STATUTES AND REGULATIONS

The full text of Nevada Revised Statutes (NRS) and Nevada Administrative Code (NAC) can be found at:  http://www.leg.state.nv.us/

The full text of federal statutes (laws), also known as the U.S. Code (U.S.C. or U.S.C.A.), or federal rules, also known as the Code of Federal Regulations (C.F.R.), may be found through many internet cites, one of which is:  http://www.law.cornell.edu/

The full text of any cases cited in this chapter may be found through the county legal library or through the UNLV legal library.

               FEDERAL STATUTES  referenced

42 U.S.C. 1395  Prohibition against any Federal interference

Nothing in this subchapter shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided, or over the selection, tenure, or compensation of any officer or employee of any institution, agency, or person providing health services; or to exercise any supervision or control over the administration or operation of any such institution, agency, or person.

1395mm. Payments to health maintenance organizations and competitive medical plans

(c) Enrollment in plan; duties of organization to enrollees

(5) (A) The organization must provide meaningful procedures for hearing and resolving grievances between the organization (including any entity or individual through which the organization provides health care services) and members enrolled with the organization under this section.

(e) Limitation on charges; election of coverage; ''adjusted community rate'' defined; workmen's compensation and insurance benefits

              (1) In no case may ‑

                    (A) the portion of an eligible organization's premium rate and the actuarial value of its deductibles, coinsurance, and copayments charged (with respect to services covered under parts A and B of this subchapter) to individuals who are enrolled under this section with the organization and who are entitled to                benefits under part A of this subchapter and enrolled under part B of this subchapter, or

             (B) the portion of its premium rate and the actuarial value of its deductibles, coinsurance, and copayments charged (with respect to services covered under part B of this subchapter) to individuals who are enrolled under this section with the organization and enrolled under part B of this subchapter only exceed the actuarial value of the coinsurance and deductibles that would be applicable on the average to individuals enrolled under this section with the organization (or, if the Secretary finds that adequate data are not available to determine that actuarial value, the actuarial value of the coinsurance and deductibles applicable on the average to individuals in the area, in the State, or in the United States, eligible to enroll under this section with  the organization, or other appropriate data) and entitled to benefits under part A of this subchapter and enrolled under part B of

                    this subchapter, or enrolled under part B only, respectively, if they were not members of an eligible organization.

              (2) If the eligible organization provides to its members enrolled under this section services in addition to services covered under parts A and B of this subchapter, election of coverage for such additional services (unless such services have been approved by the Secretary under subsection (c)(2) of this section) shall be optional for such members and such organization shall furnish such members with information on the portion of its premium rate or other charges applicable to such additional services. In no case may the sum of ‑ 

                   (A) the portion of such organization's premium rate charged,   with respect to such additional services, to              members enrolled under this section, and

                    (B) the actuarial value of its deductibles, coinsurance, and

                    copayments charged, with respect to such services to such members exceed the adjusted community rate for such services.

              (3) For purposes of this section, the term ''adjusted community rate'' for a service or services means, at the election of an eligible organization, either ‑

                                                                  (A) the rate of payment for that service or services which the Secretary annually determines would apply to a member enrolled under this section with an eligible organization if the rate of  payment were determined under a ''community rating system'' (as defined in section 300e‑1(8) of this title, other than subparagraph (C)), or

   (B) such portion of the weighted aggregate premium, which the Secretary annually estimates would apply to a      member enrolled  under this section with the eligible organization, as the Secretary annually estimates is            attributable to that service or  services, but adjusted for differences between the utilization characteristics of the members enrolled with the eligible organization  under this section and the utilization characteristics of the other members of the organization (or, if the Secretary finds that adequate data are not available to adjust for those differences, the differences between the utilization characteristics of members in other eligible organizations, or individuals in the area, in the State, or in the United States, eligible to enroll under this section with an eligible organization and the utilization characteristics of the rest of the population in the area, in the State, or in the United States, respectively).

