A.B. 470
- *AB470*
ASSEMBLY BILL NO. 470–ASSEMBLYMEMBER KASAMA
MARCH 17, 2025
____________
Referred to Committee on Commerce and Labor
SUMMARY—Revises provisions relating to prior authorization for
medical or dental care under health insurance plans.
(BDR 57-883)
FISCAL NOTE: Effect on Local Government: May have Fiscal Impact.
Effect on the State: Yes.
CONTAINS UNFUNDED MANDATE (§ 18)
(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; 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, insurance for public employees and certain entities designated 9
by health insurers to perform utilization reviews. 10
Specifically, sections 15 and 27 of this bill require that a procedure for 11
obtaining prior authorization includes: (1) a list of the specific goods and services 12
for which the insurer requires prior authorization; and (2) the clinical review 13
criteria used by the insurer to evaluate requests for prior authorization. Sections 15 14
and 27 also require an insurer to publish its procedure for obtaining prior 15
authorization on its Internet website and update that website as necessary to 16
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account for any changes in the procedure. Sections 15 and 27 prohibit an insurer 17
from denying a claim for payment for medical or dental care because of the failure 18
to obtain prior authorization if the insurer’s procedures for obtaining prior 19
authorization in effect on the date that the care was provided did not require prior 20
authorization for that care. 21
Sections 15 and 28 of this bill revise the period for insurers to take action on a 22
request for prior authorization by requiring an insurer to approve or make an 23
adverse determination on such a request, or request additional, medically relevant 24
information: (1) within 48 hours after receiving the request, for medical or dental 25
care that is not urgent; or (2) within 24 hours after receiving the request, for care 26
that is urgent. Sections 10 and 29 of this bill require an insurer, in certain 27
circumstances, to allow the provider of health care who requested the prior 28
authorization to discuss the issues involved in the request with a person who is 29
responsible for making a determination on the request. Sections 10 and 29 require 30
an insurer, upon making an adverse determination on a request for prior 31
authorization, to transmit certain information to the insured to whom the request 32
pertains, including information relating to the right of the insured to appeal the 33
adverse determination. 34
Sections 11 and 30 of this bill: (1) provide that a request for prior authorization 35
that has been approved by the insurer remains valid for 12 months; and (2) require 36
an insurer, for the first 90 days of the coverage period for a new insured, to honor a 37
request for prior authorization that has been approved by the previous insurer of the 38
new insured, under certain circumstances. Sections 11 and 30 prohibit an insurer 39
from denying or imposing additional limits on a request for prior authorization that 40
the insurer has previously approved if the care at issue in the request is provided 41
within 45 business days after the date on which the insurer receives the request and 42
certain other requirements are met. 43
Sections 12 and 33 of this bill prohibit an insurer from requiring prior 44
authorization for covered emergency services. Sections 12 and 33 also prohibit an 45
insurer from requiring that an insured or provider of health care notify the insurer 46
earlier than the end of the business day following the date of admission or the date 47
on which the emergency services are provided. Finally, sections 12 and 33: (1) 48
prohibit an insurer from denying coverage for covered medically necessary 49
emergency services; and (2) establish a presumption of medical necessity under 50
certain conditions. 51
Sections 3-9 and 23-26 of this bill define certain terms relating to the process 52
of obtaining and processing requests for prior authorization, and sections 2 and 22 53
of this bill establish the applicability of those definitions. Sections 13 and 32 of 54
this bill provide that if an insurer violates any provision of section 10-12, 15 or 27-55
31 of this bill with respect to a particular request for prior authorization, that the 56
request is deemed approved. Sections 13 and 32 also clarify that nothing in the 57
provisions of section 10-12, 15 or 27-31 require an insurer to provide coverage: (1) 58
for care that the insurer does not cover, regardless of the medical necessity of the 59
care; or (2) to persons to whom the insured is not obligated to provide coverage. 60
Sections 14 and 33 of this bill require an insurer to annually publish on its 61
Internet website certain information relating to requests for prior authorization that 62
have been processed by the insurer during the immediately preceding year. Section 63
16 of this bill requires a nonprofit hospital and medical or dental service 64
corporation to comply with sections 2-14. Section 17 of this bill requires the 65
Director of the Department of Health and Human Services to administer the 66
provisions of sections 21-33 of this bill in the same manner as other provisions 67
governing Medicaid. Sections 18, 19 and 35 of this bill require plans of self-68
insurance for employees of local governments, the Public Employees’ Benefits 69
Program and plans of self-insurance for private employers, respectively, to comply 70
with the requirements of sections 2-15 to the extent applicable. Section 21 provides 71
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that a health maintenance organization or another managed care organization that 72
provides services to recipients of Medicaid or the Children’s Health Insurance 73
Program is not subject to sections 22-33, but must comply with sections 2-15. 74
Section 34 of this bill requires the policies and procedures for coverage for 75
prescription drugs under Medicaid to comply with sections 22-33. 76
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 14, inclusive, of this 2
act. 3
Sec. 2. As used in NRS 687B.225 and sections 2 to 14, 4
inclusive, of this act, unless the context otherwise requires, the 5
words and terms defined in sections 3 to 9, 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. “Health carrier” has the meaning ascribed to it in 16
NRS 695G.024, and includes, without limitation: 17
1. An organization for dental care, as defined in NRS 18
695D.060; and 19
2. A utilization review organization, as defined in 20
NRS 695G.085. 21
Sec. 5. “Insured” means a policyholder, subscriber, enrollee 22
or other person covered by a health carrier. 23
Sec. 6. “Medically necessary” has the meaning ascribed to it 24
in NRS 695G.055. 25
Sec. 7. “Network” means a defined set of providers of health 26
care who are under contract with a health carrier to provide 27
