Nev. Admin. Code § 689B.120

Current through October 11, 2024

Section 689B.120 - Contents of policy: General requirements

A policy of group health insurance issued pursuant to NRS 689B.061:

1. Must include a definition for preferred providers of health care and providers of health care who are not preferred.

2. Must include an explanation of the amount of disincentives to be paid for using the services of providers of health care who are not preferred.

3. Must include in the schedule of benefits the amounts for deductibles and coinsurance payable for preferred providers of health care and providers of health care who are not preferred.

4. Must include a description of the type of plan used for preferred providers of health care and whether it is limited to specific services only, such as services obtained from a physician or hospital or for prescription drugs.

5. Must provide that the services covered, if provided by preferred providers of health care, are the same for providers of health care who are not preferred.

6. Must include a statement that the insured should verify whether a provider of health care is a preferred provider of health care.

7. Must provide that, if the insured is confined in a facility which is a preferred provider of health care at a time when the facility terminates its agreement with the insurer, coverage will be provided for the period of confinement at the rate negotiated for that facility before it terminated its agreement and at no additional cost to the insured.

8. Must provide that, if the insured obtains prior authorization for health care services to be rendered by a preferred provider of health care and the provider subsequently terminates his agreement with the insurer, coverage will be provided for those services at the rate negotiated for that provider before he terminated his agreement and at no additional cost to the insured.

9. May not require that the payments to a provider of health care who is not preferred be based upon the fee schedule or arrangements for preferred providers of health care.

10. May not provide for more than a 50 percent difference or reduction in any payment of otherwise eligible expenses for not complying with any procedures requiring the prior authorization of care or notification that treatment was received for an emergency.

Nev. Admin. Code § 689B.120

Added to NAC by Comm'r of Insurance, 7-19-90, eff. 10-1-90