SB398 - Revises provisions relating to health insurance. (BDR 57-731)

S.B. 398 - *SB398* SENATE BILL NO. 398–SENATOR ROGICH MARCH 17, 2025 ____________ Referred to Committee on Commerce and Labor SUMMARY—Revises provisions relating to health insurance. (BDR 57-731) FISCAL NOTE: Effect on Local Government: May have Fiscal Impact. Effect on the State: Yes. CONTAINS UNFUNDED MANDATE (§ 45) (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; revising provisions relating to prior authorization for certain medical and dental care; revising provisions relating to the coverage of autism spectrum disorders for certain persons; prohibiting health insurers from considering the availability of certain public benefits for certain purposes; 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 medical 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 medical and dental care by health insurers, including Medicaid, the Children’s 8 Health Insurance Program and insurance for public employees. 9 Specifically, sections 25 and 56 of this bill require that a procedure for 10 obtaining prior authorization includes: (1) a list of the specific goods and services 11 for which the insurer requires prior authorization; and (2) the clinical review 12 criteria used by the insurer to evaluate requests for prior authorization. Sections 25 13 and 56 also require an insurer to publish its procedure for obtaining prior 14 authorization on its Internet website and update that website as necessary to 15 account for any changes in the procedure. Sections 25 and 56 prohibit an insurer 16 from denying a claim for payment for medical or dental care because of the failure 17 to obtain prior authorization if the insurer’s procedures for obtaining prior 18 – 2 – - *SB398* authorization in effect on the date on which the care was provided did not require 19 prior authorization for that care. 20 Sections 25 and 57 of this bill require a determination concerning a request for 21 prior authorization to include a determination of whether the purported insured is 22 currently insured by the insurer and eligible for coverage. Sections 25 and 57 also 23 revise the period for insurers to take action on a request for prior authorization by 24 requiring an insurer to approve or make an adverse determination on such a request, 25 or request additional, medically relevant information within: (1) 48 hours after 26 receiving the request, for medical or dental care that is not urgent; or (2) 24 hours 27 after receiving the request, for care that is urgent. Sections 13 and 58 of this bill 28 require any adverse determination on a request for prior authorization to be made 29 by a licensed physician or, for a request relating to dental care, a dentist, who has 30 certain qualifications. Sections 13 and 58 require an insurer, in certain 31 circumstances, to allow the provider of health care who requested the prior 32 authorization to discuss the issues involved in the request with the physician or 33 dentist who is responsible for making a determination on the request. Sections 13 34 and 58 require an insurer, upon making an adverse determination on a request for 35 prior authorization, to transmit certain information to the insured to whom the 36 request pertains, including information relating to the right of the insured to appeal 37 the adverse determination. Sections 13 and 58 further require: (1) an insurer to 38 establish a process for appeals that provides for the timely resolution of appeals 39 submitted by insureds; and (2) a decision upholding an adverse determination on an 40 appeal submitted by an insured to be made by a physician or dentist who has 41 qualifications beyond those required of a physician or dentist who evaluates initial 42 requests for prior authorization. 43 Sections 14 and 59 of this bill: (1) require an insurer to continue to honor the 44 approval of a request for prior authorization despite certain changes to coverage or 45 the criteria for approving such requests; (2) prohibit an insurer from requiring an 46 insured with a chronic or long-term condition who has received prior authorization 47 for care for the condition to seek additional prior authorization for that same care in 48 certain circumstances; and (3) require an insurer, for the first 90 days after the 49 coverage period begins for a new insured, to honor a request for prior authorization 50 that has been approved by the previous insurer of the new insured, under certain 51 circumstances. Sections 15 and 60 of this bill establish certain limited 52 circumstances under which an insurer may revoke, limit, condition or restrict an 53 approval of a request for prior authorization previously granted by the insurer. 54 Sections 16 and 61 of this bill prohibit an insurer from refusing to pay a claim or 55 reducing the amount paid to a provider of health care for a claim for medical or 56 dental care that was previously approved by the insurer, with certain exceptions. 57 Sections 17 and 63 of this bill prohibit an insurer from requiring prior 58 authorization for covered emergency services. Sections 17 and 63 prohibit an 59 insurer from requiring that an insured or provider of health care notify the insurer 60 earlier than the end of the business day following the date of admission or the date 61 on which the emergency services are provided. Sections 17 and 63: (1) prohibit an 62 insurer from denying coverage for covered medically necessary emergency 63 services; and (2) establish a presumption of medical necessity under certain 64 conditions. Sections 17 and 63 also require an insurer to respond to a request for 65 prior authorization for certain follow-up care relating to the emergency care 66 received by an insured within 60 minutes after receiving the request. 67 Sections 18 and 62 of this bill prohibit an insurer from requiring prior 68 authorization for: (1) certain invasive procedures that are incidental to or different 69 from a procedure for which the insurer has already granted prior authorization or 70 does not require prior authorization; and (2) prescription drugs for pain relief 71 prescribed to an insured that has been diagnosed with a terminal condition. 