health care services pursuant to a network plan offered or issued 28
by the health carrier. 29
Sec. 8. “Network plan” means a contract or policy of 30
insurance offered by a health carrier under which the financing 31
and delivery of medical or dental care is provided, in whole or in 32
part, through a defined set of providers under contract with the 33
health carrier. 34
Sec. 9. “Provider of health care” has the meaning ascribed 35
to it in NRS 695G.070. 36
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Sec. 10. 1. If a health carrier is considering making an 1
adverse determination on a request for prior authorization on the 2
basis that the medical or dental care involved in the request is not 3
medically necessary, the health carrier that received the request 4
shall: 5
(a) Immediately notify the provider of health care who 6
submitted the request that the medical necessity of the requested 7
care is being questioned by the health carrier; and 8
(b) Offer the provider of health care an opportunity to speak 9
with a person responsible for making the determination over the 10
telephone or by videoconference to discuss the clinical issues 11
involved in the request before the health carrier renders an initial 12
determination on the request. 13
2. Upon rendering an adverse determination on a request for 14
prior authorization, a health carrier shall immediately transmit to 15
the insured to whom the request pertains a written notice that 16
contains: 17
(a) A specific description of all reasons that the health carrier 18
made the adverse determination; 19
(b) A description of any documentation that the health carrier 20
requested from the insured or a provider of health care of the 21
insured and did not receive or deemed insufficient, if the failure to 22
receive sufficient documentation contributed to the adverse 23
determination; and 24
(c) A statement that the insured has the right to appeal the 25
adverse determination. 26
Sec. 11. 1. If a health carrier approves a request for prior 27
authorization, the approval remains valid, including for any 28
changes in the dosage of a medication: 29
(a) Until 12 months after the date on which the request is 30
approved; or 31
(b) If the approval is for the treatment of a chronic or long 32
term condition, for the length of the treatment and for any 33
subsequent treatments of the same type and for the same 34
condition. 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 45 business days after the date on which the health 40
carrier received 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. 12. 1. A health carrier shall not require prior 28
authorization for emergency services covered by the health 29
carrier, including, without limitation, where applicable, 30
transportation by ambulance to a hospital or other medical 31
facility. 32
2. If a health carrier requires an insured or his or her 33
provider of health care to notify the health carrier that the insured 34
has been admitted to a hospital to receive emergency services or 35
has received emergency services, the health carrier shall not 36
require an insured or a provider of health care to transmit such a 37
notice earlier than the end of the business day immediately 38
following the day after the date on which the insured was admitted 39
or the emergency services were provided, as applicable. 40
3. A health carrier shall not deny coverage for emergency 41
services covered by the health carrier that are medically necessary. 42
Emergency services are presumed to be medically necessary if, 43
within 72 hours after an insured is admitted to receive emergency 44
services, the insured’s provider of health care transmits to the 45
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health carrier a certification, in writing, that the condition of the 1
insured required emergency services. The health carrier may rebut 2
that presumption by establishing, by clear and convincing 3
evidence, that the emergency services were not medically 4
necessary. 5
4. A health carrier shall make all determinations for whether 6
emergency services are medically necessary without regard to 7
whether a provider of health care that provided or billed for those 8
services participates in the network of the health carrier. 9
5. For emergency services which require immediate post 10
evaluation or post stabilization services, a health carrier shall 11
approve or make an adverse determination on any request for 12
prior authorization for the post evaluation or post stabilization 13
services submitted by or on behalf of the insured within 1 hour of 14
the time the health carrier receives the request. 15
6. As used in this section, “emergency services” means health 16
care services that are provided by a provider of health care to 17
screen and to stabilize an insured after the sudden onset of a 18
medical condition that manifests itself by symptoms of such 19
sufficient severity that a prudent person would believe that the 20
absence of immediate medical attention could result in: 21
(a) Serious jeopardy to the health of the insured; 22
(b) Serious jeopardy to the health of an unborn child of the 23
insured; 24
(c) Serious impairment of a bodily function of the insured; or 25
(d) Serious dysfunction of any bodily organ or part of the 26
insured. 27
Sec. 13. 1. If a health carrier violates NRS 687B.225 or 28
section 10, 11 or 12 of this act with respect to a particular request 29
for prior authorization, the request shall be deemed approved. 30
2. Nothing in NRS 687B.225 or section 10, 11 or 12 of this 31
act shall be construed to require a health carrier to provide 32
coverage: 33
(a) For medical or dental care that, regardless of whether such 34
care is medically necessary, would not be a covered benefit under 35
the terms and conditions of the contract or policy of insurance; 36
(b) To a person who is not insured by the health carrier on the 37
date on which medical or dental care is provided to the person; or 38
(c) To an insured who, as a result of his or her failure to pay 39
the applicable premiums required under the terms and conditions 40
of a contract or policy of insurance, has no coverage under the 41
contract or policy on the date on which medical or dental care is 42
provided to the insured. 43
Sec. 14. 1. On or before March 1 of each calendar year, a 44
health carrier shall publish on an Internet website maintained by 45
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the health carrier in an easily accessible format the following 1
information for the immediately preceding calendar year, in 2
aggregated form for all requests for prior authorization received 3
by the insurer during the immediately preceding year and 4
disaggregated in accordance with subsection 2: 5
(a) The percentage of requests for prior authorization for 6
medical or dental care in this State that were approved upon initial 7
