Existing law authorizes certain health insurers to require prior authorization before an insured may receive coverage for medical and dental care in certain circumstances. If an insurer requires prior authorization, existing law requires the insurer to: (1) file its procedure for obtaining prior authorization with the Commissioner of Insurance for approval; and (2) respond to a request for prior authorization within 20 days after receiving the request. (NRS 687B.225) This bill establishes additional requirements relating to the use of prior authorization for medical and dental care by health insurers, including Medicaid, the Children's Health Insurance Program and insurance for public employees. Specifically, sections 25 and 56 of this bill require that a procedure for obtaining prior authorization includes: (1) a list of the specific goods and services for which the insurer requires prior authorization; and (2) the clinical review criteria used by the insurer to evaluate requests for prior authorization. Sections 25 and 56 also require an insurer to publish its procedure for obtaining prior authorization on its Internet website and update that website as necessary to account for any changes in the procedure. Sections 25 and 56 prohibit an insurer from denying a claim for payment for medical or dental care because of the failure to obtain prior authorization if the insurer's procedures for obtaining prior authorization in effect on the date on which the care was provided did not require prior authorization for that care. Sections 25 and 57 of this bill require a determination concerning a request for prior authorization to include a determination of whether the purported insured is currently insured by the insurer and eligible for coverage. Sections 25 and 57 also revise the period for insurers to take action on a request for prior authorization by requiring an insurer to approve or make an adverse determination on such a request, or request additional, medically relevant information within: (1) 48 hours after receiving the request, for medical or dental care that is not urgent; or (2) 24 hours after receiving the request, for care that is urgent. Sections 13 and 58 of this bill require any adverse determination on a request for prior authorization to be made by a licensed physician or, for a request relating to dental care, a dentist, who has certain qualifications. Sections 13 and 58 require an insurer, in certain circumstances, to allow the provider of health care who requested the prior authorization to discuss the issues involved in the request with the physician or dentist who is responsible for making a determination on the request. Sections 13 and 58 require an insurer, upon making an adverse determination on a request for prior authorization, to transmit certain information to the insured to whom the request pertains, including information relating to the right of the insured to appeal the adverse determination. Sections 13 and 58 further require: (1) an insurer to establish a process for appeals that provides for the timely resolution of appeals submitted by insureds; and (2) a decision upholding an adverse determination on an appeal submitted by an insured to be made by a physician or dentist who has qualifications beyond those required of a physician or dentist who evaluates initial requests for prior authorization. Sections 14 and 59 of this bill: (1) require an insurer to continue to honor the approval of a request for prior authorization despite certain changes to coverage or the criteria for approving such requests; (2) prohibit an insurer from requiring an insured with a chronic or long-term condition who has received prior authorization for care for the condition to seek additional prior authorization for that same care in certain circumstances; and (3) require an insurer, for the first 90 days after the coverage period begins for a new insured, to honor a request for prior authorization that has been approved by the previous insurer of the new insured, under certain circumstances. Sections 15 and 60 of this bill establish certain limited circumstances under which an insurer may revoke, limit, condition or restrict an approval of a request for prior authorization previously granted by the insurer. Sections 16 and 61 of this bill prohibit an insurer from refusing to pay a claim or reducing the amount paid to a provider of health care for a claim for medical or dental care that was previously approved by the insurer, with certain exceptions. Sections 17 and 63 of this bill prohibit an insurer from requiring prior authorization for covered emergency services. Sections 17 and 63 prohibit an insurer from requiring that an insured or provider of health care notify the insurer earlier than the end of the business day following the date of admission or the date on which the emergency services are provided. Sections 17 and 63: (1) prohibit an insurer from denying coverage for covered medically necessary emergency services; and (2) establish a presumption of medical necessity under certain conditions. Sections 17 and 63 also require an insurer to respond to a request for prior authorization for certain follow-up care relating to the emergency care received by an insured within 60 minutes after receiving the request. Sections 18 and 62 of this bill prohibit an insurer from requiring prior authorization for: (1) certain invasive procedures that are incidental to or different from a procedure for which the insurer has already granted prior authorization or does not require prior authorization; and (2) prescription drugs for pain relief prescribed to an insured that has been diagnosed with a terminal condition. Sections 18 and 62 require an insured to treat appeals and requests for prior authorization for care relating to mental, emotional, behavioral or substance use disorders or conditions equally to appeals and requests for prior authorization for other types of care. Sections 22 and 69 of this bill require insurers to receive and respond to requests for prior authorization for prescription drugs through a secure transmission that complies with a standard established by the