72 Sections 18 and 62 require an insured to treat appeals and requests for prior 73 – 3 – - *SB398* authorization for care relating to mental, emotional, behavioral or substance use 74 disorders or conditions equally to appeals and requests for prior authorization for 75 other types of care. 76 Sections 22 and 69 of this bill require insurers to receive and respond to 77 requests for prior authorization for prescription drugs through a secure transmission 78 that complies with a standard established by the National Council for Prescription 79 Drug Programs for the electronic transmission of pharmaceutical records. Section 80 69 additionally prohibits Medicaid from requiring prior authorization for certain 81 prescription drugs for medication-assisted treatment for opioid use disorder in 82 conformance with similar requirements in existing law governing private insurers. 83 (NRS 689A.0459, 689B.0319, 689C.1665, 695A.1874, 695B.19197, 695C.1699, 84 695G.1719) 85 Sections 19 and 64 of this bill require insurers to exempt a provider of health 86 care from the requirement to obtain prior authorization for specific goods or 87 services if the insurer has granted requests for prior authorization for those goods or 88 services submitted by the provider at a rate of 80 percent or more during the 89 previous year. Sections 19 and 64 require insurers to annually conduct reviews of 90 each provider of health care in the network of the insurer or who participates in 91 Medicaid, as applicable, to determine whether each such provider qualifies for an 92 exemption. If a provider of health care qualifies for an exemption, sections 19 and 93 64 require an insurer to automatically grant the exemption for the applicable goods 94 or services without requiring the provider of health care to affirmatively request an 95 exemption. Sections 20 and 65 of this bill prescribe the requirements and 96 procedure for an insurer to revoke an exemption granted to a provider of health 97 care. Sections 20 and 65 also require an insurer to establish a procedure by which a 98 provider of health care may appeal such a revocation. 99 Sections 3-12 and 50-55 of this bill define certain terms relating to the process 100 of obtaining and processing requests for prior authorization, and sections 2 and 49 101 of this bill establish the applicability of those definitions. Sections 21 and 66 of 102 this bill provide that if an insurer violates any provision of section 13-18, 25 or 56- 103 63 with respect to a particular request for prior authorization, that the request is 104 deemed approved. Sections 21 and 66 also provide that a provision of any contract 105 or agreement that conflicts with the provisions of section 13-21, 25 or 56-66 is 106 void and unenforceable. 107 Sections 23 and 67 of this bill require an insurer to annually publish on its 108 Internet website certain information relating to requests for prior authorization that 109 have been processed by the insurer during the immediately preceding year. 110 Sections 24 and 68 of this bill additionally require an insurer to compile and 111 publish an annual report of certain information relating to requests for prior 112 authorization processed by the insurer during the immediately preceding year. 113 Section 36 of this bill requires a nonprofit hospital and medical or dental 114 service corporation to comply with sections 2-25. Section 44 of this bill requires 115 the Director of the Department of Health and Human Services to administer the 116 provisions of sections 48-68 of this bill in the same manner as other provisions 117 governing Medicaid. Sections 45, 46 and 70 of this bill require plans of self- 118 insurance for employees of local governments, the Public Employees’ Benefits 119 Program and plans of self-insurance for private employers, respectively, to comply 120 with the requirements of sections 2-25 to the extent applicable. Section 48 provides 121 that a managed care organization that provides services to recipients of Medicaid or 122 the Children’s Health Insurance Program is not subject to sections 49-68, but must 123 comply with sections 2-25. Section 69 requires the policies and procedures for 124 coverage for prescription drugs under Medicaid to comply with sections 49-68. 125 Existing law prohibits certain insurers from considering the availability of, or 126 eligibility of an insured for medical assistance under Medicaid when making 127 payments for claims under a policy of health insurance, or determining the 128 – 4 – - *SB398* insured’s eligibility for coverage under the policy. (NRS 689A.430, 689B.300, 129 695A.151, 695B.340, 695C.163, 695F.440) Sections 30, 32 and 41 of this bill also 130 impose this prohibition on health carriers for small employers and managed care 131 organizations. Sections 27, 29, 30, 32, 34, 37, 38, 40 and 41 of this bill additionally 132 prohibit all private health insurers regulated under state law from considering the 133 availability of, or eligibility of an insured for any other governmental program, 134 including Medicare and benefits under Social Security, for these purposes. 135 Existing law requires certain private health insurance plans to provide coverage 136 for screening for, diagnosing and treating autism spectrum disorders to insureds 137 who are less than 18 years of age, or until the insured reaches 22 years of age, if the 138 insured is enrolled in high school. Existing law subjects this coverage to a 139 maximum benefit of $72,000 per year for applied behavior analysis treatment. 140 Existing law also requires the course of treatment for autism spectrum disorders to 141 be identified in a treatment plan. (NRS 689A.0435, 689B.0335, 689C.1655, 142 695C.1717, 695G.1645) Sections 33 and 35 of this bill additionally impose this 143 requirement on fraternal benefit societies and nonprofit hospital or medical services 144 corporations. Sections 26, 28, 31, 33, 35, 39 and 43 of this bill require private 145 health insurance plans to provide coverage for screening for, diagnosing and 146 treating autism spectrum disorders to an insured until he or she reaches 27 years of 147 age. Sections 26, 28, 31, 33, 35, 39 and 43 also: (1) remove the maximum benefit 148 for coverage of applied behavior analysis treatment; (2) eliminate the requirement 149 that the course of treatment be identified in a treatment plan; and (3) eliminate 150 certain other authorized restrictions and limitations on coverage of screening for, 151 diagnosing and treating autism spectrum disorders. 152 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 24, inclusive, of this 2 act. 3 Sec. 2. As used in NRS 687B.225 and sections 2 to 24, 4 inclusive, of this act, unless the context otherwise requires, the 5 words and terms defined in sections 3 to 12, 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. “Coverage period” means the current term of a 16 contract or policy of insurance issued by a health carrier. 17 [Text truncated for display. Full text available on LegiScan.]