review; 8
(b) The percentage of requests for prior authorization for 9
medical or dental care in this State that resulted in an adverse 10
determination upon initial review; 11
(c) The percentage of the adverse determinations described in 12
paragraph (b) that were appealed; 13
(d) The percentage of appeals of adverse determinations 14
described in paragraph (c) that resulted in a reversal of the 15
adverse determination; 16
(e) The five most common reasons for the adverse 17
determinations described in paragraph (b); and 18
(f) The average time between a request for prior authorization 19
for medical or dental care in this State and the resolution of the 20
request. 21
2. The information described in subsection 1 must be 22
disaggregated for the following categories: 23
(a) The specialty of the provider of health care who submitted 24
a request for prior authorization; and 25
(b) The types of health or dental care at issue in the request for 26
prior authorization, including, without limitation, the specific 27
types of prescription drugs, procedures or diagnostic tests involved 28
in the requests. 29
3. A health carrier shall not include individually identifiable 30
health information in the information published pursuant to 31
subsection 1. 32
4. As used in this section, “individually identifiable health 33
information” means information relating to the provision of 34
health care to an insured: 35
(a) That specifically identifies the insured; or 36
(b) For which there is a reasonable basis to believe that the 37
information can be used to identify the insured. 38
Sec. 15. NRS 687B.225 is hereby amended to read as follows: 39
687B.225 1. Except as otherwise provided in NRS 40
689A.0405, 689A.0412, 689A.0413, 689A.0418, 689A.0437, 41
689A.044, 689A.0445, 689A.0459, 689B.031, 689B.0312, 42
689B.0313, 689B.0315, 689B.0317, 689B.0319, 689B.0374, 43
689B.0378, 689C.1665, 689C.1671, 689C.1675, 689C.1676, 44
695A.1843, 695A.1856, 695A.1865, 695A.1874, 695B.1912, 45
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695B.1913, 695B.1914, 695B.1919, 695B.19197, 695B.1924, 1
695B.1925, 695B.1942, 695C.1696, 695C.1699, 695C.1713, 2
695C.1735, 695C.1737, 695C.1743, 695C.1745, 695C.1751, 3
695G.170, 695G.1705, 695G.171, 695G.1714, 695G.1715, 4
695G.1719 and 695G.177, and section 12 of this act, any contract 5
[for group, blanket or individual health] or policy of insurance [or 6
any contract by a nonprofit hospital, medical or dental service 7
corporation or organization for dental care] issued by a health 8
carrier which provides for payment of a certain part of medical or 9
dental care may require the insured [or member] to obtain prior 10
authorization for that care from the [insurer or organization. The 11
insurer or organization] health carrier in a manner consistent with 12
this section and sections 2 to 14, inclusive, of this act. 13
2. A health carrier that requires an insured to obtain prior 14
authorization shall: 15
(a) File its procedure for obtaining [approval of care] prior 16
authorization pursuant to this section , including, without 17
limitation, a list of the specific goods and services for which the 18
health carrier requires prior authorization and the clinical review 19
criteria used by the health carrier to evaluate requests for prior 20
authorization, for approval by the Commissioner . [; and] 21
(b) Unless a shorter time period is prescribed by a specific 22
statute, including, without limitation, NRS 689A.0446, 689B.0361, 23
689C.1688, 695A.1859, 695B.19087, 695C.16932 and 695G.1703, 24
[respond to] and except as otherwise provided by paragraph (c), 25
approve or make an adverse determination on any request for 26
[approval by the insured or member] prior authorization submitted 27
by or on behalf of the insured pursuant to this section [within 20 28
days after it receives the request.] and notify the insured and his or 29
her provider of health care of the approval or adverse 30
determination: 31
(1) For medical or dental care that is not urgent health 32
care, within 48 hours after receiving the request. 33
(2) For urgent health care, within 24 hours after receiving 34
the request. 35
(c) If the health carrier requires additional, medically relevant 36
information or documentation in order to adequately evaluate a 37
request for prior authorization: 38
(1) Notify the insured and the provider of health care who 39
submitted the request within the applicable amount of time 40
described in paragraph (b) that additional information is required 41
to evaluate the request; 42
(2) Include within the notification sent pursuant to 43
subparagraph (1) a description, with reasonable specificity, of the 44
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information that the health carrier requires to make a 1
determination on the request for prior authorization; and 2
(3) Approve or make an adverse determination on the 3
request: 4
(I) For medical or dental care that is not urgent health 5
care, within 48 hours after receiving the information. 6
(II) For urgent health care, within 24 hours after 7
receiving the information. 8
[2.] 3. The procedure for prior authorization may not 9
discriminate among persons licensed to provide the covered care. 10
4. If a health carrier seeks to amend its procedure for 11
obtaining prior authorization, including, without limitation, 12
changing the goods and services for which the health carrier 13
requires prior authorization or changing the clinical review 14
criteria used by the health carrier, the health carrier: 15
(a) Must file a request to amend the procedure for approval by 16
the Commissioner. 17
(b) May not allow the amended procedure to take effect until: 18
(1) The Commissioner notifies the health carrier that the 19
request is approved; and 20
(2) The health carrier satisfies the requirements of 21
subsection 5 after the health carrier receives a notice of approval 22
from the Commissioner. 23
5. A change to a health carrier’s procedure for obtaining 24
prior authorization may not take effect until: 25
(a) The health carrier transmits a notice that contains a 26
summary of the changes to the procedure to each of its insureds 27
and providers of health care who participate in the network of the 28
health carrier; 29
(b) The health carrier updates the information published on its 30
Internet website pursuant to subsection 6 to reflect the amended 31
procedure for obtaining prior authorization and the date on which 32
the amended procedure takes effect; and 33
(c) At least 60 days have passed after the later of: 34
(1) The date on which the health carrier transmitted the 35
notice to its insureds and providers of health care who participate 36
in the network of the health carrier pursuant to paragraph (a); or 37
(2) The date on which the health carrier updated the 38
information published on its Internet website pursuant to 39
