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 f or 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, th e 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 f or medical or dental care because of the failure 17
to obtain prior authorization if the insurer’s procedures for obtaining prior 18

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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 cover age. Sections 25 and 57 also 23
revise the period for ins urers 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 med ical 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 reque sted 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 informati on 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 bil l: (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 pr ior 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 pr ior 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 previou sly 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 inva sive 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 di agnosed with a terminal condition. 72
Sections 18 and 62 require an insured to treat appeals and requests for prior 73

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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 a t 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

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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 c overed 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 pay ment 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
Sec. 5. “Emergency services” means health care services 18
that are provided by a provider of health care to screen and to 19
stabilize an insured after the sudden onset of a medical condition 20
that manifests itself by symptoms of such sufficient severity that a 21

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prudent person would believe that the absence of immediate 1
medical attention could result in: 2
1. Serious jeopardy to the health of the insured; 3
2. Serious jeopardy to the health of an unborn child of the 4
insured; 5
3. Serious impairment of a bodily function of the insured; or 6
4. Serious dysfunction of any bodily organ or part of the 7
insured. 8
Sec. 6. “Health carrier” has the meaning ascribed to it in 9
NRS 695G.024, and includes, without limitation, an organization 10
for dental care. The term additionally includes a utilization review 11
organization, as defined in NRS 695G.085. 12
Sec. 7. “Individually identifiable health information” means 13
information relating to the provision of medical or dental care to 14
an insured: 15
1. That specifically identifies the insured; or 16
2. For which there is a reasonable basis to believe that the 17
information can be used to identify the insured. 18
Sec. 8. “Insured” means a policyholder, subscriber, enrollee 19
or other person covered by a health carrier. 20
Sec. 9. “Medically necessary” has the meaning ascribed to it 21
in NRS 695G.055. 22
Sec. 10. “Network” means a defin ed set of providers of 23
health care who are under contract with a health carrier to 24
provide health care services pursuant to a network plan offered or 25
issued by the health carrier. 26
Sec. 11. “Network plan” means a contract or policy of 27
insurance offered by a health carrier under which the financing 28
and delivery of medical or dental care is provided, in whole or in 29
part, through a defined set of providers under contract with the 30
health carrier. 31
Sec. 12. “Provider of health care” has the meaning ascribed 32
to it in NRS 695G.070. 33
Sec. 13. 1. A health carrier shall not make an adverse 34
determination on a request for prior authorization unless: 35
(a) The adverse determination is made by a physician or, for 36
dental care, a dentist, who: 37
(1) Holds an unrestricted license to practice medicine or 38
dentistry, as applicable, in any state or territory of the United 39
States; 40
(2) Is of the same or similar specialty as a p hysician or 41
dentist, as applicable, who typically manages or treats the medical 42
or dental condition or provides the medical or dental care involved 43
in the request; and 44

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(3) Has experience treating or managing the medical or 1
dental condition involved in the request; and 2
(b) The adverse determination is made under the clinical 3
direction or supervision of a medical director employed by the 4
health carrier who is a physician who is licensed to practice 5
medicine in any state or territory of the United States. 6
2. If a physician or dentist described in paragraph (a) of 7
subsection 1 is considering making an adverse determination on a 8
request for prior authorization on the basis that the medical or 9
dental care involved in the request is not medically necessary, th e 10
health carrier that received the request shall: 11
(a) Immediately notify the provider of health care who 12
submitted the request that the medical necessity of the requested 13
care is being questioned by the health carrier; and 14
(b) Offer the provider of healt h care an opportunity to speak 15
with the physician or dentist, as applicable, over the telephone or 16
by videoconference to discuss the clinical issues involved in the 17
request before the physician or dentist renders an initial 18
determination on the request. 19
3. Upon rendering an adverse determination on a request for 20
prior authorization, a health carrier shall immediately transmit to 21
the insured to whom the request pertains a written notice that 22
contains: 23
(a) A specific description of all reasons that the hea lth carrier 24
made the adverse determination; 25
(b) A description of any documentation that the health carrier 26
requested from the insured or a provider of health care of the 27
insured and did not receive or deemed insufficient, if the failure to 28
receive suffici ent documentation contributed to the adverse 29
determination; 30
(c) A statement that the insured has the right to appeal the 31
adverse determination; 32
(d) Instructions, written in clear language that is 33
understandable to an ordinary layperson, describing how th e 34
insured can appeal the adverse determination through the process 35
established pursuant to subsection 4; and 36
(e) A description of any documentation that may be necessary 37
or pertinent to a potential appeal. 38
4. A health carrier shall establish a process t hat allows an 39
insured to appeal an adverse determination on a request for prior 40
authorization. The process must allow for the clear resolution of 41
each appeal within a reasonable time. 42
5. A health carrier shall not uphold on appeal an adverse 43
determination pertaining to a request for prior authorization 44

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unless the decision on the appeal is made by a physician or, for 1
dental care, a dentist, who: 2
(a) Holds an unrestricted license to practice medicine or 3
dentistry, as applicable, in any state or territory o f the United 4
States; 5
(b) Is actively practicing medicine or dentistry, as applicable, 6
within the same or similar specialty as a physician or dentist, as 7
applicable, who typically manages or treats the medical or dental 8
condition or provides the medical or dental care involved in the 9
request and has been actively practicing in that specialty for at 10
least 5 consecutive years preceding the date on which the 11
physician or dentist, as applicable, makes the determination on the 12
appeal; 13
(c) Is knowledgeable of and h as experience treating or 14
managing the medical or dental condition involved in the request; 15
(d) Was not involved in making the adverse determination that 16
is the subject of the appeal; 17
(e) Has no financial interest in the outcome of the request for 18
prior authorization that is the subject of the appeal; 19
(f) Is not employed by or contracted with the health carrier 20
except: 21
(1) To participate in the network of the health carrier in his 22
or her capacity as a practicing physician or dentist, as applicable; 23
(2) To make determinations on reviews or appeals of 24
adverse determinations; or 25
(3) For the purposes described in both subparagraph s (1) 26
and (2); and 27
(g) Considers all known clinical aspects of the medical or 28
dental care involved in the request, including, without limitation: 29
(1) The medical records of the insured that are provided or 30
accessible to the health carrier, including those records provided 31
to the health carrier by the insured or a provider of health care of 32
the insured; 33
(2) The clinical review criteria adopted by the health carrier 34
pursuant to subsection 2 of NRS 687B.225; and 35
(3) Medical or scientific evidence provided to the health 36
carrier by the provider of health care who requested prior 37
authorization for the care at issue. 38
6. As used in this section, “medical or scientific evidence” 39
has the meaning ascribed to it in NRS 695G.053. 40
Sec. 14. 1. If a health carrier approves a request for prior 41
authorization, the benefit to which the approval pert ains shall be 42
deemed a covered benefit for the remainder of the applicable 43
coverage period, regardless of any subsequent changes to the 44

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coverage provided by the applicable contract or policy of health 1
insurance. 2
2. If an insured for whom a request for pr ior authorization 3
has been approved by a health carrier obtains coverage under a 4
different policy or contract of health insurance issued by the same 5
health carrier, the health carrier shall honor the approval to the 6
same extent as if the insured were still covered under the policy or 7
contract of health insurance under which the insured was covered 8
when the health carrier approved the request. 9
3. If a health carrier approves a request for prior 10
authorization that relates to a chronic or long -term condition that 11
is specifically identified in the request, the approval remains valid 12
for the entire length of the treatment, subject to the provisions of 13
section 15 of this act. A health carrier shall not require an insured 14
who receives an approval pursuant to this subsection to obtain 15
additional prior authorization for the same care so long as the 16
insured is covered by any policy or contract of insurance issued by 17
the health carrier. 18
4. Within the first 90 days after the coverage period for an 19
insured begins, a health carrier shall honor a request for prior 20
authorization that has been approved by a health carr ier or other 21
entity that previously provided the insured with coverage for 22
medical or dental care if: 23
(a) The approval was issued within the 12 months immediately 24
preceding the first day of the coverage period under the current 25
contract or policy of insurance; and 26
(b) The specific medical or dental care included within the 27
request is not affirmatively excluded under the terms and 28
conditions of the contract or policy of insurance issued by the 29
health carrier. 30
5. A health carrier may undertake an independ ent review of 31
the care approved by the previous health carrier of an insured 32
which is subject to the requirements of subsection 4, for the 33
purpose of granting its own approval of the care. A health carrier 34
may not deny approval in violation of subsection 4 as the result of 35
such a review. 36
Sec. 15. 1. A health carrier may revoke, limit, condition or 37
restrict an approval granted for a request for prior authorization 38
only if: 39
(a) The care to which the request pertains was not provided 40
within 45 business days after the health carrier received the 41
request; 42
(b) The health carrier determines that any of the conditions 43
under which the health carrier may refuse to pay a claim pursuant 44
to subsection 4, 5, 6 or 7 of section 16 of this act exist; or 45

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(c) The health carrier: 1
(1) Determines that the insured was not covered by a policy 2
or contract of insurance issued by the health carr ier on the date 3
on which the approved care was provided; and 4
(2) Has satisfied the conditions of subsection 2. 5
2. A health carrier may revoke, limit, condition or restrict an 6
approval granted for a request for prior authorization pursuant to 7
paragraph (c) of subsection 1 only if, before the care to which the 8
request pertains was provided, the health carrier provided to the 9
provider of health care who provided the care a mechanism by 10
which the provider of health care could confirm whether the 11
insured is: 12
(a) Covered by the health carrier; and 13
(b) Eligible to receive coverage for the care on the date on 14
which the care is scheduled to be provided, including, without 15
limitation, the length of any approved inpatient stay in a medical 16
facility. 17
3. As used in this section, “medical facility” has the meaning 18
ascribed to it in NRS 449.0151. 19
Sec. 16. A health carrier that has approved a request for 20
prior authorization shall not refuse to pay a claim for the medical 21
or dental car e approved by the health carrier or refuse to pay a 22
provider of health care who participates in the network of the 23
health carrier at the applicable contracted rate for the approved 24
care unless: 25
1. The approval is later revoked, limited, conditioned or 26
restricted pursuant to section 15 of this act in a manner that 27
precludes payment of the claim. 28
2. The medical or dental care at issue was never performed. 29
3. The claim for the medical or dental care was not timely 30
submitted in accordance with the applicable terms and conditions 31
of the policy or contract of insurance issued by the health carrier. 32
4. The medical or dental care at issue was not a covered 33
benefit on the date on which the care was provided. 34
5. The health carrier possesses specific evidence available for 35
review by the Commissioner or by law enforcement that the 36
insured to whom the approval pertains or the provider of health 37
care of the insured made a material or fraudulent representation 38
to obtain the approval or fraudulent ly obtained the approval by 39
other means. 40
6. The insured exhausted the applicable coverage or benefit 41
under the terms and conditions of the policy or contract of 42
insurance after the health carrier approved the care but before the 43
claim for the care was pr ocessed by the health carrier. A health 44
carrier may refuse to provide coverage or pay a claim on these 45

