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- 83rd Session (2025)
Assembly Bill No. 463–Assemblymember Backus
CHAPTER..........
AN ACT relating to insurance; requiring certain health insurers to
respond to requests for prior authorization for medical or
dental care within a certain amount of time; prohibiting
certain insurers from requiring prior authorization for certain
types of medical care; and providing other matters properly
relating thereto.
Legislative Counsel’s Digest:
Existing law au thorizes 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 proc edure 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) Sections
27 and 45 of this bill require private insurers and insurers providing coverage for
recipients of Medicaid and the Children’s Health Insurance Program , respectively,
to respond to a request for prior authorization within 2 business days after receiving
the request , unless certain nationally recognized operating rules governing prior
authorization would allow the insurer to have additional time to respond to the
particular request. In such a case, sections 27 and 45 authorize an insurer to
respond to the request withi n the period of time prescribed by the operating rules,
unless doing so would result in the insurer responding to the request more than 7
calendar days after receiving the request.
Sections 19 and 48 of this bill prohibit insurers from requiring an insur ed to
obtain prior authorization for : (1) certain preventive care services; (2) hospice care
provided to pediatric patients; and (3) care provided to treat neonatal abstinence
syndrome. Section 19 additionally prohibits insurers, other than those covering
recipients of Medicaid or the Children’s Health Insurance Program, from requiring
prior authorization for: (1) outpatient services for the treatment of substance use
disorder; and (2) the prescription of test strips for measuring blood glucose in
persons w ith diabetes. Section 27 makes conforming changes to clarify that a
private insurer may not require prior authorization where prohibited by section 19.
Sections 4-15 and 35-42 of this bill define certain terms relating to the process
of obtaining and proc essing requests for prior authorization, and sections 2 and 34
of this bill establish the applicability of those definitions. Section 23 of this bill
provides that if a private insurer violates any provision of section 19 or 27 with
respect to a particular request for prior authorization, that the request is deemed
approved.
Section 28 of this bill requires a nonprofit hospital and medical or dental
service corporation to comply with sections 2-26 of this bill. Section 29 of this bill
requires the Director of the Department to administer the provisions of sections 33-
52 of this bill in the same manner as other provisions governing Medicaid. Section
56 of this bill requires plans of self-insurance for private employers, respectively, to
comply with the requirements of sections 19 and 27 to the extent applicable.
Section 15.5 of this bill provides that a health maintenance organization or other
managed care organization that p rovides services to recipients of Medicaid or the
Children’s Health Insurance Program or members of the Public Employees’
Benefits Program, or a utilization review organization that conducts utilization
reviews for such entities, is not subject to sections 2-27.
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EXPLANATION – Matter in bolded italics is new; matter between brackets [omitted material] is material to be omitted.
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
thereto the provisions set forth as sections 2 to 26, inclusive, of this
act.
Sec. 2. As used in NRS 687B.225 and sections 2 to 26,
inclusive, of this act, unless the context otherwise requires, the
words and terms defined in sections 3 to 16, inclusive, of this act
have the meanings ascribed to them in those sections.
Secs. 3-6. (Deleted by amendment.)
Sec. 7. “Health carrier” has the meaning ascribed to it in
NRS 695G.024, and includes, without limitation, an organization
for dental care. The term additionally includes a utilization review
organization, as defined i n NRS 695G.085 , while acting in its
capacity as a utilization review organization for a health carrier.
Sec. 8. (Deleted by amendment.)
Sec. 9. “Insured” means a policyholder, subscriber, enrollee
or other person covered by a health carrier.
Sec. 10. (Deleted by amendment.)
Sec. 11. “Medically necessary” has the meaning ascribed to
it in NRS 695G.055.
Secs. 12 and 13. (Deleted by amendment.)
Sec. 14. “Prior authorization” means:
1. Any process by which a health carrier determines, before
medical care or dental care that is otherwise covered by the health
carrier is provided to an insured, that the medical care or dental
care is medically necessary or medically appropriate with respect
to the particular insured; or
2. Any requirement that an insured or a provider of health
care of the insured notify the health carrier before medical or
dental care is provided to the insured.