paragraph (b). 40
6. A health carrier shall publish its procedures for obtaining 41
prior authorization, including, without limitation, the clinical 42
review criteria, on its Internet website: 43
(a) Using clear language that is understandable to an ordinary 44
layperson, where practicable; and 45
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(b) In a place that is readily accessible and conspicuous to 1
insureds and the public. 2
7. A health carrier shall not deny a claim based on the failure 3
of an insured to obtain prior authorization for medical or dental 4
care if the procedure for obtaining prior authorization established 5
by the health carrier did not require the insured to obtain prior 6
authorization for that medical or dental care on the date that the 7
medical or dental care was provided to the insured. 8
8. As used in this section: 9
(a) “Clinical review criteria” means any written screening 10
procedure, decision abstract, clinical protocol or practice 11
guideline used by the health carrier to determine the necessity and 12
appropriateness of medical or dental care. 13
(b) “Emergency services” has the meaning ascribed to it in 14
section 12 of this act. 15
(c) “Urgent health care”: 16
(1) Means health care that, in the opinion of a provider of 17
health care with knowledge of an insured’s medical condition, if 18
not rendered to the insured within 48 hours could: 19
(I) Seriously jeopardize the life or health of the insured 20
or the ability of the insured to regain maximum function; or 21
(II) Subject the insured to severe pain that cannot be 22
adequately managed without receiving such care. 23
(2) Does not include emergency services. 24
Sec. 16. NRS 695B.320 is hereby amended to read as follows: 25
695B.320 1. Nonprofit hospital and medical or dental service 26
corporations are subject to the provisions of this chapter, and to the 27
provisions of chapters 679A and 679B of NRS, subsections 2, 4, 17, 28
18 and 30 of NRS 680B.010, NRS 680B.025 to 680B.060, 29
inclusive, chapter 681B of NRS, NRS 686A.010 to 686A.315, 30
inclusive, 686B.010 to 686B.175, inclusive, 687B.010 to 31
687B.040, inclusive, 687B.070 to 687B.140, inclusive, 687B.150, 32
687B.160, 687B.180, 687B.200 to 687B.255, inclusive, and 33
sections 2 to 14, inclusive, of this act, 687B.270, 687B.310 to 34
687B.380, inclusive, 687B.410, 687B.420, 687B.430, 687B.500 and 35
chapters 692B, 692C, 693A and 696B of NRS, to the extent 36
applicable and not in conflict with the express provisions of this 37
chapter. 38
2. For the purposes of this section and the provisions set forth 39
in subsection 1, a nonprofit hospital and medical or dental service 40
corporation is included in the meaning of the term “insurer.” 41
Sec. 17. NRS 232.320 is hereby amended to read as follows: 42
232.320 1. The Director: 43
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(a) Shall appoint, with the consent of the Governor, 1
administrators of the divisions of the Department, who are 2
respectively designated as follows: 3
(1) The Administrator of the Aging and Disability Services 4
Division; 5
(2) The Administrator of the Division of Welfare and 6
Supportive Services; 7
(3) The Administrator of the Division of Child and Family 8
Services; 9
(4) The Administrator of the Division of Health Care 10
Financing and Policy; and 11
(5) The Administrator of the Division of Public and 12
Behavioral Health. 13
(b) Shall administer, through the divisions of the Department, 14
the provisions of chapters 63, 424, 425, 427A, 432A to 442, 15
inclusive, 446 to 450, inclusive, 458A and 656A of NRS, NRS 16
127.220 to 127.310, inclusive, 422.001 to 422.410, inclusive, and 17
sections 21 to 33, inclusive, of this act, 422.580, 432.010 to 18
432.133, inclusive, 432B.6201 to 432B.626, inclusive, 444.002 to 19
444.430, inclusive, and 445A.010 to 445A.055, inclusive, and all 20
other provisions of law relating to the functions of the divisions of 21
the Department, but is not responsible for the clinical activities of 22
the Division of Public and Behavioral Health or the professional line 23
activities of the other divisions. 24
(c) Shall administer any state program for persons with 25
developmental disabilities established pursuant to the 26
Developmental Disabilities Assistance and Bill of Rights Act of 27
2000, 42 U.S.C. §§ 15001 et seq. 28
(d) Shall, after considering advice from agencies of local 29
governments and nonprofit organizations which provide social 30
services, adopt a master plan for the provision of human services in 31
this State. The Director shall revise the plan biennially and deliver a 32
copy of the plan to the Governor and the Legislature at the 33
beginning of each regular session. The plan must: 34
(1) Identify and assess the plans and programs of the 35
Department for the provision of human services, and any 36
duplication of those services by federal, state and local agencies; 37
(2) Set forth priorities for the provision of those services; 38
(3) Provide for communication and the coordination of those 39
services among nonprofit organizations, agencies of local 40
government, the State and the Federal Government; 41
(4) Identify the sources of funding for services provided by 42
the Department and the allocation of that funding; 43
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(5) Set forth sufficient information to assist the Department 1
in providing those services and in the planning and budgeting for the 2
future provision of those services; and 3
(6) Contain any other information necessary for the 4
Department to communicate effectively with the Federal 5
Government concerning demographic trends, formulas for the 6
distribution of federal money and any need for the modification of 7
programs administered by the Department. 8
(e) May, by regulation, require nonprofit organizations and state 9
and local governmental agencies to provide information regarding 10
the programs of those organizations and agencies, excluding 11
detailed information relating to their budgets and payrolls, which the 12
Director deems necessary for the performance of the duties imposed 13
upon him or her pursuant to this section. 14
(f) Has such other powers and duties as are provided by law. 15
2. Notwithstanding any other provision of law, the Director, or 16
the Director’s designee, is responsible for appointing and removing 17
subordinate officers and employees of the Department. 18
Sec. 18. NRS 287.010 is hereby amended to read as follows: 19
287.010 1. The governing body of any county, school 20
district, municipal corporation, political subdivision, public 21
corporation or other local governmental agency of the State of 22
Nevada may: 23
(a) Adopt and carry into effect a system of group life, accident 24
or health insurance, or any combination thereof, for the benefit of its 25
