AB470 - Revises provisions relating to prior authorization for medical or dental care under health insurance plans. (BDR 57-883)

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 – 2 – - *AB470* 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 – 3 – - *AB470* 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 – 4 – - *AB470* 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 – 5 – - *AB470* (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 – 6 – - *AB470* health ca [Text truncated for display. Full text available on LegiScan.]