              (4) Notwithstanding any other provision of law, the eligible organization may (in the case of the provision of services to a member enrolled under this section for an illness or injury for which the member is entitled to benefits under a workmen's compensation law or  plan of the United States or a State, under an automobile or liability insurance policy or plan, including a self‑insured plan, or under no fault insurance) charge or authorize the provider of such services to charge, in accordance with the charges allowed under such law or  policy ‑

                    (A) the insurance carrier, employer, or other entity which under such law, plan, or policy is to pay for the             provision of  such services, or

                    (B) such member to the extent that the member has been paid under such law, plan, or policy for such                  services.

              CODE OF FEDERAL REGULATIONS  referenced

42 CFR 417.604  General provisions.

    (a) Responsibilities of the HMO or CMP. (1) The HMO or CMP must establish and maintain‑‑

    (i) Appeals procedures that meet the requirements of this subpart for issues that involve organization determinations; and

    (ii) Grievance procedures for dealing with issues that do not involve organization determinations.

(2) The HMO or CMP must ensure that all enrollees receive written information about the grievance and appeals procedures that are available to them.

    (b) Limits on applicability of this subpart. (1) If an enrollee requests immediate PRO review (as provided in Sec. 417.605) of a determination of noncoverage of inpatient hospital care‑‑

    (i) The enrollee is not entitled to subsequent review of that issue under this subpart; and

    (ii) The PRO review decision is subject to the appeals procedures set forth in part 473 of this chapter.

(2) Any determination regarding services that were furnished by the HMO or CMP, either directly or under arrangement, for which the enrollee has no further liability for payment are not subject to appeal.

(3) Services included in an optional supplemental plan under (Sec. 417.440(b)(2)) are subject only to a grievance procedure.

(4) Physicians and other individuals who furnish services under arrangement with an HMO or CMP have no right of appeal under this subpart, except as provided in Secs. 417.609(c)(4) and 417.617(c)(4), which allow physicians and other health professionals to act on behalf of an enrollee in time‑sensitive situations when an organization determination or reconsideration is being requested.

    (c) Applicability of other regulations. Unless otherwise provided in this subpart, regulations at 20 CFR, part 404, subparts J and R,

(pertaining respectively to conduct of hearings and representation of parties under title II of the Act) are applicable under this subpart.

[60 FR 46233, Sept. 6, 1995, as amended at 62 FR 23374, Apr. 30, 1997]

42 CFR 417.605  Immediate PRO review of a determination of noncoverage of inpatient hospital care.

    (a) Right to review. A Medicare enrollee who disagrees with a determination made by an HMO, CMP, or a hospital that inpatient care is

no longer necessary may remain in the hospital and may (directly or through his or her authorized representative) request immediate PRO review of the determination.

    (b) Procedures. For the immediate PRO review process, the following rules apply:

(1) The enrollee or authorized representative must submit the request for immediate review‑‑

(i) To the PRO that has an agreement with the hospital under Sec. 466.78 of this chapter;

(ii) In writing or by telephone; and

(iii) By noon of the first working day after receipt of the written notice of the determination that the hospital stay is no longer necessary.

(2) On the date it receives the enrollee's request, the PRO must notify the HMO or CMP that a request for immediate review has been

filed.

(3) The HMO or CMP must supply any information that the PRO requires to conduct its review and must make it available, by phone or in writing, by the close of business of the first full working day immediately following the day the enrollee submits the request for

review.

    (4) In response to a request from the HMO or CMP, the hospital must submit medical records and other pertinent information to the PRO by

close of business of the first full working day immediately following the day the HMO or CMP makes its request.

    (5) The PRO must solicit the views of the enrollee who requested the immediate PRO review (or the enrollee's representative).

    (6) The PRO must make a determination and notify the enrollee, the hospital, and the HMO or CMP by close of business of the first working

day after it receives the information from the hospital, or the HMO or CMP, or both.