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grounds only if the health carrier disclosed to the insured at the 1
time that the health carrier approved the request for the care that 2
the care authorized might exceed the coverage or benefits provided 3
under the policy or contract, and would accordingly not be 4
covered. 5
7. The provider of health care was not participating in the 6
network of the health carrier on the date on which the care was 7
provided. 8
Sec. 17. 1. A health carrier shall not require prior 9
authorization for emergency services covered by the health 10
carrier, including, where applicable, transportation by ambulance 11
to a hospital or other medical facility. 12
2. If a health carrier requires an insured or his or her 13
provider of health care to notify the health carrier that the insured 14
has been admitted to a hospital to receive emergency services or 15
has received emergency services, the health carrier shall not 16
require an insured or a provider of health care to transmit such a 17
notice earlier than the end of the business day immediately 18
following the day on which the insured was admitted or the 19
emergency services were provided, as applicable. 20
3. A health carrier shall not deny coverage for emergency 21
services covered by the health carrier that are medically necessary. 22
Emergency services are presumed to be medically necessary if, 23
within 72 hours after an insured is admitted to receive emergency 24
services, the provider of health care of the insured transmits to the 25
health carrier a certification, in writing, that the condition of the 26
insured required emergency services. The health carrier may rebut 27
that presumption by establishing, by clear and convincing 28
evidence, that the emergency services were not medically 29
necessary. 30
4. If an insured receives emergency services and must 31
additionally receive post -evaluation or post -stabilization medical 32
care, and a health carrier requires prior authorization for the 33
post-evaluation or post-stabilization medical care, the health 34
carrier shall approve or make an adverse determination on a 35
request for prior authorization for such care within 60 minutes 36
after receiving the request. 37
5. A health carrier shall make all determinations for whe ther 38
emergency services are medically necessary without regard to 39
whether a provider of health care that provided or billed for those 40
services participates in the network of the health carrier. 41
6. A health carrier shall not impose a restriction or limita tion 42
on coverage of emergency services provided by a provider of 43
health care who does not participate in the network of the health 44
carrier that is greater than any restriction or limitation imposed on 45

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coverage for emergency services that are provided by a provider of 1
health care who participates in the network of the health carrier. 2
Sec. 18. 1. A health carrier shall not require prior 3
authorization for a surgical procedure or other invasive procedure 4
that is related or incidental to , and performed during the course 5
of, a different procedure for which the health carrier: 6
(a) Has granted prior authorization; or 7
(b) Does not require prior authorization. 8
2. A health carrier shall not deny a request for prior 9
authorization for a covered prescription drug that is prescribed for 10
the purpose of treating or managing pain if the insured to whom 11
the request pertains is diagnosed with a terminal condition and the 12
diagnosis of the condition is indicated on the request for prior 13
authorization. 14
3. A health carrier shall act on a request for prior 15
authorization relating to a course of treatment for a mental, 16
emotional, behavioral or substance use disorder or conditio n in a 17
manner that is consistent with the manner that the health carrier 18
would act on a request for prior authorization relating to a course 19
of treatment for any other type of disease or condition. A health 20
carrier shall additionally treat an appeal of an adverse 21
determination on a request for prior authorization relating to a 22
course of treatment for a mental, emotional, behavioral or 23
substance use disorder or condition in the same manner as it 24
would act on any other appeal of an adverse determination. 25
4. As used in this section, “terminal condition” means an 26
incurable and irreversible condition that, without the 27
administration of life -sustaining treatment, will , in the opinion of 28
the attending physician, physician assistant or attending advanced 29
practice registered nurse, result in death within a relatively short 30
time. 31
Sec. 19. 1. A health carrier shall exempt a provider of 32
health care who participates in the network of the health carrier 33
from the requirement to obtain prior authorization for a specific 34
good or service if, within the immediately preceding 12 months, 35
the health carrier approved 80 percent or more of the requests for 36
prior authorization for that specific good or service subm itted by 37
the provider of health care. If a provider of health care qualifies 38
for an exemption pursuant to this section, a health carrier shall: 39
(a) Automatically grant the exemption without requiring the 40
provider of health care to submit a request for the exemption; and 41
(b) Transmit to the provider of health care after granting the 42
exemption a notice that includes: 43
(1) A statement that the provider of health care has been 44
granted an exemption from the requirement to obtain prior 45

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authorization from the health carrier for the specific goods and 1
services listed pursuant to subparagraph (2); 2
(2) A list of goods and services to which the exemption 3
applies; and 4
(3) The date on which the exemption expires, which must 5
not be earlier than 12 months after the date on which the health 6
carrier granted the exemption. 7
2. A health carrier shall provide for an annual review of the 8
requests for prior authorization submitted by providers of health 9
care who participate in the network of the health carrier to 10
determine whether those providers meet the criteria prescribed by 11
subsection 1 for an exemption from the requirement to obtain 12
prior authorization. If a provider of health care is initially 13
determined to be ineligible for an exemption based on such a 14
review, the el igibility of the provider of health care to receive an 15
exemption must be independently determined by a provider of 16
health care who: 17
(a) Is licensed in this State; 18
(b) Is of the same or similar specialty as the provider of health 19
care who is being evaluated for an exemption; and 20
(c) Has experience providing the good or service for which the 21
exemption has been initially denied. 22
3. A provider of health care who is not granted an exemption 23
from the requirement to obtain prior authorization for a particular 24
good or service may, for that specific good or service, request from 25
the health carrier any evidence that supported the decision of the 26
health carrier to not grant the exemption for that good or service. 27
A provider of health care may submit a request for supporting 28
evidence pursuant to this subsection not more than once during a 29
single 12 -month period for each good or service for which the 30
provider of health care has not been granted an exemption. 31
4. An exemption from the requirement to obtain prior 32
authorization pursuant to this section applies to the provision of 33
any good or service covered by the exemption which is provided or 34
ordered by the provider of health care to whom the exception 35
applies. 36
5. A health carrier shall not deny a claim or reduce th e 37
amount of payment paid under a claim for a good or service that is 38
subject to an exemption pursuant to this section unless: 39
(a) The provider of health care who submitted the claim 40
knowingly and materially misrepresented the goods or services 41
actually pr ovided to an insured, and the provider of health care 42
made the misrepresentation with the specific intent to obtain a 43
payment from the health carrier to which the provider of health 44
care is not legally or contractually entitled; or 45

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(b) The service or good for which payment is sought was not 1
substantially performed or provided, as applicable. 2
Sec. 20. 1. Not more than once during a single 12 -month 3
period, a health carrier may reevaluate the eligibility of a provider 4
of health care to receive an exemption from the requirement to 5
obtain prior authorization pursuant to section 19 of this act. 6
2. A h ealth carrier may revoke an exemption from the 7
requirement to obtain prior authorization granted to a provider of 8
health care pursuant to subsection 1 only if the health carrier 9
determines that the provider of health care would not have met the 10
criteria prescribed in subsection 1 of section 19 of this act for the 11
good or service to which the exemption applies based on: 12
(a) A retrospective review of claims submitted by the provider 13
of health care for that good or service during the immediately 14
preceding 3 months; or 15
(b) If the provider of health care did not submit at least 10 16
claims for that good or service during the immediately preceding 3 17
months, a retrospective review of at least the last 10 claims 18
submitted by the provider of health care for that good or service. 19
3. If it is initially determined that a provider of health care 20
meets the criteria prescribed in subsection 2 for the revocation of 21
an exemption based on a review conducted pursuant to that 22
subsection, the satisfaction of those criteria must be independently 23
determined by a provider of health care described in subsection 2 24
of section 19 of this act before the health carrier may revoke the 25
exemption. 26
4. A health carrier that revokes an exemption from the 27
requirement to obtain prior authorization pursuant to subsection 2 28
shall transmi t to the provider of health care to which the 29
revocation pertains a notice that includes: 30
(a) The information that the health carrier relied upon when 31
making the determination described in subsection 2; 32
(b) An identification of each good or service to wh ich the 33
revoked exemption applies; 34
(c) The date on which the revocation takes effect, which must 35
not be earlier than 30 days after the date on which the health 36
carrier transmits the notice; and 37
(d) A description, written in easily comprehensible language , 38
of how the provider of health care may appeal the revocation 39
pursuant to subsection 5. 40
5. A health carrier shall adopt a procedure by which a 41
provider of health care may appeal the revocation of an exemption 42
from the requirement to obtain prior authori zation. If a provider 43
of health care appeals a revocation of such exemption, the 44
exemption must remain in effect: 45