officers and employees, and the dependents of officers and 26
employees who elect to accept the insurance and who, where 27
necessary, have authorized the governing body to make deductions 28
from their compensation for the payment of premiums on the 29
insurance. 30
(b) Purchase group policies of life, accident or health insurance, 31
or any combination thereof, for the benefit of such officers and 32
employees, and the dependents of such officers and employees, as 33
have authorized the purchase, from insurance companies authorized 34
to transact the business of such insurance in the State of Nevada, 35
and, where necessary, deduct from the compensation of officers and 36
employees the premiums upon insurance and pay the deductions 37
upon the premiums. 38
(c) Provide group life, accident or health coverage through a 39
self-insurance reserve fund and, where necessary, deduct 40
contributions to the maintenance of the fund from the compensation 41
of officers and employees and pay the deductions into the fund. The 42
money accumulated for this purpose through deductions from the 43
compensation of officers and employees and contributions of the 44
governing body must be maintained as an internal service fund as 45
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defined by NRS 354.543. The money must be deposited in a state or 1
national bank or credit union authorized to transact business in the 2
State of Nevada. Any independent administrator of a fund created 3
under this section is subject to the licensing requirements of chapter 4
683A of NRS, and must be a resident of this State. Any contract 5
with an independent administrator must be approved by the 6
Commissioner of Insurance as to the reasonableness of 7
administrative charges in relation to contributions collected and 8
benefits provided. The provisions of NRS 439.581 to 439.597, 9
inclusive, 686A.135, paragraphs (b) and (c) of subsection 2 of 10
NRS 687B.225, subsections 1, 3, 5, 6 and 7 of NRS 687B.225, 11
687B.352, 687B.408, 687B.692, 687B.723, 687B.725, 687B.805, 12
689B.030 to 689B.0317, inclusive, paragraphs (b) and (c) of 13
subsection 1 of NRS 689B.0319, subsections 2, 4, 6 and 7 of NRS 14
689B.0319, 689B.033 to 689B.0369, inclusive, 689B.0375 to 15
689B.050, inclusive, 689B.0675, 689B.265, 689B.287 and 16
689B.500 and sections 2 to 14, inclusive, of this act apply to 17
coverage provided pursuant to this paragraph, except that the 18
provisions of NRS 689B.0378, 689B.03785 and 689B.500 only 19
apply to coverage for active officers and employees of the 20
governing body, or the dependents of such officers and employees. 21
(d) Defray part or all of the cost of maintenance of a self-22
insurance fund or of the premiums upon insurance. The money for 23
contributions must be budgeted for in accordance with the laws 24
governing the county, school district, municipal corporation, 25
political subdivision, public corporation or other local governmental 26
agency of the State of Nevada. 27
2. If a school district offers group insurance to its officers and 28
employees pursuant to this section, members of the board of trustees 29
of the school district must not be excluded from participating in the 30
group insurance. If the amount of the deductions from compensation 31
required to pay for the group insurance exceeds the compensation to 32
which a trustee is entitled, the difference must be paid by the trustee. 33
3. In any county in which a legal services organization exists, 34
the governing body of the county, or of any school district, 35
municipal corporation, political subdivision, public corporation or 36
other local governmental agency of the State of Nevada in the 37
county, may enter into a contract with the legal services 38
organization pursuant to which the officers and employees of the 39
legal services organization, and the dependents of those officers and 40
employees, are eligible for any life, accident or health insurance 41
provided pursuant to this section to the officers and employees, and 42
the dependents of the officers and employees, of the county, school 43
district, municipal corporation, political subdivision, public 44
corporation or other local governmental agency. 45
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4. If a contract is entered into pursuant to subsection 3, the 1
officers and employees of the legal services organization: 2
(a) Shall be deemed, solely for the purposes of this section, to be 3
officers and employees of the county, school district, municipal 4
corporation, political subdivision, public corporation or other local 5
governmental agency with which the legal services organization has 6
contracted; and 7
(b) Must be required by the contract to pay the premiums or 8
contributions for all insurance which they elect to accept or of which 9
they authorize the purchase. 10
5. A contract that is entered into pursuant to subsection 3: 11
(a) Must be submitted to the Commissioner of Insurance for 12
approval not less than 30 days before the date on which the contract 13
is to become effective. 14
(b) Does not become effective unless approved by the 15
Commissioner. 16
(c) Shall be deemed to be approved if not disapproved by the 17
Commissioner within 30 days after its submission. 18
6. As used in this section, “legal services organization” means 19
an organization that operates a program for legal aid and receives 20
money pursuant to NRS 19.031. 21
Sec. 19. NRS 287.04335 is hereby amended to read as 22
follows: 23
287.04335 If the Board provides health insurance through a 24
plan of self-insurance, it shall comply with the provisions of NRS 25
439.581 to 439.597, inclusive, 686A.135, paragraphs (b) and (c) of 26
subsection 2 of NRS 687B.225, subsections 1, 3, 5, 6 and 7 of NRS 27
687B.225, 687B.352, 687B.409, 687B.692, 687B.723, 687B.725, 28
687B.805, 689B.0353, 689B.255, 695C.1723, 695G.150, 695G.155, 29
695G.160, 695G.162, 695G.1635, 695G.164, 695G.1645, 30
695G.1665, 695G.167, 695G.1675, 695G.170 to 695G.1712, 31
inclusive, 695G.1714 to 695G.174, inclusive, 695G.176, 695G.177, 32
695G.200 to 695G.230, inclusive, 695G.241 to 695G.310, inclusive, 33
695G.405 and 695G.415, and sections 2 to 14, inclusive, of this act 34
in the same manner as an insurer that is licensed pursuant to title 57 35
of NRS is required to comply with those provisions. 36
Sec. 20. Chapter 422 of NRS is hereby amended by adding 37
thereto the provisions set forth as sections 21 to 33, inclusive, of this 38
act. 39
Sec. 21. 1. The provisions of sections 22 to 33, inclusive, of 40
this act and any policies developed pursuant thereto do not apply 41
to the delivery of services to recipients of Medicaid or the 42
Children’s Health Insurance Program through managed care in 43
accordance with NRS 422.273. 44
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2. A health maintenance organization or other managed care 1