Sec. 15. “Provider of health care” has the meaning ascribed
to it in NRS 695G.070.
Sec. 15.5. The provisions of NRS 687B.225 and sections 2 to
26, inclusive, of this act, do not apply to:
1. A health maintenance organization or other managed care
organization that enters into a contract with the Department of
Health and Human Services or the Division of Health Car e
Financing and Policy of the Department pursuant to NRS 422.273
to provide health care services to recipients of Medicaid under the
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State Plan for Medicaid or insurance under the Children’s Health
Insurance Program to the extent that the organization is providing
such services.
2. A managed care organization that provides health care
services to members of the Public Employees’ Benefits Program or
utilization review organization that conducts utilization reviews
for a managed care organization that provides health care services
to members of the Public Employees’ Benefits Program while the
utilization review organization is providing such services.
3. A utilization review organization that conducts utilization
reviews for an entity described in subsecti on 1, while the
utilization review organization is providing such services.
Secs. 16-18. (Deleted by amendment.)
Sec. 19. 1. A health carrier shall not require prior
authorization for:
(a) Outpatient services for the treatment of a substance use
disorder.
(b) Evidence-based goods or services for preventive care that
have in effect a grade of “A” or “B” identified by the United
States Preventive Services Task Force.
(c) Preventive care for women described in 45 C.F.R. §
147.130(a)(1)(iv).
(d) Hospice care provided to pediatric patients in a facility for
hospice care licensed pursuant to chapter 449 of NRS.
(e) Care provided to treat neonatal abstinence syndrome
provided by a provider of health care who specializes in pain
management for pedia tric patients or palliative care provided to
pediatric patients.
(f) The prescription of test strips for measuring blood glucose
in persons with diabetes.
2. As used in this section:
(a) “Facility for hospice care” has the meaning ascribed to it
in NRS 449.0033.
(b) “Hospice care” has the meaning ascribed to it in
NRS 449.0115.
Secs. 20-22. (Deleted by amendment.)
Sec. 23. If a health carrier violates NRS 687B.225 or section
19 of this act with respect to a particular request for prior
authorization, the request shall be deemed approved.
Secs. 24-26. (Deleted by amendment.)
Sec. 27. NRS 687B.225 is hereby amended to read as follows:
687B.225 1. Except as otherwise provided in NRS
689A.0405, 689A.0412, 689A.0413, 689A.0418, 689A.0437,
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689A.044, 689A.0445, 689A.0459, 689B.031, 689B.0312,
689B.0313, 689B.0315, 689B.0317, 689B.0319, 689B.0374,
689B.0378, 689C.1665, 689C.1671, 689C.1675, 689C.1676,
695A.1843, 695A.1856, 695A.1865, 695A.1874, 695B.1912,
695B.1913, 695B.1914, 695B.1919, 695B.19197, 695B.1924,
695B.1925, 695B.1942, 695C.1696, 695C.1699, 695C.1713,
695C.1735, 695C.1737, 695C.1743, 695C.1745, 695C.1751,
695G.170, 695G.1705, 695G.171, 695G.1 714, 695G.1715,
695G.1719 and 695G.177, and section 19 of this act, any contract
[for group, blanket or individual health ] or policy of insurance [or
any contract by a nonprofit hospital, medical or dental service
corporation or organization for dental car e] issued by a health
carrier which provides for payment of a certain part of medical or
dental care may require the insured [or member ] to obtain prior
authorization for that care from the [insurer or organization. The
insurer or organization] health carrier. The health carrier shall:
(a) File its procedure for obtaining [approval of care ] prior
authorization pursuant to this section for approval by the
Commissioner; and
(b) Unless a shorter time period is prescribed by a specific
statute, including, without limitation, NRS 689A.0446, 689B.0361,
689C.1688, 695A.1859, 695B.19087, 695C.16932 and 695G.1703,
and except as otherwise provided by subsection 2, respond to any
request for [approval] prior authorization by the insured [or
member] pursuant to this section within [20] :
(1) Two business days after it receives the request [.] ; or
(2) If the Prior Authorization and Referrals Operating
Rules prescribed by the Committee on Operating Rules for
Information Exchange of the Council for Affordable Qual ity
Healthcare, or its successor organization, would allow the health
carrier more than 2 business days to respond to a particular
request for prior authorization after receiving the request, the time
period prescribed by the Rules.