    (c) Financial responsibility. (1) General rule. Except as provided in paragraph (c)(2) of this section, the HMO or CMP continues to be

financially responsible for the costs of the hospital stay until noon of the calendar day following the day the PRO notifies the enrollee of its review determination.

    (2) Exception. The hospital may not charge the HMO or CMP (or the enrollee) if‑‑

    (i) It was the hospital (acting on behalf of the enrollee) that filed the request for immediate PRO review; and

    (ii) The PRO upholds the noncoverage determination made by the HMO or CMP.

[59 FR 59941, Nov. 21, 1994]

42 CFR 417.608  Notice of adverse organization determination.

    (a) If an HMO or CMP makes an organization determination that is partially or fully adverse to the enrollee, it must notify the enrollee

of the determination‑‑

    (1) Within 60 days of receiving the enrollee's request for payment for services; or

    (2) As specified in Sec. 417.609(c)(3) for expedited organization determinations.

    (b) The notice must‑‑

(1) State the specific reasons for the determination; and

(2) Inform the enrollee of his or her right to a reconsideration, including the right to and conditions for obtaining an expedited

reconsidered determination.

    (c) The failure to provide the enrollee with timely notification of an adverse organization determination as specified in paragraph (a) of

this section or in Sec. 417.609(b) (concerning time frames for expediting certain organization determinations) constitutes an adverse

organization determination and may be appealed.

[50 FR 1346, Jan. 10, 1985, as amended at 59 FR 59942, Nov. 21, 1994; 62 FR 23375, Apr. 30, 1997]

42 CFR 417.609  Expediting certain organization determinations.

    (a) An enrollee, or an authorized representative of the enrollee, may request that an organization determination as defined in

Secs. 417.606(a)(3) and (a)(4) be expedited. The request may be made orally to the HMO or CMP.

    (b) The HMO or CMP must maintain procedures for expediting organization determinations when, upon request from an enrollee or

authorized representative of the enrollee, the organization decides that making the determination according to the procedures and time frames set forth in Sec. 417.608(a)(1) could seriously jeopardize the life or health of the enrollee or the enrollee's ability to regain maximum function.

    (c) The procedures must include the following:

(1) Receipt of oral requests, followed by written documentation of the oral requests.

(2) Prompt decision‑making regarding whether the request will be expedited, or handled within the standard time frame set forth at

Sec. 417.608(a)(1), including notification of the enrollee if the request is not expedited.

(3) Notification of the enrollee, and the physician as appropriate, as expeditiously as the enrollee's health condition requires, but within 72 hours of the request. An extension of up to 10 working days is permitted if requested by the enrollee or if the HMO or CMP finds that additional information is necessary and the delay is in the interest of the enrollee.

(i) Notification must comply with Sec. 417.608(b), concerning the content of a notice of adverse organization determination.

(ii) If the initial notification is not in writing, written confirmation must be mailed to the enrollee within 2 working days.

(iii) In cases for which the HMO or CMP must receive medical information from a physician or provider not affiliated with the HMO or CMP, the time standard begins with receipt of the information.

    (4) Granting the request of a physician, regardless of whether the physician is affiliated with the organization or not, to expedite the

enrollee's request.

[62 FR 23375, Apr. 30, 1997]

42 CFR  417.614  Right to reconsideration.

    Any party who is dissatisfied with an organization determination or with one that has been reopened and revised may request reconsideration

of the determination in accordance with the procedures of Sec. 417.616, concerning a request for reconsideration, or Sec. 417.617, concerning

certain expedited reconsiderations.

[62 FR 23375, Apr. 30, 1997]

42 CFR 417.620  Responsibility for reconsiderations; time limits.

(a) If the HMO or CMP can make a reconsidered determination that is completely favorable to the enrollee, the HMO or CMP issues the reconsidered determination.

(b) If the HMO or CMO recommends partial or complete affirmation of its adverse determination, the HMO or CMP must prepare a written explanation and send the entire case to HFCA. HCFA makes the reconsidered datermination.