National Council for Prescription Drug Programs for the electronic transmission of pharmaceutical records. Section 69 additionally prohibits Medicaid from requiring prior authorization for certain prescription drugs for medication-assisted treatment for opioid use disorder in conformance with similar requirements in existing law governing private insurers. (NRS 689A.0459, 689B.0319, 689C.1665, 695A.1874, 695B.19197, 695C.1699, 695G.1719) Sections 19 and 64 of this bill require insurers to exempt a provider of health care from the requirement to obtain prior authorization for specific goods or services if the insurer has granted requests for prior authorization for those goods or services submitted by the provider at a rate of 80 percent or more during the previous year. Sections 19 and 64 require insurers to annually conduct reviews of each provider of health care in the network of the insurer or who participates in Medicaid, as applicable, to determine whether each such provider qualifies for an exemption. If a provider of health care qualifies for an exemption, sections 19 and 64 require an insurer to automatically grant the exemption for the applicable goods or services without requiring the provider of health care to affirmatively request an exemption. Sections 20 and 65 of this bill prescribe the requirements and procedure for an insurer to revoke an exemption granted to a provider of health care. Sections 20 and 65 also require an insurer to establish a procedure by which a provider of health care may appeal such a revocation. Sections 3-12 and 50-55 of this bill define certain terms relating to the process of obtaining and processing requests for prior authorization, and sections 2 and 49 of this bill establish the applicability of those definitions. Sections 21 and 66 of this bill provide that if an insurer violates any provision of section 13-18, 25 or 56-63 with respect to a particular request for prior authorization, that the request is deemed approved. Sections 21 and 66 also provide that a provision of any contract or agreement that conflicts with the provisions of section 13-21, 25 or 56-66 is void and unenforceable. Sections 23 and 67 of this bill require an insurer to annually publish on its Internet website certain information relating to requests for prior authorization that have been processed by the insurer during the immediately preceding year. Sections 24 and 68 of this bill additionally require an insurer to compile and publish an annual report of certain information relating to requests for prior authorization processed by the insurer during the immediately preceding year. Section 36 of this bill requires a nonprofit hospital and medical or dental service corporation to comply with sections 2-25. Section 44 of this bill requires the Director of the Department of Health and Human Services to administer the provisions of sections 48-68 of this bill in the same manner as other provisions governing Medicaid. Sections 45, 46 and 70 of this bill require plans of self-insurance for employees of local governments, the Public Employees' Benefits Program and plans of self-insurance for private employers, respectively, to comply with the requirements of sections 2-25 to the extent applicable. Section 48 provides that a managed care organization that provides services to recipients of Medicaid or the Children's Health Insurance Program is not subject to sections 49-68, but must comply with sections 2-25. Section 69 requires the policies and procedures for coverage for prescription drugs under Medicaid to comply with sections 49-68. Existing law prohibits certain insurers from considering the availability of, or eligibility of an insured for medical assistance under Medicaid when making payments for claims under a policy of health insurance, or determining the insured's eligibility for coverage under the policy. (NRS 689A.430, 689B.300, 695A.151, 695B.340, 695C.163, 695F.440) Sections 30, 32 and 41 of this bill also impose this prohibition on health carriers for small employers and managed care organizations. Sections 27, 29, 30, 32, 34, 37, 38, 40 and 41 of this bill additionally prohibit all private health insurers regulated under state law from considering the availability of, or eligibility of an insured for any other governmental program, including Medicare and benefits under Social Security, for these purposes. Existing law requires certain private health insurance plans to provide coverage for screening for, diagnosing and treating autism spectrum disorders to insureds who are less than 18 years of age, or until the insured reaches 22 years of age, if the insured is enrolled in high school. Existing law subjects this coverage to a maximum benefit of $72,000 per year for applied behavior analysis treatment. Existing law also requires the course of treatment for autism spectrum disorders to be identified in a treatment plan. (NRS 689A.0435, 689B.0335, 689C.1655, 695C.1717, 695G.1645) Sections 33 and 35 of this bill additionally impose this requirement on fraternal benefit societies and nonprofit hospital or medical services corporations. Sections 26, 28, 31, 33, 35, 39 and 43 of this bill require private health insurance plans to provide coverage for screening for, diagnosing and treating autism spectrum disorders to an insured until he or she reaches 27 years of age. Sections 26, 28, 31, 33, 35, 39 and 43 also: (1) remove the maximum benefit for coverage of applied behavior analysis treatment; (2) eliminate the requirement that the course of treatment be identified in a treatment plan; and (3) eliminate certain other authorized restrictions and limitations on coverage of screening for, diagnosing and treating autism spectrum disorders.

Statutes affected:
As Introduced: 687B.225, 689A.0435, 689A.430, 689B.0335, 689B.300, 689C.1655, 689C.425, 695A.151, 695B.320, 695B.340, 695C.163, 695C.1717, 695F.440, 695G.053, 695G.1645, 232.320, 287.010, 287.04335, 422.403, 608.1555
BDR: 687B.225, 689A.0435, 689A.430, 689B.0335, 689B.300, 689C.1655, 689C.425, 695A.151, 695B.320, 695B.340, 695C.163, 695C.1717, 695F.440, 695G.053, 695G.1645, 232.320, 287.010, 287.04335, 422.403, 608.1555