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(a) If the revocation is reversed on appeal, until the next 1
reevaluation pursuant to subsection 1 of the eligibility of the 2
provider of health care to continue receiving the exemption. 3
(b) If the revocation is upheld on appeal, until the later of the 4
5th calendar day after the revocation is upheld or the date 5
contained within the notice sent to the provider of health care 6
pursuant to subsection 4. 7
Sec. 21. 1. If a health carrier violates NRS 687B.225 or 8
sections 13 to 18, inclusive, of this act with respect to a particular 9
request for prior authorization, the re quest shall be deemed 10
approved. 11
2. Any provision of a policy or contract issued by a health 12
carrier or any other contract or agreement that conflicts with this 13
section, NRS 687B.225 or sections 13 to 20, inclusive, of this act is 14
against public policy, void and unenforceable. 15
Sec. 22. A health carrier that requires prior authorization for 16
prescription drugs shall accept and respond to any request for 17
prior authorization for a prescription drug through a secure 18
electronic transmission using the Nationa l Council for 19
Prescription Drug Programs SCRIPT standard described in 42 20
C.F.R. § 423.160(b). 21
Sec. 23. 1. On or before March 1 of each calendar year, a 22
health carrier shall publish on an Internet website maintained by 23
the health carrier in an easily accessible format the following 24
information for the immediately preceding calendar year, in 25
aggregated form for all requests for prior authorization received 26
by the insurer during the immediately preceding year and 27
disaggregated in accordance with subsection 2: 28
(a) The percentage of requests for prior authorization for 29
medical or dental care in this State that were approved upon initial 30
review; 31
(b) The percentage of requests for prior authorization for 32
medical or dental care in this State that resulted in an adverse 33
determination upon initial review; 34
(c) The percentage of the adverse determinations described in 35
paragraph (b) that were appealed; 36
(d) The percentage of appeals of adverse determinations 37
described in paragraph (c) that resulted in a reversal of the 38
adverse determination; and 39
(e) The average time between a request for prior authorization 40
for medical or dental care in this State and the resolution of the 41
request. 42
2. The information described in subsection 1 must be 43
disaggregated for the following categories: 44

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(a) The specialty of the provider of health care who submitted 1
a request for prior authorization; and 2
(b) The types of medical or dental care at issue in the request 3
for prior authorization, including the specific types of prescription 4
drugs, procedures or diagnostic tests involved in the requests. 5
3. A health carrier shall not include individually identifiable 6
health information in the information published pursuant to 7
subsection 1. 8
Sec. 24. 1. On or before March 1 of each calendar year, a 9
health carrier shall compile and transmit to the Commissioner, in 10
a form prescribed by the Commissioner, and publish on an 11
Internet website maintained by the health carrier a report 12
containing the following information: 13
(a) The specific goods and services for which the health 14
carrier requires prior authorization and, for each good or service: 15
(1) The number of requests for prior authorization received 16
by the health carrier during the immediately preceding calendar 17
year for the provision of the good or service to insureds in this 18
State; 19
(2) The average and median amount of time, in hours, 20
between the health carrier receiving a request for prior 21
authorization listed pursuant to subpara graph (1), except those 22
requests for which the health carrier required additional 23
information to process the request, and the health carrier 24
approving or making an adverse determination on the request; 25
(3) The number and percentage of requests for prior 26
authorization listed pursuant to subparagraph (1) that were not 27
included in calculating the times described in subparagraph (2); 28
(4) The number and percentage of the requests listed 29
pursuant to subparagraph (1) that were approved; 30
(5) The number and pe rcentage of the requests listed 31
pursuant to subparagraph ( 1) that resulted in adverse 32
determinations; 33
(6) The number of appeals from adverse determinations 34
listed pursuant to subparagraph (5) during the immediately 35
preceding calendar year and the number and percentage of those 36
adverse determinations that were reversed on appeal by the health 37
carrier; 38
(7) The number of appeals described in subparagraph (6) 39
processed at each level of the appeals process established by the 40
health carrier, as applicable; 41
(8) The number and percentage of requests listed pursuant 42
to subparagraph s (4) and (5) that were processed by the health 43
carrier with the assistance of artificial intelligence, machine -44
learning technology or other similar technologies that are 45

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- *SB398*
independently capable of generating recommendations for or 1
decisions on requests for prior authorization; 2
(9) The number of civil actions brought against the health 3
carrier which challenged an adverse determination described in 4
subparagraph (5); and 5
(10) The numbe rs and percentages of civil actions 6
described in subparagraph (9) that, through verdict or settlement, 7
resulted in the adverse determination being reversed or the health 8
carrier paying money to the insured; 9
(b) The information required pursuant to subparagraphs (1) to 10
(10), inclusive, of paragraph (a) aggregated for all requests for 11
prior authorization received by the health carrier for insureds in 12
this State during the immediately preceding year; 13
(c) The number of grievances received by the health carrie r 14
from insureds in this State in the immediately preceding calendar 15
year relating to requests for prior authorization or the 16
requirements established by the health carrier for prior 17
authorization; 18
(d) A description of the type and nature of any technology 19
described in subparagraph (8) of paragraph (a) used by the health 20
carrier, if applicable , to process requests for prior authorization 21
for insureds in this State; 22
(e) A list of each surgical procedure for which the health 23
carrier required prior authorizat ion during the immediately 24
preceding calendar year where, in the course of the surgical 25
procedure, the provider of health care performing the procedure 26
determined that an additional or substitute item or service was 27
medically necessary and, for each such s urgical procedure, the 28
number of times during the immediately preceding calendar year 29
that: 30
(1) The surgical procedure was performed on an insured; 31
(2) The provider of health care performing the surgical 32
procedure determined that an additional or subst itute item or 33
service was medically necessary; 34
(3) The health carrier agreed to cover the additional or 35
substitute item or service; and 36
(4) The health carrier made an adverse determination 37
concerning coverage for the additional or substitute item or 38
service; and 39
(f) Such additional information as the Commissioner may 40
prescribe by regulation. 41
2. On or before May 1 of each even -numbered year, the 42
Commissioner shall: 43
(a) Compile a report: 44

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- *SB398*
(1) Summarizing the information submitted to the 1
Commissioner pursuant to subsection 1 during the immediately 2
preceding biennium; 3
(2) Listing the specific goods and services for which health 4
carriers approved requests for prior authorization for insureds in 5
this State at a combined rate of 80 percent or more duri ng the 6
immediately preceding biennium; and 7
(3) Recommending legislation to prohibit health carriers 8
from requiring prior authorization for the specific goods and 9
services listed pursuant to subparagraph (2); and 10
(b) Submit the report and all information provided to the 11
Commissioner pursuant to subsection 1 to the Director of the 12
Legislative Counsel Bureau for transmittal to the Joint Interim 13
Standing Committee on Health and Human Services and the Joint 14
Interim Standing Committee on Commerce and Labor. 15
3. A health carrier shall not include individually identifiable 16
health information in a report published pursuant to this section. 17
Sec. 25. NRS 687B.225 is hereby amended to read as follows: 18
687B.225 1. Except as otherwise provided in NRS 19
689A.0405, 689A.0412, 689A.0413, 689A.0418, 689A.0437, 20
689A.044, 689A.0445, 689A.0459, 689B.031, 689B.0312, 21
689B.0313, 689B.0315, 689B.0317, 689B.0319, 689B.0374, 22
689B.0378, 689C.1665, 689C.1671, 689C.1675, 689C.1676, 23
695A.1843, 695A.1856, 695A.1865, 695A.1874, 695B.1912, 24
695B.1913, 695B.1914, 695B.1919, 695B.19197, 695B.1924, 25
695B.1925, 695B.1942, 695C.1696, 695C.1699, 695C.1713, 26
695C.1735, 695C.1737, 695C.1743, 695C.1745, 695C.1751, 27
695G.170, 695G.1705, 695G.171, 695G.1 714, 695G.1715, 28
695G.1719 and 695G.177, and sections 17, 18 and 19 of this act, 29
any contract [for group, blanket or individual health ] or policy of 30
insurance [or any contract by a nonprofit hospital, medical or dental 31
service corporation or organization for dental c are] issued by a 32
health carrier which provides for payment of a certain part of 33
medical or dental care may require the insured [or member ] to 34
obtain prior authorization for that care from the [insurer or 35
organization. The insurer or organization ] health ca rrier in a 36
manner consistent with this section and sections 2 to 24, inclusive, 37
of this act. 38
2. A health carrier that requires an insured to obtain prior 39
authorization shall: 40
(a) File its procedure for obtaining [approval of care ] prior 41
authorization pursuant to this section , including, without 42
limitation, a list of the specific goods and services for which the 43
health carrier requires prior authorization and the clinical review 44

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- *SB398*
criteria used by the health carrier to evaluate requests for prior 1
authorization, for approval by the Commissioner . [; and] 2
(b) When determining whether to approve or make an adverse 3
determination on a request for prior authorization, determine 4
whether the purported insured is: 5
(1) Currently covered by a contract or policy of health 6
insurance issued by the health carrier; and 7
(2) Eligible to receive coverage for the goods or services to 8
which the request pertains. 9
(c) Unless a shorter time period is prescribed by a specific 10
statute, including, without limitation, NRS 689A.0446, 689B.0361, 11
689C.1688, 695A.1859, 695B.19087, 695C.16932 and 695G.1703, 12
[respond to ] and except as otherwise provided by paragraph ( d), 13
approve or make an adverse determination on any request for 14
[approval by the insured or member ] prior authorization submitted 15
by or on beha lf of the insured pursuant to this section [within 20 16
days after it receives the request. 17
2.] and notify the insured and his or her provider of health 18
care of the approval or adverse determination: 19
(1) For non-urgent medical or dental care, within 48 hours 20
after receiving the request. 21
(2) For urgent health care, within 24 hours after receiving 22
the request. 23
(d) If the health carrier requires additional, medically relevant 24
information or documentation , including, without limitation, an 25
in-person evalu ation of the insured or a second opinion from a 26
different provider of health care, in order to adequately evaluate a 27
request for prior authorization: 28
(1) Notify the insured and the provider of health care who 29
submitted the request within the applicable a mount of time 30
described in paragraph ( c) that additional information is required 31
to evaluate the request; 32
(2) Include within the notification sent pursuant to 33
subparagraph (1) a description, with reasonable specificity, of the 34
information that the health carrier requires to make a 35
determination on the request for prior authorization; and 36
(3) Approve or make an adverse determination on the 37
request: 38
(I) For non -urgent medical or dental care, within 48 39
hours after receiving the information. 40
(II) For urgent health care, within 24 hours after 41
receiving the information. 42
3. The procedure for prior authorization may not discriminate 43
among persons licensed to provide the covered care. 44