2. Notwithstanding any time period prescribed by the Rules
described in subparagraph (2) of paragraph (b) of subsection 1, a
health carrier shall respond to a request for prior authorization
within 7 calendar days after receiving the request.
3. The Commissioner, in collaboration with the Department
of Health and Human Services, shall review each revision to the
Rules described in subparagraph (2) of paragraph (b) of
subsection 1 to ensure their suitability for this State. If the
Commissioner determines that a revision is not suitable for this
State, the Commissioner shall give notice within 30 days after the
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hearing that the revisions are not suitable for this State. If the
Commissioner gives such notice, a health carrier shall respond to
any request for pri or authorization that is submitted to the health
carrier after the date on which such notice is given within 2
business days after receiving the request.
4. The procedure for prior authorization may not discriminate
among persons licensed to provide the covered care.
Sec. 28. NRS 695B.320 is hereby amended to read as follows:
695B.320 1. Nonprofit hospital and medical or dental service
corporations are subject to the provisions of this chapter, and to the
provisions of chapters 679A and 679B of NRS, subsections 2, 4, 17,
18 and 30 of NRS 680B.010, NRS 680B.025 to 680B.060,
inclusive, chapter 681B of NRS, NRS 686A.010 to 686A.315,
inclusive, 686B.010 to 686B.175, inclusive, 687B.010 to
687B.040, inclusive, 687B.070 to 687B.140, inclusive, 687B.150,
687B.160, 687B.180, 687B.200 to 687B.255, inclusive, and
sections 2 to 26, inclusive, of this act, 687B.270, 687B.310 to
687B.380, inclusive, 687B.410, 687B.420, 687B.430, 687B.500 and
chapters 692B, 692C, 693A and 696B of NRS, to the extent
applicable and not in conflict with the express provisions of this
chapter.
2. For the purposes of this section and the provisions set forth
in subsection 1, a nonprofit hospital and medical or dental service
corporation is included in the meaning of the term “insurer.”
Sec. 29. NRS 232.320 is hereby amended to read as follows:
232.320 1. The Director:
(a) Shall appoint, with the consent of the Governor,
administrators of the divisions of the Department, who are
respectively designated as follows:
(1) The Admini strator of the Aging and Disability Services
Division;
(2) The Administrator of the Division of Welfare and
Supportive Services;
(3) The Administrator of the Division of Child and Family
Services;
(4) The Administrator of the Division of Health Care
Financing and Policy; and
(5) The Administrator of the Division of Public and
Behavioral Health.
(b) Shall administer, through the divisions of the Department,
the provisions of chapters 63, 424, 425, 427A, 432A to 442,
inclusive, 446 to 450, inclusive, 458A and 656A of NRS, NRS
127.220 to 127.310, inclusive, 422.001 to 422.410, inclusive, and
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sections 33 to 54, inclusive, of this act, 422.580, 432.010 to
432.133, inclusive, 432B.6201 to 432B.626, inclusive, 444.002 to
444.430, inclusive, and 445A.010 to 445A.055, inclusive, and all
other provisions of law relating to the functions of the divisions of
the Department, but is not responsible for the clinical activities of
the Division of Public and Behavioral Health or the professional line
activities of the other divisions.
(c) Shall administer any state program for persons with
developmental disabilities established pursuant to the
Developmental Disabilities Assistance and Bill of Rights Act of
2000, 42 U.S.C. §§ 15001 et seq.
