Department that the recipient 28
has been admitted to a hospital to receive emergency services or 29
has received emergency services, the Department shall not require 30
a recipient or a provider of health care to transmit such a notice 31
earlier than the end of the business day immediately following the 32
date on which the recipient was admitted or the emergency 33
services were provided, as applicable. 34
3. The Department shall not deny coverage for emergency 35
services covered by Medicaid or the Children’s Health Insurance 36
Program that are medically necessary. Emergency services are 37
presumed to be medically necessary if, within 72 hours after a 38
recipient is admitted to receive emergency services, the provider of 39
health care of the recipient transmits to the Department a 40
certification, in writing, that the condition of the recipient 41
required emergency services. The Department may rebut that 42
presumption by establishing, by clear and convincing evidence, 43
that the emergency services were not medically necessary. 44
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4. If a recipient receives emergency services and must 1
additionally receive post-evaluation or post-stabilization medical 2
care, and the Department requires prior authorization for the post-3
evaluation or post-stabilization care, the Department shall approve 4
or deny a request for prior authorization for such care within 60 5
minutes after receiving the request. 6
5. As used in this section: 7
(a) “Emergency services” means health care services that are 8
provided in a medical facility by a provider of health care to screen 9
and to stabilize a recipient after the sudden onset of a medical 10
condition that manifests itself by symptoms of such sufficient 11
severity that a prudent layperson who possesses average 12
knowledge of health and medicine would believe that the absence 13
of immediate medical attention could result in: 14
(1) Placing the health of the recipient in serious jeopardy; 15
(2) Placing the health of an unborn child of the recipient in 16
serious jeopardy; 17
(3) A serious impairment of a bodily function of the 18
recipient; or 19
(4) A serious dysfunction of any bodily organ or part of the 20
recipient. 21
(b) “Medical facility” has the meaning ascribed to it in 22
NRS 449.0151. 23
Sec. 50. (Deleted by amendment.) 24
Sec. 51. (Deleted by amendment.) 25
Sec. 52. 1. If the Department violates sections 44 to 51, 26
inclusive, of this act with respect to a particular request for prior 27
authorization, the request shall be deemed approved. 28
2. Nothing in sections 44 to 51, inclusive, of this act shall be 29
construed to require the Department to provide coverage: 30
(a) For medical or dental care that, regardless of whether such 31
care is medically necessary, would not be a covered benefit under 32
the terms and conditions of Medicaid or the Children’s Health 33
Insurance Program, as applicable; or 34
(b) To a person who is not a recipient or is not otherwise 35
eligible to receive coverage under Medicaid or the Children’s 36
Health Insurance Program, as applicable, on the date on which 37
medical or dental care is provided to the person. 38
Sec. 53. (Deleted by amendment.) 39
Sec. 54. (Deleted by amendment.) 40
Sec. 55. NRS 422.403 is hereby amended to read as follows: 41
422.403 1. The Department shall, by regulation, establish and 42
manage the use by the Medicaid program of step therapy and prior 43
authorization for prescription drugs. 44
2. The Drug Use Review Board shall: 45
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(a) Advise the Department concerning the use by the Medicaid 1
program of step therapy and prior authorization for prescription 2
drugs; 3
(b) Develop step therapy protocols and prior authorization 4
policies and procedures that comply with the provisions of sections 5
34 to 54, inclusive, of this act for use by the Medicaid program for 6
prescription drugs; and 7
(c) Review and approve, based on clinical evidence and best 8
clinical practice guidelines and without consideration of the cost of 9
the prescription drugs being considered, step therapy protocols used 10
by the Medicaid program for prescription drugs. 11
3. The step therapy protocol established pursuant to this section 12
must not apply to a drug approved by the Food and Drug 13
Administration that is prescribed to treat a psychiatric condition of a 14
recipient of Medicaid, if: 15
(a) The drug has been approved by the Food and Drug 16
Administration with indications for the psychiatric condition of the 17