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- *SB398*
4. If a health carrier seeks to amend its procedure for 1
obtaining prior authorization, including, without limitation, 2
changing the goods and services for which the health carrier 3
requires prior authorization or changing the clinical review 4
criteria used by the health carrier, the health carrier: 5
(a) Must file a request to amend the procedure for approval by 6
the Commissioner. 7
(b) May not allow the amended procedure to take effect until: 8
(1) The Commissioner notifies the health carrier that the 9
request is approved; and 10
(2) The requirements of subsection 5 are satisfied. 11
5. Except as otherwise provided by subsection 8, a change to 12
a health carrier’s procedure for obtaining prior authorization may 13
not take effect until: 14
(a) The health carrier transmits a notice that contains a 15
summary of the changes to the procedure t o each of its insureds 16
and providers of health care who participate in the network of the 17
health carrier; 18
(b) The health carrier updates the information published on its 19
Internet website pursuant to subsection 6 to reflect the amended 20
procedure for obtaining prior authorization and the date on which 21
the amended procedure takes effect; and 22
(c) At least 60 days have passed after the later of: 23
(1) The date on which the health carrier transmitted the 24
notice to its insureds and providers of health care who p articipate 25
in the network of the health carrier pursuant to paragraph (a); or 26
(2) The date on which the health carrier updated the 27
information published on its Internet website pursuant to 28
paragraph (b). 29
6. A health carrier shall publish its procedures for obtaining 30
prior authorization, including, without limitation, the clinical 31
review criteria, on its Internet website: 32
(a) Using clear language that is understandable to an ordinary 33
layperson, where practicable; and 34
(b) In a place that is readily acce ssible and conspicuous to 35
insureds and the public. 36
7. A health carrier shall not deny a claim based on the failure 37
of an insured to obtain prior authorization for medical or dental 38
care if the procedure for obtaining prior authorization established 39
by th e health carrier did not require the insured to obtain prior 40
authorization for that medical or dental care on the date on which 41
the medical or dental care was provided to the insured. 42
8. A change in the health carrier’s procedure for obtaining 43
prior auth orization or a new exclusion or limitation of coverage 44

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- *SB398*
adopted by a health carrier may not take effect until the next 1
coverage period with respect to: 2
(a) An insured for whom the health carrier has, within the 3
current coverage period, approved a request f or prior 4
authorization; and 5
(b) The medical or dental care that is identical to the care for 6
which the health carrier had previously approved a request for 7
prior authorization within the current coverage period. 8
9. As used in this section: 9
(a) “Clinical review criteria” means any written screening 10
procedure, formulary decision abstract, clinical protocol , practice 11
guideline or other criteria used by the health carrier to determine 12
the necessity and appropriateness of medical or dental care. 13
(b) “Urgent health care”: 14
(1) Means health care that, in the opinion of a provider of 15
health care with knowledge of an insured’s medical condition, if 16
not rendered to the insured within 48 hours could: 17
(I) Seriously jeopardize the life or health of the insured 18
or the ability of the insured to regain maximum function; or 19
(II) Subject the insured to severe pain that cannot be 20
adequately managed without receiving such care. 21
(2) Does not include emergency services. 22
Sec. 26. NRS 689A.0435 is hereby amended to read as 23
follows: 24
689A.0435 1. A health benefit plan must provide an option 25
of coverage for screening for and diagnosis of autism spectrum 26
disorders and for treatment of autism spectrum disorders for persons 27
covered by the policy under the age of [18] 27 years . [or, if enrolled 28
in high school, until the person reaches the age of 22 years.] 29
2. Optional coverage provided pursuant to this section must be 30
subject to [: 31
(a) A maximum benefit of not less than the actuarial equivalent 32
of $72,000 per year for applied behavior analysis treatment; and 33
(b) Copayment,] copayment, deductible and coinsurance 34
provisions and any other general exclusions or limitations of a 35
policy of health insurance to the same extent as other medical 36
services or prescription drugs covered by the policy. 37
3. A health benefit plan [that offers or issues a policy of health 38
insurance which provides coverage for outpatient care] shall not: 39
(a) Require an insured to pay a higher deductible, copayment or 40
coinsurance or require a longer waiting period for optional c overage 41
for [outpatient] care related to autism spectrum disorders than is 42
required for other [outpatient] care covered by the policy; [or] 43
(b) Refuse to issue a policy of health insurance or cancel a 44
policy of health insurance [solely] because the person applying for 45

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- *SB398*
or covered by the policy uses or may use in the future any of the 1
services listed in subsection 1 [.] ; or 2
(c) Except as authorized by subsection 6, exclude coverage for 3
medically necessary care related to autism spectrum disorders 4
because t he care is provided in a school or other educational 5
setting. 6
4. [Except as otherwise provided in subsections 1 and 2, an ] 7
An insurer [who offers optional coverage pursuant to subsection 1 ] 8
shall not limit the number of visits an insured may make to any 9
person, entity or group for treatment of autism spectrum disorders. 10
5. Treatment of autism spectrum disorders [must] may be 11
identified in a treatment plan and [may] must include medically 12
necessary habilitative or rehabilitative care, prescription care, 13
psychiatric care, psychological care, behavioral therapy , applied 14
behavior analysis therapy or therapeutic care that is: 15
(a) Prescribed for a person diagnosed with an autism spectrum 16
disorder by a licensed physician or licensed psychologist; and 17
(b) Provided for a person diagnosed with an autism spectrum 18
disorder by a licensed physician, licensed psychologist, licensed 19
behavior analyst or other provider that is supervised by the licensed 20
physician, psychologist or behavior analyst. 21
 An insurer may request a copy of and review a treatment plan 22
that may be created pursuant to this subsection. 23
6. Nothing in this section shall be construed as requiring an 24
insurer to provide reimbursement to a school for services delivered 25
through school services. 26
7. As used in this section: 27
(a) “Applied behavior analysis” [means the design, 28
implementation and evaluation of environmental modifications 29
using behavioral stimuli and consequences to produce soci ally 30
significant improvement in human behavior, including, without 31
limitation, the use of direct observation, measurement and 32
functional analysis of the relations between environment and 33
behavior.] has the meaning ascribed to the term “practice of 34
applied behavior analysis” in NRS 641D.080. 35
(b) “Autism spectrum disorder” has the meaning ascribed to it in 36
NRS 427A.875. 37
(c) “Behavioral therapy” means any interactive therapy derived 38
from evidence-based research, including, without limitation, discrete 39
trial training, early intensive behavioral intervention, intensive 40
intervention programs, pivotal response training and verbal behavior 41
provided by a licensed psychologist, licensed behavior analyst, 42
licensed assistant behavior analyst or registered behavior technician. 43

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- *SB398*
(d) “Evidence-based research” means research that applies 1
rigorous, systematic and objective procedures to obtain valid 2
knowledge relevant to autism spectrum disorders. 3
(e) “Habilitative or rehabilitative care” means counseling, 4
guidance and professional services and treatment programs, 5
including, without limitation, applied behavior analysis, that are 6
necessary to develop, maintain and restore, to the maximum extent 7
practicable, the functioning of a person. 8
(f) “Licensed assistant behavior a nalyst” has the meaning 9
ascribed to the term “assistant behavior analyst” in NRS 641D.020. 10
(g) “Licensed behavior analyst” has the meaning ascribed to the 11
term “behavior analyst” in NRS 641D.030. 12
(h) “Medically necessary” means any care, treatment, 13
intervention, service or item which will or is reasonably expected 14
to: 15
(1) Prevent the onset of an illness, condition, injury, disease 16
or disability; 17
(2) Reduce or ameliorate the physical, mental or 18
developmental effects of an illness, condition, injury, di sease or 19
disability; or 20
(3) Assist a person to achieve or maintain maximum 21
function in performing daily activities. 22
(i) “Prescription care” means medications prescribed by a 23
licensed physician and any health-related services deemed medically 24
necessary to determine the need or effectiveness of the medications. 25
[(i)] (j) “Psychiatric care” means direct or consultative services 26
provided by a psychiatrist licensed in the state in which the 27
psychiatrist practices. 28
[(j)] (k) “Psychological care” means direct or consultative 29
services provided by a psychologist licensed in the state in which 30
the psychologist practices. 31
[(k)] (l) “Registered behavior technician” has the meaning 32
ascribed to it in NRS 641D.100. 33
[(l)] (m) “Screening for autism spectrum disorders” means 34
medically necessary assessments, evaluations or tests to screen and 35
diagnose whether a person has an autism spectrum disorder. 36
[(m)] (n) “Therapeutic care” means services provided by 37
licensed or certified speech -language pathologists, occupational 38
therapists and physical therapists. 39
[(n)] (o) “Treatment plan” means a plan to treat an autism 40
spectrum disorder that is prescribed by a licensed physician or 41
licensed psychologist and may be developed pursuant to a 42
comprehensive evaluation in coordinatio n with a licensed behavior 43
analyst. 44

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Sec. 27. NRS 689A.430 is hereby amended to read as follows: 1
689A.430 1. An insurer shall not, when considering 2
eligibility for coverage or making payments under a policy of health 3
insurance, consider the availability of, or eligibility of a person for [, 4
medical] : 5
(a) Medical assistance under Medicaid [.] ; or 6
(b) Any other governmental program that may be used to pay 7
for or reimburse any of the costs of health care services , 8
including, without limitation, Medicare and any program to 9
provide benefits under the Social Security Act. 10
2. To the extent that payment has been made by Medicaid for 11
health care, an insurer: 12
(a) Shall treat Medicaid as having a valid and enforceable 13
assignment of an insured’s benefits regardless of any exclusion of 14
Medicaid or the absence of a written assignment; and 15
(b) May, as otherwise allowed by the policy, evidence of 16
coverage or contract and applicable law or regulation concerning 17
subrogation, seek to enforce any right of a recipient of Medicaid to 18
reimbursement against any other liable party if: 19
(1) It is so authorized pursuant to a contract with Medicaid 20
for managed care; or 21
(2) It has reimbursed Medicaid in full for the health care 22
provided by Medicaid to its insured. 23
3. If a state agency is assigned any rights of a person who is: 24
(a) Eligible for medical assistance under Medicaid; and 25
(b) Covered by a policy of health insurance, 26
 the insurer that issued the policy shall not impose any 27
requirements upon the state agency except requirements it imposes 28
upon the agents or assignees of other persons covered by the policy. 29
4. If a state agency is assigned any rights of an insured who is 30
eligible for medical assistance under Medicaid, an insurer shall: 31
(a) Upon request of the state agency, provide to the state agency 32
information regarding the insured to determine: 33
(1) Any period during which the insured or the insured’s 34
spouse or dependent may be or may have been covered by the 35
insurer; and 36
(2) The nature of the coverage that is or was provided by the 37
insurer, including, without limitation, the name and address of the 38
insured and the identifying number of the policy, evidence of 39
coverage or contract; 40
(b) Respond to any inquiry by the state agency regarding a claim 41
for payment for the provision of any medical item or service not 42
later than 3 years after the date of the provision of the medical item 43
or service; and 44

