Nev. Admin. Code § 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.
Notes
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