(c) The HMO or CMP must issue the reconsidered determination to the enrollee, or submit the explanation and file to HCFA within 60 calendar days from the date of receipt of the request for reconsideration. In the case of an expedited reconsideration, the HMO or CMP must issue the reconsidered determination as specified in Sec. 417.617(c)(3) or submit the explanation and file to HCFA within 24 hours of its determination, the expiration of the 72‑hour review period, or the expiration of the extension.

(d) For good cause shown, HCFA may allow extensions to the time limit set forth in paragraph (c) of this section.

(e) Failure by the HMO or CMP to provide the enrollee with a reconsidered determination within the time limits described in paragraph (c) of this section or to obtain a good cause extension described in paragraph (d) of this section constitutes an adverse determination, and the HMO or CMP must submit the file to HCFA.

(f) If the HMO or CMP refers the matter to HCFA, it must concurrently notify the beneficiary of that action.

[59 FR 59942, Nov. 21, 1994, as amended at 62 FR 23376, Apr. 30, 1997]

42 CFR 417.630  Right to a hearing.

    If the amount remaining in controversy is $100 or more, any party to the reconsideration who is dissatisfied with the reconsidered

determination has a right to a hearing. (The amount remaining in controversy, which can include any combination of Part A and Part B

services, is computed in accordance with Sec. 405.740 of this chapter for Part A services and Sec. 405.820(b) of this chapter for Part B

services. If the basis for the appeal is the refusal of services, the projected value of those services is used in computing the amount

remaining in controversy.)

[59 FR 59942, Nov. 21, 1994]

NEVADA REVISED STATUTES referenced

NRS 689A   INDIVIDUAL HEALTH INSURANCE

NRS 689A.042 Coverage relating to complications of pregnancy.

1. No health insurance policy may be delivered or issued for delivery in this state if it contains any exclusion, reduction or other limitation of coverage relating to complications of pregnancy, unless the provision applies generally to all benefits payable under the policy.

2. As used in this section, the term "complications of pregnancy" includes any condition which requires hospital confinement for medical treatment and:

(a) If the pregnancy is not terminated, is caused by an injury or sickness not directly related to the pregnancy or by acute nephritis, nephrosis, cardiac decompensation, missedabortion or similar medically diagnosed conditions; or

(b) If the pregnancy is terminated, results in nonelective cesarean section, ectopic pregnancy or spontaneous termination.

3. A policy subject to the provisions of this chapter which is delivered or issued for delivery on or after July 1, 1977, has the legal effect of including the coverage required by this section, and any provision of the policy which is in conflict with this section is void.

(Added to NRS by 1977, 415)

NRS 689A.0425 Individual health benefit plan that includes coverage for maternity care and pediatric care: Requirement to allow minimum stay in hospital in connection with childbirth; prohibited acts.

1. Except as otherwise provided in this subsection, an individual health benefit plan issued pursuant to this chapter that includes coverage for maternity care and pediatric care for newborn infants may not restrict benefits for any length of stay in a hospital in connection with childbirth for a mother or newborn infant covered by the plan to:

(a) Less than 48 hours after a normal vaginal delivery; and

(b) Less than 96 hours after a cesarean section.

If a different length of stay is provided in the guidelines established by the American College of Obstetricians and Gynecologists, or its successor organization, and the American Academy of Pediatrics, or its successor organization, the individual health benefit plan may follow such guidelines in lieu of following the length of stay set forth above. The provisions of this subsection do not apply to any individual health benefit plan in any case in which the decision to discharge the mother or newborn infant before the expiration of the minimum length of stay set forth in this subsection is made by the attending physician of the mother or newborn infant.

2. Nothing in this section requires a mother to:

(a) Deliver her baby in a hospital; or

(b) Stay in a hospital for a fixed period following the birth of her child.