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- *SB398*
(c) Agree not to deny a claim submitted by the state agency 1
solely on the basis of the date of submission of the claim, the type or 2
format of the claim form or failure to present proper documentation 3
at the point of sale that is the basis for the claim if: 4
(1) The claim is submitted by the state agency not later than 5
3 years after the date of the provision of the medical item or service; 6
and 7
(2) Any action by the state agency to enforce its rights with 8
respect to such claim is commenced not later than 6 years after the 9
submission of the claim. 10
5. As used in this section, “insur er” includes, without 11
limitation, a self -insured plan, group health plan as defined in 12
section 607(1) of the Employee Retirement Income Security Act of 13
1974, 29 U.S.C. § 1167(1), service benefit plan or other 14
organization that has issued a policy of health insurance or any other 15
party described in section 1902(a)(25)(A), (G) or (I) of the Social 16
Security Act, 42 U.S.C. § 1396a(a)(25)(A), (G) or (I), as being 17
legally responsible for payment of a claim for a health care item or 18
service. 19
Sec. 28. NRS 689B.0335 is hereby amended to read as 20
follows: 21
689B.0335 1. A health benefit plan must provide coverage 22
for screening for and diagnosis of autism spectrum disorders and for 23
treatment of autism spectrum disorders to persons covered by the 24
policy of group health insurance under the age of [18] 27 years . [or, 25
if enro lled in high school, until the person reaches the age of 22 26
years.] 27
2. Coverage provided under this section is subject to [: 28
(a) A maximum benefit of the actuarial equivalent of $72,000 29
per year for applied behavior analysis treatment; and 30
(b) Copayment,] copayment, deductible and coinsurance 31
provisions and any other general exclusion or limitation of a policy 32
of group health insurance to the same extent as other medical 33
services or prescription drugs covered by the policy. 34
3. A health benefit plan [that offers or issues a policy of group 35
health insurance which provides coverage for outpatient care ] shall 36
not: 37
(a) Require an insured to pay a higher deductible, copayment or 38
coinsurance or require a longer waiting period for coverage for 39
[outpatient] care related to autism spectrum disorders than is 40
required for other [outpatient] care covered by the policy; [or] 41
(b) Refuse to issue a policy of group health insurance or cancel a 42
policy of group health insurance [solely] because the person 43
applying for or covered by the policy uses or may use in the future 44
any of the services listed in subsection 1 [.] ; or 45

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(c) Except as authorized by subsection 7, exclude coverage for 1
medically necessary care related to autism spectrum disorders 2
because the care is pro vided in a school or other educational 3
setting. 4
4. [Except as otherwise provided in subsections 1 and 2, an ] 5
An insurer shall not limit the number of visits an insured may make 6
to any person, entity or group for treatment of autism spectrum 7
disorders. 8
5. Treatment of autism spectrum disorders [must] may be 9
identified in a treatment plan and [may] must include medically 10
necessary habilitative or rehabilitative care, prescription care, 11
psychiatric care, psychological care, behavioral therapy , applied 12
behavior analysis therapy or therapeutic care that is: 13
(a) Prescribed for a person diagnosed with an autism spectrum 14
disorder by a licensed physician or licensed psychologist; and 15
(b) Provided for a person diagnosed with an autism spectrum 16
disorder by a li censed physician, licensed psychologist, licensed 17
behavior analyst or other provider that is supervised by the licensed 18
physician, psychologist or behavior analyst. 19
 An insurer may request a copy of and review a treatment plan 20
that may be created pursuant to this subsection. 21
6. A policy subject to the provisions of this chapter that is 22
delivered, issued for delivery or renewed on or after January 1, 23
[2011,] 2026, has the legal effect of including the coverage required 24
by subsection 1, and any provision o f the policy or the renewal 25
which is in conflict with subsection 1 or 2 is void. 26
7. Nothing in this section shall be construed as requiring an 27
insurer to provide reimbursement to a school for services delivered 28
through school services. 29
8. As used in this section: 30
(a) “Applied behavior analysis” [means the design, 31
implementation and evaluation of environmental modifications 32
using behavioral stimuli and consequences to produce socially 33
significant improvement in human behavior, including, without 34
limitation, the use of direct observation, measurement and 35
functional analysis of the relations between environment and 36
behavior.] has the meaning ascribed to the term “practice of 37
applied behavior analysis” in NRS 641D.080. 38
(b) “Autism spectrum disorder” has the meaning ascribed to it in 39
NRS 427A.875. 40
(c) “Behavioral therapy” means any interactive therapy derived 41
from evidence-based research, including, without limitation, discrete 42
trial training, early intensive behavioral intervention, intensive 43
intervention programs, pivotal response training and verbal behavior 44

– 26 –

- *SB398*
provided by a licensed psychologist, licensed behavior analyst, 1
licensed assistant behavior analyst or registered behavior technician. 2
(d) “Evidence-based research” means research that applies 3
rigorous, systematic and objective procedures to obtain valid 4
knowledge relevant to autism spectrum disorders. 5
(e) “Habilitative or rehabilitative care” means counseling, 6
guidance and professional services and treatment programs, 7
including, without limit ation, applied behavior analysis, that are 8
necessary to develop, maintain and restore, to the maximum extent 9
practicable, the functioning of a person. 10
(f) “Licensed assistant behavior analyst” has the meaning 11
ascribed to the term “assistant behavior analyst” in NRS 641D.020. 12
(g) “Licensed behavior analyst” has the meaning ascribed to the 13
term “behavior analyst” in NRS 641D.030. 14
(h) “Medically necessary” means any care, treatment, 15
intervention, service or item which will or is reasonably expected 16
to: 17
(1) Prevent the onset of an illness, condition, injury, disease 18
or disability; 19
(2) Reduce or ameliorate the physical, mental or 20
developmental effects of an illness, condition, injury, disease or 21
disability; or 22
(3) Assist a person to achieve or maintain maximum 23
function in performing daily activities. 24
(i) “Prescription care” means medications prescribed by a 25
licensed physician and any health-related services deemed medically 26
necessary to determine the need or effectiveness of the medications. 27
[(i)] (j) “Psychiatric care” means direct or consultative services 28
provided by a psychiatrist licensed in the state in which the 29
psychiatrist practices. 30
[(j)] (k) “Psychological care” means direct or consultative 31
services provided by a psychologist licensed in the state in which 32
the psychologist practices. 33
[(k)] (l) “Registered behavior technician” has the meaning 34
ascribed to it in NRS 641D.100. 35
[(l)] (m) “Screening for autism spectrum disorders” means 36
medically necessary assessments, evaluations or tests to screen and 37
diagnose whether a person has an autism spectrum disorder. 38
[(m)] (n) “Therapeutic care” means services provided by 39
licensed or certified speech -language pathologists, occupational 40
therapists and physical therapists. 41
[(n)] (o) “Treatment plan” means a plan to treat an autism 42
spectrum disorder that is prescribed by a licensed physician or 43
licensed psychologist and may be developed pursuant to a 44

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- *SB398*
comprehensive evaluation in coordination with a licensed behavior 1
analyst. 2
Sec. 29. NRS 689B.300 is hereby amended to read as follows: 3
689B.300 1. An insurer shall not, when considering 4
eligibility for coverage or making payments under a group health 5
policy, consider the availability of, or eligibility of a person for [, 6
medical] : 7
(a) Medical assistance under Medicaid [.] ; or 8
(b) Any other governmental program that may be used to pay 9
for or reimburse any of the costs of health care services , 10
including, without limitation, Medicare and any program to 11
provide benefits under the Social Security Act. 12
2. To the extent that payment has been made by Medicaid for 13
health care, an insurer: 14
(a) Shall treat Medicaid as having a valid and enforceable 15
assignment of an insured’s benefits regardless of any exclusion of 16
Medicaid or the absence of a written assignment; and 17
(b) May, as otherwise allowed by the policy, evidence of 18
coverage or contract and applicable law or regulation concerning 19
subrogation, seek to enforce any rights of a recipient of Medicaid to 20
reimbursement against any other liable party if: 21
(1) It is so authorized pursuant to a contract with Medicaid 22
for managed care; or 23
(2) It has reimbursed Medicaid in full for the health care 24
provided by Medicaid to its insured. 25
3. If a state agency is assigned any rights of a person who is: 26
(a) Eligible for medical assistance under Medicaid; and 27
(b) Covered by a group health policy, 28
 the insurer that issued the policy shall not impose any 29
requirements upon the state agency except requirements it imposes 30
upon the agents or assignees of other persons covered by the policy. 31
4. If a state agency is assigned any rights of an insured who is 32
eligible for medical assistance under Medicaid, an insurer shall: 33
(a) Upon request of the state agency, provide to the state agency 34
information regarding the insured to determine: 35
(1) Any period during which the insured or the spouse or 36
dependent of the insured may be or may have been covered by the 37
insurer; and 38
(2) The nature of the coverage that is or was provided by the 39
insurer, including, without limitation, the name and address of the 40
insured and the identifying number of the policy; 41
(b) Respond to any inquiry by the state agency regarding a claim 42
for payment for the provision of any medical item or service not 43
later than 3 years after the date of the provision of the medical item 44
or service; and 45