insured or the use of the drug to treat that psychiatric condition is 18
otherwise supported by medical or scientific evidence; 19
(b) The drug is prescribed by: 20
(1) A psychiatrist; 21
(2) A physician assistant under the supervision of a 22
psychiatrist; 23
(3) An advanced practice registered nurse who has the 24
psychiatric training and experience prescribed by the State Board of 25
Nursing pursuant to NRS 632.120; or 26
(4) A primary care provider that is providing care to an 27
insured in consultation with a practitioner listed in subparagraph (1), 28
(2) or (3), if the closest practitioner listed in subparagraph (1), (2) or 29
(3) who participates in Medicaid is located 60 miles or more from 30
the residence of the recipient; and 31
(c) The practitioner listed in paragraph (b) who prescribed the 32
drug knows, based on the medical history of the recipient, or 33
reasonably expects each alternative drug that is required to be used 34
earlier in the step therapy protocol to be ineffective at treating the 35
psychiatric condition. 36
4. The Department shall not require the Drug Use Review 37
Board to develop, review or approve prior authorization policies or 38
procedures necessary for the operation of the list of preferred 39
prescription drugs developed pursuant to NRS 422.4025. 40
5. The Department shall accept recommendations from the 41
Drug Use Review Board as the basis for developing or revising step 42
therapy protocols and prior authorization policies and procedures 43
used by the Medicaid program for prescription drugs. 44
6. As used in this section: 45
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(a) “Medical or scientific evidence” has the meaning ascribed to 1
it in NRS 695G.053. 2
(b) “Step therapy protocol” means a procedure that requires a 3
recipient of Medicaid to use a prescription drug or sequence of 4
prescription drugs other than a drug that a practitioner recommends 5
for treatment of a psychiatric condition of the recipient before 6
Medicaid provides coverage for the recommended drug. 7
Sec. 56. NRS 608.1555 is hereby amended to read as follows: 8
608.1555 Any employer who provides benefits for health care 9
to his or her employees shall provide the same benefits and pay 10
providers of health care in the same manner as a policy of insurance 11
pursuant to chapters 689A and 689B of NRS, including, without 12
limitation, as required by paragraph (b) of subsection 1 of NRS 13
687B.225, subsection 2 of NRS 687B.225, NRS 687B.409, 14
687B.723 and 687B.725 [.] and sections 2 to 26, inclusive, of this 15
act. 16
Sec. 57. 1. The amendatory provisions of this act do not 17
apply to a request for prior authorization submitted: 18
(a) Under a contract or policy of health insurance issued before 19
January 1, 2026, but apply to any request for prior authorization 20
submitted under any renewal of such a contract or policy. 21
(b) To the Department of Health and Human Services before 22
January 1, 2026, for medical or dental care provided to a recipient of 23
Medicaid. 24
2. A health carrier must, in order to continue requiring prior 25
authorization in contracts or policies of health insurance issued or 26
renewed after January 1, 2026: 27
(a) Develop a procedure for obtaining prior authorization that 28
complies with NRS 687B.225, as amended by section 27 of this act, 29
and sections 2 to 26, inclusive, of this act; and 30
(b) Obtain the approval of the Commissioner of Insurance 31
pursuant to NRS 687B.225, as amended by section 27 of this act, for 32
the procedure developed pursuant to paragraph (a). 33
3. As used in this section, “health carrier” has the meaning 34
ascribed to it in section 7 of this act. 35
Sec. 58. (Deleted by amendment.) 36
Sec. 59. The provisions of NRS 354.599 do not apply to any 37
additional expenses of a local government that are related to the 38
provisions of this act. 39
Sec. 60. 1. This section and section 57 of this act become 40
effective upon passage and approval. 41
2. Sections 1 to 56, inclusive, 58 and 59 of this act become 42
effective: 43
(a) Upon passage and approval for the purposes of adopting any 44
regulations, performing any other preparatory administrative tasks 45
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that are necessary to carry out the provisions of this act and 1
approving procedures for obtaining prior authorization pursuant to 2
NRS 687B.225, as amended by section 27 of this act, and section 57 3
of this act; and 4
(b) On January 1, 2026, for all other purposes. 5
H