3. An individual health benefit plan that offers coverage for maternity care and pediatric care of newborn infants may not:

(a) Deny a mother or her newborn infant coverage or continued coverage under the terms of the plan or coverage if the sole purpose of the denial of coverage or continued coverage is to avoid the requirements of this section;

(b) Provide monetary payments or rebates to a mother to encourage her to accept less than the minimum protection available pursuant to this section;

(c) Penalize, or otherwise reduce or limit, the reimbursement of an attending provider of health care because he provided care to a mother or newborn infant in accordance with the provisions of this section;

(d) Provide incentives of any kind to an attending physician to induce him to provide care to a mother or newborn infant in a manner that is inconsistent with the provisions of this section; or

(e) Except as otherwise provided in subsection 4, restrict benefits for any portion of a hospital stay required pursuant to the provisions of this section in a manner that is less favorable than the benefits provided for any preceding portion of that stay.

4. Nothing in this section:

(a) Prohibits an individual health benefit plan from imposing a deductible, coinsurance or other mechanism for sharing costs relating to benefits for hospital stays in connection with childbirth for a mother or newborn child covered by the plan, except that such coinsurance or other mechanism for sharing costs for any portion of a hospital stay required by this section may not be greater than the coinsurance or other mechanism for any preceding portion of that stay.

(b) Prohibits an arrangement for payment between an individual health benefit plan and a provider of health care that uses capitation or other financial incentives, if the arrangement is designed to provide services efficiently and consistently in the best interest of the mother and her newborn infant.

(c) Prevents an individual health benefit plan from negotiating with a provider of health care concerning the level and type of reimbursement to be provided in accordance with this section.

(Added to NRS by 1997, 2898)

NRS 695G   MANAGED CARE

NRS 695G.040 "Managed care" defined.

"Managed care" means a system for delivering health care services that encourages the efficient use of health care services by using employed or independently contracted providers of health care and by using various techniques which may include, without limitation:

1. Managing the health care services of an insured who has a serious, complicated, protracted or other health‑related condition that requires the use of numerous providers of health care or other costly services;

2. Providing utilization review;

3. Offering financial incentives for the effective use of health care services; or

4. Any combination of those techniques.

(Added to NRS by 1997, 301)

NRS 695G.050 "Managed care organization" defined. "Managed care organization" means any insurer or organization authorized pursuant to this Title to conduct business in this state that provides or arranges for the provision of health care services through managed care.

(Added to NRS by 1997, 302)

NRS 695G.070 "Provider of health care" defined.

"Provider of health care" means any physician, hospital or other person who is licensed or otherwise authorized in this state to furnish any health care service.

(Added to NRS by 1997, 302)

NRS 695G.080 "Utilization review" defined.

"Utilization review" means the various methods that may be used by a managed care organization to review the amount and appropriateness of the provision of a specific health care service to an insured.

(Added to NRS by 1997, 302)

NRS 695G.160 Written criteria concerning coverage of health care services and standards for quality of health care services.

1. Each managed care organization shall establish written criteria:

(a) Setting forth the manner in which it determines whether to authorize coverage of a health care service; and

(b) Setting forth its method for reviewing standards for the quality of health care services provided to an insured.

2. Such written criteria must be:

(a) Developed with the assistance of practicing providers of health care;

(b) Developed using generally recognized and, if appropriate, specialized clinical principles and processes;

(c) Reviewed at least one time each year and, if appropriate, updated; and

(d) Made available to an insured for review upon request of the insured any time that the managed care organization denies coverage of a specific health care service to the insured.

(Added to NRS by 1997, 302)

NRS 695G.250 Certain actions taken against provider solely because provider advocates on behalf of patient, assists patient or reports violation of law prohibited.

A managed care organization shall not terminate a contract with, demote, refuse to contract with or refuse to compensate a provider of health care solely because the provider, in good faith:

1. Advocates in private or in public on behalf of a patient;

2. Assists a patient in seeking reconsideration of a decision by the managed care organization to deny coverage for a health care service; or

3. Reports a violation of law to an appropriate authority.

(Added to NRS by 1997, 304)