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- *SB398*
(c) Agree not to deny a claim submitted by the state agency 1
solely on the basis of the date of submission of the claim, the type or 2
format of the claim form or failure to present proper documentation 3
at the point of sale that is the basis for the claim if: 4
(1) The claim is submitted by the state agency not later than 5
3 years after the date of the provision of the medical item or service; 6
and 7
(2) Any action by the state agency to enforce its rights with 8
respect to such claim is commenced not later than 6 years after the 9
submission of the claim. 10
5. As used in this section, “insurer” includes, without 11
limitation, a self -insured plan, group health plan as defined in 12
section 607(1) of the Employee Retirement Income Security Act of 13
1974, 29 U.S.C. § 1167(1), service benefit plan or other 14
organization that has issued a group health policy or any other party 15
described in section 1902(a)(25)(A), (G) or (I) of the Social Security 16
Act, 42 U.S.C. § 1396a(a)(25)(A), (G) or (I), as being legally 17
responsible for payment of a claim for a health care item or service. 18
Sec. 30. Chapter 689C of NRS is hereby amended by adding 19
thereto a new section to read as follows: 20
A carrier shall not, when considering eligibility for coverage or 21
making payments under a health benefit plan, consider the 22
availability of, or eligibility of a person for: 23
1. Medical assistance under Medicaid; or 24
2. Any other governmental program that may be used to pay 25
for or reimburse any of the costs of health care services , 26
including, without limitation, Medicare and any program to 27
provide benefits under the Social Security Act. 28
Sec. 31. NRS 689C.1655 is hereby amended to read as 29
follows: 30
689C.1655 1. A health benefit plan must provide coverage 31
for screening for and diagnosis of autism spectrum disorders and for 32
treatment of autism spectrum disorders to persons covered by the 33
health benefit plan under the age of [18] 27 years . [or, if enrolled in 34
high school, until the person reaches the age of 22 years.] 35
2. Coverage provided under this section is subject to [: 36
(a) A maximum benefit of the actuarial equivalent of $72,000 37
per year for applied behavior analysis treatment; and 38
(b) Copayment,] copayment, deductible and coinsurance 39
provisions and any other general exclusion or limitation of a health 40
benefit plan to the same extent as other medical services or 41
prescription drugs covered by the plan. 42
3. A health benefit plan [that offers or issue s a policy of group 43
health insurance which provides coverage for outpatient care ] shall 44
not: 45

– 29 –

- *SB398*
(a) Require an insured to pay a higher deductible, copayment or 1
coinsurance or require a longer waiting period for coverage for 2
[outpatient] care related to autis m spectrum disorders than is 3
required for other [outpatient] care covered by the plan; [or] 4
(b) Refuse to issue a health benefit plan or cancel a health 5
benefit plan [solely] because the person applying for or covered by 6
the plan uses or may use in the fu ture any of the services listed in 7
subsection 1 [.] ; or 8
(c) Except as authorized by subsection 7, exclude coverage for 9
medically necessary care related to autism spectrum disorders 10
because the care is provided in a school or other educational 11
setting. 12
4. [Except as otherwise provided in subsections 1 and 2, a ] A 13
carrier shall not limit the number of visits an insured may make to 14
any person, entity or group for treatment of autism spectrum 15
disorders. 16
5. Treatment of autism spectrum disorders [must] may be 17
identified in a treatment plan and [may] must include medically 18
necessary habilitative or rehabilitative care, prescription care, 19
psychiatric care, psychological care, behavioral therapy , applied 20
behavior analysis therapy or therapeutic care that is: 21
(a) Prescribed for a person diagnosed with an autism spectrum 22
disorder by a licensed physician or licensed psychologist; and 23
(b) Provided for a person diagnosed with an autism spectrum 24
disorder by a licensed physician, licensed psychologist, licensed 25
behavior analyst or other provider that is supervised by the licensed 26
physician, psychologist or behavior analyst. 27
 A carrier may request a copy of and review a treatment plan that 28
may be created pursuant to this subsection. 29
6. A health benefit plan subject to the provisions of this chapter 30
that is delivered, issued for delivery or renewed on or after 31
January 1, [2011,] 2026, has the legal effect of including the 32
coverage required by subsection 1, and any provision of the plan or 33
the renewal which is in conflict with subsection 1 or 2 is void. 34
7. Nothing in this section shall be construed as requiring a 35
carrier to provide reimbursement to a school for services delivered 36
through school services. 37
8. As used in this section: 38
(a) “Applied behavior analysis ” [means the design, 39
implementation and evaluation of environmental modifications 40
using behavioral stimuli and consequences to produce socially 41
significant improvement in human behavior, including, without 42
limitation, the use of direct observation, measure ment and 43
functional analysis of the relations between environment and 44

– 30 –

- *SB398*
behavior.] has the meaning ascribed to the term “practice of 1
applied behavior analysis” in NRS 641D.080. 2
(b) “Autism spectrum disorder” has the meaning ascribed to it in 3
NRS 427A.875. 4
(c) “Behavioral therapy” means any interactive therapy derived 5
from evidence-based research, including, without limitation, discrete 6
trial training, early intensive behavioral intervention, intensive 7
intervention programs, pivotal response training and verbal behavior 8
provided by a licensed psychologist, licensed behavior analyst, 9
licensed assistant behavior analyst or registered behavior technician. 10
(d) “Evidence-based research” means research that applies 11
rigorous, systematic and objective procedures to obtain valid 12
knowledge relevant to autism spectrum disorders. 13
(e) “Habilitative or rehabilitative care” means counseling, 14
guidance and professional services and treatment programs, 15
including, without limitation, applied behavior analysis, that are 16
necessary to develop, maintain and restore, to the maximum extent 17
practicable, the functioning of a person. 18
(f) “Licensed assistant behavior analyst” has the meaning 19
ascribed to the term “assistant behavior analyst” in NRS 641D.020. 20
(g) “Licensed behavior analyst” has the meaning ascribed to the 21
term “behavior analyst” in NRS 641D.030. 22
(h) “Medically necessary” means any care, treatment, 23
intervention, service or item which will or is reasonably expected 24
to: 25
(1) Prevent the onset of an illness, condition, injury, disease 26
or disability; 27
(2) Reduce or ameliorate the physical, mental or 28
developmental effects of an illness, condition, injury, disease or 29
disability; or 30
(3) Assist a person to achieve or maintain maximum 31
function in performing daily activities. 32
(i) “Prescription care” means medications prescribed by a 33
licensed physician and any health-related services deemed medically 34
necessary to determine the need or effectiveness of the medications. 35
[(i)] (j) “Psychiatric care” means direct or consultative ser vices 36
provided by a psychiatrist licensed in the state in which the 37
psychiatrist practices. 38
[(j)] (k) “Psychological care” means direct or consultative 39
services provided by a psychologist licensed in the state in which 40
the psychologist practices. 41
[(k)] (l) “Registered behavior technician” has the meaning 42
ascribed to it in NRS 641D.100. 43

– 31 –

- *SB398*
[(l)] (m) “Screening for autism spectrum disorders” means 1
medically necessary assessments, evaluations or tests to screen and 2
diagnose whether a person has an autism spectrum disorder. 3
[(m)] (n) “Therapeutic care” means services provided by 4
licensed or certified speech -language pathologists, occupational 5
therapists and physical therapists. 6
[(n)] (o) “Treatment plan” means a plan to treat an autism 7
spectrum disorder that is prescribed by a licensed physician or 8
licensed psychologist and may be developed pursuant to a 9
comprehensive evaluation in coordination with a licensed behavior 10
analyst. 11
Sec. 32. NRS 689C.425 is hereby amended to read as follows: 12
689C.425 A voluntary purchasing group and any contract 13
issued to such a group pursuant to NRS 689C.360 to 689C.600, 14
inclusive, are subject to the provisions of NRS 689C.015 to 15
689C.355, inclusive, and section 30 of this act to the extent 16
applicable and not in conflict with the express provisions of NRS 17
687B.408 and 689C.360 to 689C.600, inclusive. 18
Sec. 33. Chapter 695A of NRS is hereby amended by adding 19
thereto a new section to read as follows: 20
1. A benefit contract must provide coverage for screening for 21
and diagnosis of autism spectrum disorders and for treatment of 22
autism spectrum disorders to persons c overed by the benefit 23
contract under the age of 27 years. 24
2. Coverage provided under this section is subject to 25
copayment, deductible and coinsurance provisions and any other 26
general exclusions or limitations of a benefit to the same extent as 27
other medical services or prescription drugs covered by the benefit 28
contract. 29
3. A society shall not: 30
(a) Require an insured to pay a higher deductible, copayment 31
or coinsurance or require a longer waiting period for coverage for 32
care related to autism spectrum d isorders than is required for 33
other care covered by the benefit contract; 34
(b) Refuse to issue a benefit contract or cancel a benefit 35
contract because the person applying for or covered by the benefit 36
contract uses or may use in the future any of the servi ces listed in 37
subsection 1; or 38
(c) Except as authorized by subsection 7, exclude coverage for 39
medically necessary care related to autism spectrum disorders 40
because the care is provided in a school or other educational 41
setting. 42
4. A society shall not lim it the number of visits an insured 43
may make to any person, entity or group for treatment of autism 44
spectrum disorders. 45

– 32 –

- *SB398*
5. Treatment of autism spectrum disorders may be identified 1
in a treatment plan and must include medically necessary 2
habilitative or re habilitative care, prescription care, psychiatric 3
care, psychological care, behavioral therapy, applied behavior 4
analysis therapy or therapeutic care that is: 5
(a) Prescribed for a person diagnosed with an autism spectrum 6
disorder by a licensed physician or licensed psychologist; and 7
(b) Provided for a person diagnosed with an autism spectrum 8
disorder by a licensed physician, licensed psychologist, licensed 9
behavior analyst or other provider that is supervised by the 10
licensed physician, psychologist or behavior analyst. 11
 A society may request a copy of and review a treatment plan 12
that may be created pursuant to this subsection. 13
6. A benefit contract subject to the provisions of this chapter 14
that is delivered, issued for delivery or renewed on or after 15
January 1, 2026, has the legal effect of including the coverage 16
required by subsection 1, and any provision of the benefit contract 17
or the renewal which is in conflict with subsection 1 or 2 is void. 18
7. Nothing in this section shall be construed as requ iring a 19
society to provide reimbursement to a school for services delivered 20
through school services. 21
8. As used in this section: 22
(a) “Applied behavior analysis” has the meaning ascribed to 23
the term “practice of applied behavior analysis” in NRS 641D.080. 24
(b) “Autism spectrum disorder” has the meaning ascribed to it 25
in NRS 427A.875. 26
(c) “Behavioral therapy” means any interactive therapy 27
derived from evidence -based research, including, without 28
limitation, discrete trial training, early intensive behavioral 29
intervention, intensive intervention programs, pivotal response 30
training and verbal behavior provided by a licensed psychologist, 31
licensed behavior analyst, licensed assistant behavior analyst or 32
registered behavior technician. 33
(d) “Evidence-based research” means research that applies 34
rigorous, systematic and objective procedures to obtain valid 35
knowledge relevant to autism spectrum disorders. 36
(e) “Habilitative or rehabilitative care” means counseling, 37
guidance and professional services and tre atment programs, 38
including, without limitation, applied behavior analysis, that are 39
necessary to develop, maintain and restore, to the maximum extent 40
practicable, the functioning of a person. 41
(f) “Licensed assistant behavior analyst” has the meaning 42
ascribed to the term “assistant behavior analyst” in 43
NRS 641D.020. 44