organization that enters into a contract with the Department or the 2
Division pursuant to NRS 422.273 to provide health care services 3
to recipients of Medicaid under the State Plan for Medicaid or the 4
Children’s Health Insurance Program shall comply with NRS 5
687B.225 and sections 2 to 14, inclusive, of this act. 6
Sec. 22. As used in sections 22 to 33, inclusive, of this act, 7
unless the context otherwise requires, the words and terms defined 8
in sections 23 to 26, inclusive, of this act have the meanings 9
ascribed to them in those sections. 10
Sec. 23. “Adverse determination” means a determination by 11
the Department that an admission, availability of care, continued 12
stay or other medical care or dental care that is a covered benefit 13
has been reviewed and, based upon the information provided, does 14
not meet the Department’s requirements for medical necessity, 15
appropriateness, health care setting, level of care or effectiveness, 16
and the requested care or service or payment for the care or 17
service is therefore denied, reduced or terminated. 18
Sec. 24. “Medically necessary” has the meaning ascribed to 19
it in NRS 695G.055. 20
Sec. 25. “Provider of health care” has the meaning ascribed 21
to it in NRS 695G.070. 22
Sec. 26. “Recipient” means a natural person who receives 23
benefits through Medicaid or the Children’s Health Insurance 24
Program, as applicable. 25
Sec. 27. 1. The Department, with respect to Medicaid and 26
the Children’s Health Insurance Program, shall establish written 27
procedures for obtaining prior authorization for medical or dental 28
care which must include, without limitation: 29
(a) A list of the specific goods and services for which the 30
Department requires prior authorization; and 31
(b) A description of the clinical review criteria used by the 32
Department. 33
2. The Department shall publish the written procedures for 34
obtaining prior authorization established by the Department 35
pursuant to subsection 1, including, without limitation, the clinical 36
review criteria, on an Internet website maintained by the 37
Department: 38
(a) Using clear language that is understandable to an ordinary 39
layperson, where practicable; and 40
(b) In a place that is readily accessible and conspicuous to 41
recipients and the public. 42
3. If the Department amends the procedure for obtaining 43
prior authorization adopted pursuant to subsection 1, including, 44
without limitation, changing the goods and services for which the 45
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Department requires prior authorization or changing the clinical 1
review criteria used by the Department, the Department shall: 2
(a) Transmit a notice containing a summary of the changes 3
made to the procedure to each recipient and each provider of 4
goods or services under Medicaid or the Children’s Health 5
Insurance Program, as applicable; and 6
(b) Update the information published on its Internet website 7
pursuant to subsection 2 to reflect the amended procedure for 8
obtaining prior authorization and the date on which the amended 9
procedure takes effect. 10
4. A change to the Department’s procedure for obtaining 11
prior authorization may not take effect until 60 days have passed 12
after the later of: 13
(a) The date on which the Department transmitted the notice to 14
recipients and providers of goods or services under Medicaid or 15
the Children’s Health Insurance Program, as applicable, pursuant 16
to paragraph (a) of subsection 3; or 17
(b) The date on which the Department updated the 18
information published on its Internet website pursuant to 19
paragraph (b) of subsection 3. 20
5. The Department shall not deny a claim based on the 21
failure of a recipient to obtain prior authorization for medical or 22
dental care if the procedure for obtaining prior authorization 23
established by the Department pursuant to this section did not 24
require the recipient to obtain prior authorization for that medical 25
or dental care on the date that the medical or dental care was 26
provided to the recipient. 27
6. As used in this section, “clinical review criteria” means 28
any written screening procedure, decision abstract, clinical 29
protocol or practice guideline used by the Department to 30
determine the necessity and appropriateness of medical or dental 31
care. 32
Sec. 28. 1. Unless a shorter time period is prescribed by a 33
specific statute, and except as otherwise provided in subsection 2, 34
the Department, with respect to Medicaid and the Children’s 35
Health Insurance Program, shall approve or make an adverse 36
determination on a request for prior authorization submitted by or 37
on behalf of a recipient and notify the recipient and his or her 38
provider of health care of the approval or adverse determination: 39
(a) For medical or dental care that is not urgent health care, 40
within 48 hours after receiving the request. 41
(b) For urgent health care, within 24 hours after receiving the 42
request. 43
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2. If the Department requires additional, medically relevant 1
information or documentation in order to adequately evaluate a 2
request for prior authorization, the Department shall: 3
(a) Notify the recipient and the provider of health care who 4
submitted the request within the applicable amount of time 5
described in subsection 1 that additional information is required to 6
evaluate the request; 7
(b) Include within the notification sent pursuant to paragraph 8
(a) a description, with reasonable specificity, of the information 9
that the Department requires to make a determination on the 10
request for prior authorization; and 11
(c) Approve or make an adverse determination on the request: 12
(1) For medical or dental care that is not urgent health 13
care, within 48 hours after receiving the information. 14
(2) For urgent health care, within 24 hours after receiving 15
the information. 16
3. As used in this section, “urgent health care” has the 17
meaning ascribed to it in section 15 of this act. 18
Sec. 29. 1. If the Department is considering making an 19
adverse determination on a request for prior authorization on the 20
basis that the medical or dental care involved in the request is not 21
medically necessary, the Department shall: 22
(a) Immediately notify the provider of health care who 23
submitted the request that the medical necessity of the requested 24
care is being questioned by the Department; and 25
(b) Offer the provider of health care an opportunity to speak 26
with a person responsible for making the determination over the 27
telephone or by videoconference to discuss the clinical issues 28
involved in the request before the physician or dentist renders an 29
initial determination on the request. 30
2. Upon rendering an adverse determination on a request for 31