(d) Shall, after considerin g advice from agencies of local
governments and nonprofit organizations which provide social
services, adopt a master plan for the provision of human services in
this State. The Director shall revise the plan biennially and deliver a
copy of the plan to th e Governor and the Legislature at the
beginning of each regular session. The plan must:
(1) Identify and assess the plans and programs of the
Department for the provision of human services, and any
duplication of those services by federal, state and local agencies;
(2) Set forth priorities for the provision of those services;
(3) Provide for communication and the coordination of those
services among nonprofit organizations, agencies of local
government, the State and the Federal Government;
(4) Identify the sources of funding for services provided by
the Department and the allocation of that funding;
(5) Set forth sufficient information to assist the Department
in providing those services and in the planning and budgeting for the
future provision of those services; and
(6) Contain any other information necessary for the
Department to communicate effectively with the Federal
Government concerning demographic trends, formulas for the
distribution of federal money and any need for the modificatio n of
programs administered by the Department.
(e) May, by regulation, require nonprofit organizations and state
and local governmental agencies to provide information regarding
the programs of those organizations and agencies, excluding
detailed information relating to their budgets and payrolls, which the
Director deems necessary for the performance of the duties imposed
upon him or her pursuant to this section.
(f) Has such other powers and duties as are provided by law.
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2. Notwithstanding any other provision of law, the Director, or
the Director’s designee, is responsible for appointing and removing
subordinate officers and employees of the Department.
Secs. 30 and 31. (Deleted by amendment.)
Sec. 32. Chapter 422 of NRS is hereby amended by adding
thereto the provisions set forth as sections 33 to 54, inclusive, of this
act.
Sec. 33. (Deleted by amendment.)
Sec. 34. As used in sections 34 to 54, inclusive, of this act,
unless the context otherwise requires, the words and terms defined
in sections 35 to 43, inclusive, of this act have the meanings
ascribed to them in those sections.
Secs. 35-39. (Deleted by amendment.)
Sec. 39.5. “Medicaid managed care entity” means:
1. A health maintenance organization or other managed care
organization that enters into a contract with the Department or the
Division pursuant to NRS 422.273 to provide health care services
to recipients of Medicaid under the State Plan for Medicaid or the
Children’s Health Insurance Program; or
2. A utilization review organization, as defined in NRS
695G.085, that conducts utilization reviews for the Department or
a health maintenance organization or managed care organizatio n
described in subsection 1 with respect to Medicaid or the
Children’s Health Insurance Program, while acting in its capacity
as a utilization review organization for the Department or the
health maintenance organization or managed care organization.
Secs. 40 and 41. (Deleted by amendment.)
Sec. 42. “Recipient” means a natural person who receives
benefits through Medicaid or the Children’s Health Insurance
Program, as applicable.
Secs. 43 and 44. (Deleted by amendment.)
Sec. 45. 1. Unless a shorter time period is prescribed by a
specific statute, and except as otherwise provided in subsection 2,
the Department or a Medicaid managed care entity, with respect to
Medicaid and the Children’s Health Insurance Program, shall
respond to a request for prior authorization submitted by or on
behalf of a recipient within:
(a) Two business days after receiving the request; or
(b) If the Prior Authorization and Referrals Operating Rules
prescribed by the Committee on Operating Rules for Information
Exchange of the Council for Affordable Quality Healthcare, or its
successor organization, would allow the Department or Medicaid
managed care entity more than 2 business days to respond to a
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particular request for prior authorization after receiving the
request, the period of time prescribed by the Rules.
2. Notwithstanding any period of time prescribed by the Rules
described in paragraph (b) of subsection 1, the Department or a
Medicaid managed care entity shall respond to a request for prior
authorization within 7 calendar days after receiving the request.
3. The Department, in collaboration with the Commissioner
of Insurance, shall review each revision to the Rules described in
paragraph (b) of subsection 1 to ensure their suitability for
Medicaid coverage in this State. If the Department determines that
a revision is not suitable for Medicaid coverage in this State, the
Department shall give notice within 30 days after the hearing that
the revisions are not suitable for Medicaid coverage in this State.