– 33 –

- *SB398*
(g) “Licensed behavior analyst” has the meaning ascribed to 1
the term “behavior analyst” in NRS 641D.030. 2
(h) “Medically necessary” means any care, treatment, 3
intervention, service or item whic h will or is reasonably expected 4
to: 5
(1) Prevent the onset of an illness, condition, injury, disease 6
or disability; 7
(2) Reduce or ameliorate the physical, mental or 8
developmental effects of an illness, condition, injury, disease or 9
disability; or 10
(3) Assist a person to achieve or maintain maximum 11
function in performing daily activities. 12
(i) “Prescription care” means medications prescribed by a 13
licensed physician and any health -related services deemed 14
medically necessary to determine the need or effec tiveness of the 15
medications. 16
(j) “Psychiatric care” means direct or consultative services 17
provided by a psychiatrist licensed in the state in which the 18
psychiatrist practices. 19
(k) “Psychological care” means direct or consultative services 20
provided by a p sychologist licensed in the state in which the 21
psychologist practices. 22
(l) “Registered behavior technician” has the meaning ascribed 23
to it in NRS 641D.100. 24
(m) “Screening for autism spectrum disorders” means 25
medically necessary assessments, evaluations o r tests to screen 26
and diagnose whether a person has an autism spectrum disorder. 27
(n) “Therapeutic care” means services provided by licensed or 28
certified speech -language pathologists, occupational therapists 29
and physical therapists. 30
(o) “Treatment plan” m eans a plan to treat an autism 31
spectrum disorder that is prescribed by a licensed physician or 32
licensed psychologist and may be developed pursuant to a 33
comprehensive evaluation in coordination with a licensed 34
behavior analyst. 35
Sec. 34. NRS 695A.151 is hereby amended to read as follows: 36
695A.151 1. A society shall not, when considering eligibility 37
for coverage or making payments under a certificate for health 38
benefits, consider the availability of, or eligibility of a pers on for [, 39
medical] : 40
(a) Medical assistance under Medicaid [.] ; or 41
(b) Any other governmental program that may be used to pay 42
for or reimburse any of the costs of health care services , 43
including, without limitation, Medicare and any program to 44
provide benefits under the Social Security Act. 45

– 34 –

- *SB398*
2. To the extent that payment has been made by Medicaid for 1
health care, a society: 2
(a) Shall treat Medicaid as having a valid and enforceable 3
assignment of an insured’s benefits regardless of any exclusion of 4
Medicaid or the absence of a written assignment; and 5
(b) May, as otherwise allowed by its certificate for health 6
benefits, evidence of coverage or contract and applicable law or 7
regulation concerning subrogation, seek to enforce any 8
reimbursement rights o f a recipient of Medicaid against any other 9
liable party if: 10
(1) It is so authorized pursuant to a contract with Medicaid 11
for managed care; or 12
(2) It has reimbursed Medicaid in full for the health care 13
provided by Medicaid to its insured. 14
3. If a state agency is assigned any rights of a person who is: 15
(a) Eligible for medical assistance under Medicaid; and 16
(b) Covered by a certificate for health benefits, 17
 the society that issued the health policy shall not impose any 18
requirements upon the state ag ency except requirements it imposes 19
upon the agents or assignees of other persons covered by the 20
certificate. 21
4. If a state agency is assigned any rights of an insured who is 22
eligible for medical assistance under Medicaid, a society that issues 23
a certifi cate for health benefits, evidence of coverage or contract 24
shall: 25
(a) Upon request of the state agency, provide to the state agency 26
information regarding the insured to determine: 27
(1) Any period during which the insured, a spouse or 28
dependent of the ins ured may be or may have been covered by the 29
society; and 30
(2) The nature of the coverage that is or was provided by the 31
society, including, without limitation, the name and address of the 32
insured and the identifying number of the certificate for health 33
benefits, evidence of coverage or contract; 34
(b) Respond to any inquiry by the state agency regarding a claim 35
for payment for the provision of any medical item or service not 36
later than 3 years after the date of the provision of the medical item 37
or service; and 38
(c) Agree not to deny a claim submitted by the state agency 39
solely on the basis of the date of submission of the claim, the type or 40
format of the claim form or failure to present proper documentation 41
at the point of sale that is the basis for the claim if: 42
(1) The claim is submitted by the state agency not later than 43
3 years after the date of the provision of the medical item or service; 44
and 45

– 35 –

- *SB398*
(2) Any action by the state agency to enforce its rights with 1
respect to such claim is commenced not later t han 6 years after the 2
submission of the claim. 3
Sec. 35. Chapter 695B of NRS is hereby amended by adding 4
thereto a new section to read as follows: 5
1. A policy of health insurance must provide coverage for 6
screening for and diagnosis of autism spectrum disorders and for 7
treatment of autism spectrum disorders to persons covered by the 8
policy under the age of 27 years. 9
2. Coverage provided under this section is subject to 10
copayment, deductible and coinsurance provisions and any other 11
general exclusions or limitations of a benefit to the same extent as 12
other medical services or prescription drugs covered by the policy. 13
3. A hospital or medical services corporation that offers or 14
issues a policy of health insurance shall not: 15
(a) Require an insured to pay a higher deductible, copayment 16
or coinsurance or require a longer waiting period for coverage for 17
care related to autism spectrum disorders than is required for 18
other care covered by the policy; 19
(b) Refuse to issue a policy of health insurance or cancel a 20
policy of health insurance because the person applying for or 21
covered by the policy uses or may use in the future any of the 22
services listed in subsection 1; or 23
(c) Except as authorized by subsection 7, exclude coverage for 24
medically necessary care related to autism spectrum disorders 25
because the care is provided in a school or other educational 26
setting. 27
4. A hospital or medical services corporation that offers a 28
policy of he alth insurance shall not limit the number of visits an 29
insured may make to any person, entity or group for treatment of 30
autism spectrum disorders. 31
5. Treatment of autism spectrum disorders may be identified 32
in a treatment plan and must include medically necessary 33
habilitative or rehabilitative care, prescription care, psychiatric 34
care, psychological care, behavioral therapy, applied behavior 35
analysis therapy or therapeutic care that is: 36
(a) Prescribed for a person diagnosed with an autism spectrum 37
disorder by a licensed physician or licensed psychologist; and 38
(b) Provided for a person diagnosed with an autism spectrum 39
disorder by a licensed physician, licensed psychologist, licensed 40
behavior analyst or other provider that is supervised by the 41
licensed physician, psychologist or behavior analyst. 42
 A hospital or medical services corporation may request a copy 43
of and review a treatment plan that may be created pursuant to 44
this subsection. 45

– 36 –

- *SB398*
6. A policy of health insurance subject to the provisions of 1
this chapter that is delivered, issued for delivery or renewed on or 2
after January 1, 2026, has the legal effect of including the 3
coverage required by subsection 1, and any provision of the policy 4
or the renewal which is in conflict with subsection 1 or 2 is void. 5
7. Nothing in this section shall be construed as requiring a 6
hospital or medical services corporation to provide reimbursement 7
to a school for services delivered through school services. 8
8. As used in this section: 9
(a) “Applied behavior analysis” has the meaning ascribed to 10
the term “practice of applied behavior analysis” in NRS 641D.080. 11
(b) “Autism spectrum disorder” has the meaning ascribed to it 12
in NRS 427A.875. 13
(c) “Behavioral therapy” means any interactive therapy 14
derived from evidence -based research, including, without 15
limitation, discrete trial training, early intensive behavioral 16
intervention, intensive intervention programs, pivotal response 17
training and verbal behavior provided by a licensed psychologist, 18
licensed behavior analyst, lic ensed assistant behavior analyst or 19
registered behavior technician. 20
(d) “Evidence-based research” means research that applies 21
rigorous, systematic and objective procedures to obtain valid 22
knowledge relevant to autism spectrum disorders. 23
(e) “Habilitative or rehabilitative care” means counseling, 24
guidance and professional services and treatment programs, 25
including, without limitation, applied behavior analysis, that are 26
necessary to develop, maintain and restore, to the maximum extent 27
practicable, the functioning of a person. 28
(f) “Licensed assistant behavior analyst” has the meaning 29
ascribed to the term “assistant behavior analyst” in 30
NRS 641D.020. 31
(g) “Licensed behavior analyst” has the meaning ascribed to 32
the term “behavior analyst” in NRS 641D.030. 33
(h) “Medically necessary” means any care, treatment, 34
intervention, service or item which will or is reasonably expected 35
to: 36
(1) Prevent the onset of an illness, condition, injury, disease 37
or disability; 38
(2) Reduce or ameliorate the physical, mental or 39
developmental effects of an illness, condition, injury, disease or 40
disability; or 41
(3) Assist a person to achieve or maintain maximum 42
function in performing daily activities. 43
(i) “Prescription care” means medications prescribed by a 44
licensed physician and any health -related services deemed 45