prior authorization, the Department shall immediately transmit to 32
the recipient to whom the request pertains a written notice that 33
contains: 34
(a) A specific description of all reasons that the Department 35
made the adverse determination; 36
(b) A description of any documentation that the Department 37
requested from the recipient or a provider of health care of the 38
recipient and did not receive or deemed insufficient, if the failure 39
to receive sufficient documentation contributed to the adverse 40
determination; and 41
(c) A statement that the recipient has the right to appeal the 42
adverse determination. 43
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Sec. 30. 1. If the Department approves a request for prior 1
authorization, the approval remains valid, including for any 2
changes in the dosage of a medication: 3
(a) Until 12 months after the date on which the request is 4
approved; or 5
(b) If the approval is for the treatment of a chronic or long 6
term condition, for the length of the treatment and for any 7
subsequent treatments of the same type and for the same 8
condition. 9
2. The Department shall not revoke or impose an additional 10
limit, condition or restriction on a request for prior authorization 11
that the Department has previously approved unless: 12
(a) The care at issue in the request was not provided to the 13
recipient within 45 business days after the date on which the 14
Department received the request; 15
(b) The Department determines that a recipient or a provider 16
of health care procured the approval by fraud or material 17
misrepresentation; or 18
(c) The Department determines that the care at issue in the 19
request was not covered by Medicaid or the Children’s Health 20
Insurance Program, as applicable, at the time the care was 21
provided. 22
3. If the Department has approved a request for prior 23
authorization, the Department shall not deny or refuse to promptly 24
pay a claim for the approved medical or dental care unless the 25
Department determines that the recipient or provider of health 26
care procured the prior authorization by fraud or material 27
misrepresentation. The claim must be paid at the same rate that 28
the Department is contractually obligated to or would ordinarily 29
pay a provider of health care for providing the specific type of care 30
that was approved and provided to the recipient. 31
4. Within the first 90 days that a recipient is enrolled in 32
Medicaid or the Children’s Health Insurance Program, as 33
applicable, the Department shall honor a request for prior 34
authorization that has been approved by a health carrier or other 35
entity that previously provided the recipient with coverage for 36
medical or dental care if: 37
(a) The approval was issued within the 12 months immediately 38
preceding the first day of the enrollment of the recipient; and 39
(b) The specific medical or dental care included within the 40
request is not affirmatively excluded under the terms and 41
conditions of Medicaid or the Children’s Health Insurance 42
Program, as applicable. 43
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5. As used in this section, “health carrier” has the meaning 1
ascribed to it in NRS 695G.024 and includes, without limitation, 2
an organization for dental care. 3
Sec. 31. 1. The Department, with respect to Medicaid and 4
the Children’s Health Insurance Program, shall not require prior 5
authorization for covered emergency services, including, without 6
limitation, where applicable, transportation by ambulance to a 7
hospital or other medical facility. 8
2. If the Department requires a recipient or his or her 9
provider of health care to notify the Department that the recipient 10
has been admitted to a hospital to receive emergency services or 11
has received emergency services, the Department shall not require 12
a recipient or a provider of health care to transmit such a notice 13
earlier than the end of the business day immediately following the 14
day after the date on which the recipient was admitted or the 15
emergency services were provided, as applicable. 16
3. The Department shall not deny coverage for emergency 17
services covered by Medicaid or the Children’s Health Insurance 18
Program that are medically necessary. Emergency services are 19
presumed to be medically necessary if, within 72 hours after a 20
recipient is admitted to receive emergency services, the recipient’s 21
provider of health care transmits to the Department a certification, 22
in writing, that the condition of the recipient required emergency 23
services. The Department may rebut that presumption by 24
establishing, by clear and convincing evidence, that the emergency 25
services were not medically necessary. 26
4. For emergency services which require immediate post 27
evaluation or post stabilization services, the Department shall 28
approve or make an adverse determination on any request for 29
prior authorization for the post evaluation or post stabilization 30
services submitted by or on behalf of the insured within 1 hour of 31
the time the Department receives the request. 32
5. As used in this section, “emergency services” has the 33
meaning ascribed to it in section 12 of this act. 34
Sec. 32. 1. If the Department violates sections 27 to 31, 35
inclusive, of this act with respect to a particular request for prior 36
authorization, the request shall be deemed approved. 37
2. Nothing in sections 27 to 31, inclusive, of this act shall be 38
construed to require the Department to provide coverage: 39
(a) For medical or dental care that, regardless of whether such 40
care is medically necessary, would not be a covered benefit under 41
the terms and conditions of Medicaid or the Children’s Health 42
Insurance Program, as applicable; or 43
(b) To a person who is not a recipient or is not otherwise 44
eligible to receive coverage under Medicaid or the Children’s 45
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Health Insurance Program, as applicable, on the date on which 1
medical or dental care is provided to the person. 2
Sec. 33. 1. On or before March 1 of each calendar year, the 3
Department shall publish on an Internet website maintained by 4
the Department in an easily accessible format the following 5
information for the immediately preceding calendar year, in 6
aggregated form for all requests for prior authorization received 7
by the insurer during the immediately preceding year and 8
disaggregated in accordance with subsection 2: 9
(a) The percentage of requests for prior authorization for 10
medical or dental care that were approved upon initial review; 11
(b) The percentage of requests for prior authorization for 12
medical or dental care that resulted in an adverse determination 13
upon initial review; 14
(c) The percentage of the adverse determinations described in 15
paragraph (b) that were appealed; 16