If the Dep artment gives such notice, the Department or a
Medicaid managed care entity shall respond to any request for
prior authorization that is submitted to the Department or
Medicaid managed care entity, as applicable, after the date on
which such notice is give n within 2 business days after receiving
the request.
Secs. 46 and 47. (Deleted by amendment.)
Sec. 48. 1. The Department or a Medicaid managed care
entity, with respect to Medicaid and the Children’s Health
Insurance Program, shall not require prior authorization for:
(a) Evidence-based goods or services for preventive care that
have in effect a grade of “A” or “B” identified by the United
States Preventive Services Task Force.
(b) Preventive care for women described in 45 C.F.R. §
147.130(a)(iv).
(c) Hospice care provided to pediatric patients in a facility for
hospice care licensed pursuant to chapter 449 of NRS.
(d) Care provided to treat neonatal abstinence syndrome
provided by a provider of health care who specializes in pain
management for pe diatric patients or palliative care provided to
pediatric patients.
2. As used in this section:
(a) “Facility for hospice care” has the meaning ascribed to it
in NRS 449.0033.
(b) “Hospice care” has the meaning ascribed to it in
NRS 449.0115.
(c) “Provider of health care” means a person who participates
in the State Plan for Medicaid or the Children’s Health Insurance
Program as a provider of goods or services.
Secs. 49-51. (Deleted by amendment.)
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Sec. 52. Nothing in sections 44 to 51, inclusive, of this act
shall be construed to require the Department or a Medicaid
managed care entity to provide coverage:
1. For medical or dental care that, regardless of whether such
care is medically necessary, would not be a covered benefit under
the terms and conditions of Medicaid or the Children’s Health
Insurance Program, as applicable; or
2. To a person who is not a recipient or is not otherwise
eligible to receive coverage under Medicaid or the Children’s
Health Insurance Program, as applic able, on the date on which
medical or dental care is provided to the person.
Secs. 53-55. (Deleted by amendment.)
Sec. 56. NRS 608.1555 is hereby amended to read as follows:
608.1555 Any employer who provides benefits for health care
to his or her em ployees shall provide the same benefits and pay
providers of health care in the same manner as a policy of insurance
pursuant to chapters 689A and 689B of NRS, including, without
limitation, as required by paragraph (b) of subsection 1 of NRS
687B.225, subsections 2, 3 and 4 of NRS 687B.225, NRS
687B.409, 687B.723 and 687B.725 [.] and sections 2 to 26,
inclusive, of this act.
Sec. 57. 1. The amendatory provisions of this act do not
apply to a request for prior authorization submitted:
(a) Under a con tract or policy of health insurance issued before
January 1, 2026, but apply to any request for prior authorization
submitted under any renewal of such a contract or policy.
(b) To the Department of Health and Human Services or a
Medicaid managed care ent ity before January 1, 2026, for medical
or dental care provided to a recipient of Medicaid.
2. A health carrier must, in order to continue requiring prior
authorization in contracts or policies of health insurance issued or
renewed after January 1, 2026:
(a) Develop a procedure for obtaining prior authorization that
complies with NRS 687B.225, as amended by section 27 of this act,
and sections 2 to 26, inclusive, of this act; and
(b) Obtain the approval of the Commissioner of Insurance
pursuant to NRS 687B.225, as amended by section 27 of this act, for
the procedure developed pursuant to paragraph (a).
3. As used in this section:
(a) “Health carrier” has the meaning ascribed to it in section 7 of
this act.
(b) “Medicaid managed care entity” has the meaning ascribed to
it in section 39.5 of this act.
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Secs. 58 and 59. (Deleted by amendment.)
Sec. 60. 1. This section and section 57 of this act become
effective upon passage and approval.
2. Sections 1 to 56, inclusive, 58 and 59 of this act become
effective:
(a) Upon passage and approval for the purposes of adopting any
regulations, performing any other preparatory administrative tasks
that are necessary to carry out the provisions of this act and
approving procedures for obtaining prior authoriza tion pursuant to
NRS 687B.225, as amended by section 27 of this act, and section 57
of this act; and
(b) On January 1, 2026, for all other purposes.
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