(d) The percentage of appeals of adverse determinations 17
described in paragraph (c) that resulted in a reversal of the 18
adverse determination; 19
(e) The five most common reasons for the adverse 20
determinations described in paragraph (b); and 21
(f) The average time between a request for prior authorization 22
for medical or dental care in this State and the resolution of the 23
request. 24
2. The information described in subsection 1 must be 25
disaggregated for the following categories: 26
(a) The specialty of the provider of health care who submitted 27
a request for prior authorization; and 28
(b) The types of health or dental care at issue in the request for 29
prior authorization, including, without limitation, the specific 30
types of prescription drugs, procedures or diagnostic tests involved 31
in the requests. 32
3. The Department shall not include individually identifiable 33
health information in the information published pursuant to 34
subsection 1. 35
4. As used in this section, “individually identifiable health 36
information” means information relating to the provision of 37
health care to an insured: 38
(a) That specifically identifies the insured; or 39
(b) For which there is a reasonable basis to believe that the 40
information can be used to identify the insured. 41
Sec. 34. NRS 422.403 is hereby amended to read as follows: 42
422.403 1. The Department shall, by regulation, establish and 43
manage the use by the Medicaid program of step therapy and prior 44
authorization for prescription drugs. 45
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2. The Drug Use Review Board shall: 1
(a) Advise the Department concerning the use by the Medicaid 2
program of step therapy and prior authorization for prescription 3
drugs; 4
(b) Develop step therapy protocols and prior authorization 5
policies and procedures that comply with the provisions of sections 6
22 to 33, inclusive, of this act for use by the Medicaid program for 7
prescription drugs; and 8
(c) Review and approve, based on clinical evidence and best 9
clinical practice guidelines and without consideration of the cost of 10
the prescription drugs being considered, step therapy protocols used 11
by the Medicaid program for prescription drugs. 12
3. The step therapy protocol established pursuant to this section 13
must not apply to a drug approved by the Food and Drug 14
Administration that is prescribed to treat a psychiatric condition of a 15
recipient of Medicaid, if: 16
(a) The drug has been approved by the Food and Drug 17
Administration with indications for the psychiatric condition of the 18
insured or the use of the drug to treat that psychiatric condition is 19
otherwise supported by medical or scientific evidence; 20
(b) The drug is prescribed by: 21
(1) A psychiatrist; 22
(2) A physician assistant under the supervision of a 23
psychiatrist; 24
(3) An advanced practice registered nurse who has the 25
psychiatric training and experience prescribed by the State Board of 26
Nursing pursuant to NRS 632.120; or 27
(4) A primary care provider that is providing care to an 28
insured in consultation with a practitioner listed in subparagraph (1), 29
(2) or (3), if the closest practitioner listed in subparagraph (1), (2) or 30
(3) who participates in Medicaid is located 60 miles or more from 31
the residence of the recipient; and 32
(c) The practitioner listed in paragraph (b) who prescribed the 33
drug knows, based on the medical history of the recipient, or 34
reasonably expects each alternative drug that is required to be used 35
earlier in the step therapy protocol to be ineffective at treating the 36
psychiatric condition. 37
4. The Department shall not require the Drug Use Review 38
Board to develop, review or approve prior authorization policies or 39
procedures necessary for the operation of the list of preferred 40
prescription drugs developed pursuant to NRS 422.4025. 41
5. The Department shall accept recommendations from the 42
Drug Use Review Board as the basis for developing or revising step 43
therapy protocols and prior authorization policies and procedures 44
used by the Medicaid program for prescription drugs. 45
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6. As used in this section: 1
(a) “Medical or scientific evidence” has the meaning ascribed to 2
it in NRS 695G.053. 3
(b) “Step therapy protocol” means a procedure that requires a 4
recipient of Medicaid to use a prescription drug or sequence of 5
prescription drugs other than a drug that a practitioner recommends 6
for treatment of a psychiatric condition of the recipient before 7
Medicaid provides coverage for the recommended drug. 8
Sec. 35. NRS 608.1555 is hereby amended to read as follows: 9
608.1555 Any employer who provides benefits for health care 10
to his or her employees shall provide the same benefits and pay 11
providers of health care in the same manner as a policy of insurance 12
pursuant to chapters 689A and 689B of NRS, including, without 13
limitation, as required by paragraphs (b) and (c) of subsection 2 of 14
NRS 687B.225, subsections 1, 3, 5, 6 and 7 of NRS 687B.225, 15
NRS 687B.409, 687B.723 and 687B.725 [.] and sections 2 to 14, 16
inclusive, of this act. 17
Sec. 36. 1. The amendatory provisions of this act do not 18
apply to a request for prior authorization submitted: 19
(a) Under a contract or policy of health insurance issued before 20
October 1, 2025, but apply to any request for prior authorization 21
submitted under any renewal of such a contract or policy. 22
(b) To the Department of Health and Human Services before 23
October 1, 2025, for medical or dental care provided to a recipient 24
of Medicaid. 25
2. A health carrier must, in order to continue requiring prior 26
authorization in contracts or policies of health insurance issued or 27
renewed after October 1, 2025: 28
(a) Develop a procedure for obtaining prior authorization that 29
complies with NRS 687B.225, as amended by section 15 of this act, 30
and sections 2 to 14, inclusive, of this act; and 31
(b) Obtain the approval of the Commissioner of Insurance 32
pursuant to NRS 687B.225, as amended by section 15 of this act, for 33
the procedure developed pursuant to paragraph (a). 34
3. As used in this section, “health carrier” has the meaning 35
ascribed to it in section 4 of this act. 36
Sec. 37. 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. 38. 1. This section and section 36 of this act become 40
effective upon passage and approval. 41
2. Sections 1 to 35, inclusive, and 37 of this act become 42
effective: 43
(a) Upon passage and approval for the purpose of adopting any 44
regulations and performing any other preparatory administrative 45
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tasks 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 15 of this act, and section 36 3
of this act; and 4
(b) On October 1, 2025, for all other purposes. 5
H