– 37 –

- *SB398*
medically necessary to determine the need or effectiveness of the 1
medications. 2
(j) “Psychiatric care” means direct or consultative services 3
provided by a psychiatrist licensed in the state in which the 4
psychiatrist practices. 5
(k) “Psychological care” means direct or consultative services 6
provided by a psychologist licensed in the state in which the 7
psychologist practices. 8
(l) “Registered behavior technician” has the meaning ascribed 9
to it in NRS 641D.100. 10
(m) “Screening for autism spectrum disorders” means 11
medically necessary assessments, evaluations or tests to screen 12
and diagnose whether a person has an autism spectrum disorder. 13
(n) “Therapeutic care” means services provided by licensed or 14
certified speech -language p athologists, occupational therapists 15
and physical therapists. 16
(o) “Treatment plan” means a plan to treat an autism 17
spectrum disorder that is prescribed by a licensed physician or 18
licensed psychologist and may be developed pursuant to a 19
comprehensive evalu ation in coordination with a licensed 20
behavior analyst. 21
Sec. 36. NRS 695B.320 is hereby amended to read as follows: 22
695B.320 1. Nonprofit hospital and medical or dental service 23
corporations are subject to the provisions of this chapter, and to the 24
provisions of chapters 679A and 679B of NRS, subsections 2, 4, 17, 25
18 and 30 of NRS 680B.010, NRS 680B.025 to 680B.060, 26
inclusive, chapt er 681B of NRS, NRS 686A.010 to 27
686A.315, inclusive, 686B.010 to 686B.175, inclusive, 687B.010 to 28
687B.040, inclusive, 687B.070 to 687B.140, inclusive, 687B.150, 29
687B.160, 687B.180, 687B.200 to 687B.255, inclusive, and 30
sections 2 to 24, inclusive, of this act, 687B.270, 687B.310 to 31
687B.380, inclusive, 687B.410, 687B.420, 687B.430, 687B.500 and 32
chapters 692B, 692C, 693A and 696B of NRS, to the extent 33
applicable and not in conflict with the express provisions of this 34
chapter. 35
2. For the purposes of this section and the provisions set forth 36
in subsection 1, a no nprofit hospital and medical or dental service 37
corporation is included in the meaning of the term “insurer.” 38
Sec. 37. NRS 695B.340 is hereby amended to read as follows: 39
695B.340 1. A corporation shall not, when considering 40
eligibility for coverage or making payments under a contract, 41
consider the availability of, or any eligibility of a person for [, 42
medical] : 43
(a) Medical assistance under Medicaid [.] ; or 44

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(b) Any other governmental program that may be used t o pay 1
for or reimburse any of the costs of health care services, 2
including, without limitation, Medicare and any program to 3
provide benefits under the Social Security Act. 4
2. To the extent that payment has been made by Medicaid for 5
health care, a corporation: 6
(a) Shall treat Medicaid as having a valid and enforceable 7
assignment of benefits of a subscriber or policyholder or claimant 8
under the subscriber or policyholder regardless of any exclusion of 9
Medicaid or the absence of a written assignment; and 10
(b) May, as otherwise allowed by the policy, evidence of 11
coverage or contract and applicable law or regulation concerning 12
subrogation, seek to enforce any rights of a recipient of Medicaid 13
against any other liable party if: 14
(1) It is so authorized pursuan t to a contract with Medicaid 15
for managed care; or 16
(2) It has reimbursed Medicaid in full for the health care 17
provided by Medicaid to its subscriber or policyholder. 18
3. If a state agency is assigned any rights of a person who is: 19
(a) Eligible for medical assistance under Medicaid; and 20
(b) Covered by a contract, 21
 the corporation that issued the contract shall not impose any 22
requirements upon the state agency except requirements it imposes 23
upon the agents or assignees of other persons covered by th e same 24
contract. 25
4. If a state agency is assigned any rights of a subscriber or 26
policyholder who is eligible for medical assistance under Medicaid, 27
a corporation shall: 28
(a) Upon request of the state agency, provide to the state agency 29
information regarding the subscriber or policyholder to determine: 30
(1) Any period during which the subscriber or policyholder, 31
the spouse or a dependent of the subscriber or policyholder may be 32
or may have been covered by a contract; and 33
(2) The nature of the coverage t hat is or was provided by the 34
corporation, including, without limitation, the name and address of 35
the subscriber or policyholder and the identifying number of the 36
contract; 37
(b) Respond to any inquiry by the state agency regarding a claim 38
for payment for t he provision of any medical item or service not 39
later than 3 years after the date of the provision of the medical item 40
or service; and 41
(c) Agree not to deny a claim submitted by the state agency 42
solely on the basis of the date of submission of the claim, the type or 43
format of the claim form or failure to present proper documentation 44
at the point of sale that is the basis for the claim if: 45

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(1) The claim is submitted by the state agency not later than 1
3 years after the date of the provision of the medical item or service; 2
and 3
(2) Any action by the state agency to enforce its rights with 4
respect to such claim is commenced not later than 6 years after the 5
submission of the claim. 6
Sec. 38. NRS 695C.163 is hereby amended to read as follows: 7
695C.163 1. A health maintenance organization shall not, 8
when considering eligibility for coverage or making payments under 9
a health care plan, consider the availability of, or eligibility of a 10
person for [, medical] : 11
(a) Medical assistance under Medicaid [.] ; or 12
(b) Any other governmental program that may be used to pay 13
for or reimburse any of the costs of health care services , 14
including, without limitation, Medicare and any program to 15
provide benefits under the Social Security Act. 16
2. To the extent that payment has been made by Medicaid for 17
health care, a health maintenance organization: 18
(a) Shall treat Medicaid as having a valid and enforceable 19
assignment of benefits due an enrollee or claimant under the 20
enrollee regardless of any exclusion of Medicaid or the absence of a 21
written assignment; and 22
(b) May, as otherwise allowed by its plan, evidence of coverage 23
or contract and applicable law or regulation concerning subrogation, 24
seek to enforce any rights of a recipient of Medi caid to 25
reimbursement against any other liable party if: 26
(1) It is so authorized pursuant to a contract with Medicaid 27
for managed care; or 28
(2) It has reimbursed Medicaid in full for the health care 29
provided by Medicaid to its enrollee. 30
3. If a state agency is assigned any rights of a person who is: 31
(a) Eligible for medical assistance under Medicaid; and 32
(b) Covered by a health care plan, 33
 the organization responsible for the health care plan shall not 34
impose any requirements upon the state agency e xcept requirements 35
it imposes upon the agents or assignees of other persons covered by 36
the same plan. 37
4. If a state agency is assigned any rights of an enrollee who is 38
eligible for medical assistance under Medicaid, a health 39
maintenance organization shall: 40
(a) Upon request of the state agency, provide to the state agency 41
information regarding the enrollee to determine: 42
(1) Any period during which the enrollee, the spouse or a 43
dependent of the enrollee may be or may have been covered by the 44
health care plan; and 45

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(2) The nature of the coverage that is or was provided by the 1
organization, including, without limitation, the name and address of 2
the enrollee and the identifying number of the health care plan; 3
(b) Respond to any inquiry by the state agency regarding a claim 4
for payment for the provision of any medical item or service not 5
later than 3 years after the date of the provision of the medical item 6
or service; and 7
(c) Agree not to deny a claim submitted by the state agency 8
solely on the basis of the date of submission of the claim, the type or 9
format of the claim form or failure to present proper documentation 10
at the point of sale that is the basis for the claim if: 11
(1) The claim is submitted by the state agency not later than 12
3 years after the date of the provision of the medical item or service; 13
and 14
(2) Any action by the state agency to enforce its rights with 15
respect to such claim is commenced not later than 6 years after the 16
submission of the claim. 17
Sec. 39. NRS 695C.1717 is hereby amended to read as 18
follows: 19
695C.1717 1. A health care plan issued by a health 20
maintenance organization must provide coverage for screening for 21
and diagnosis of autism spectrum disorders and for treatment of 22
autism spectrum disord ers to persons covered by the health care 23
plan under the age of [18] 27 years . [or, if enrolled in high school, 24
until the person reaches the age of 22 years.] 25
2. Coverage provided under this section is subject to [: 26
(a) A maximum benefit of the actuarial equivalent of $72,000 27
per year for applied behavior analysis treatment; and 28
(b) Copayment,] copayment, deductible and coinsurance 29
provisions and any other general exclusion or limitation of a health 30
care plan to the same extent as other medical services or prescription 31
drugs covered by the plan. 32
3. A health care plan [issued by a health maintenance 33
organization that provides coverage for outpatient care] shall not: 34
(a) Require an enrollee to pay a higher deductible, copayment or 35
coinsurance or require a longer waiting period for coverage for 36
[outpatient] care related to autism spectrum disorders than is 37
required for other [outpatient] care covered by the plan; [or] 38
(b) Refuse to issue a health care plan or cancel a health care plan 39
[solely] because the person applying for or covered by the plan uses 40
or may use in the future any of the services listed in subsection 1 [.] 41
; or 42
(c) Except as authorized by subsection 7, exclude coverage for 43
medically necessary care related to autism spectrum di sorders 44

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because the care is provided in a school or other educational 1
setting. 2
4. [Except as otherwise provided in subsections 1 and 2, a ] A 3
health maintenance organization shall not limit the number of visits 4
an enrollee may make to any person, entity or group for treatment of 5
autism spectrum disorders. 6
5. Treatment of autism spectrum disorders [must] may be 7
identified in a treatment plan and [may] must include medically 8
necessary habilitative or rehabilitative care, prescription care, 9
psychiatric care , psychological care, behavioral therapy , applied 10
behavior analysis therapy or therapeutic care that is: 11
(a) Prescribed for a person diagnosed with an autism spectrum 12
disorder by a licensed physician or licensed psychologist; and 13
(b) Provided for a pers on diagnosed with an autism spectrum 14
disorder by a licensed physician, licensed psychologist, licensed 15
behavior analyst or other provider that is supervised by the licensed 16
physician, psychologist or behavior analyst. 17
 A health maintenance organization may request a copy of and 18
review a treatment plan that may be created pursuant to this 19
subsection. 20
6. Evidence of coverage subject to the provisions of this 21
chapter that is delivered, issued for delivery or renewed on o r after 22
January 1, [2011,] 2026, has the legal effect of including the 23
coverage required by subsection 1, and any provision of the 24
evidence of coverage or the renewal which is in conflict with 25
subsection 1 or 2 is void. 26
7. Nothing in this section shall be construed as requiring a 27
health maintenance organization to provide reimbursement to a 28
school for services delivered through school services. 29
8. As used in this section: 30
(a) “Applied behavior analysis” [means the design, 31
implementation and evaluation of environmental modifications 32
using behavioral stimuli and consequences to produce socially 33
significant improvement in human behavior, including, without 34
limitation, the use of direct observation, measurement and 35
functional analysis of the relations betw een environment and 36
behavior.] has the meaning ascribed to the term “practice of 37
applied behavior analysis” in NRS 641D.080. 38
(b) “Autism spectrum disorder” has the meaning ascribed to it in 39
NRS 427A.875. 40
(c) “Behavioral therapy” means any interactive the rapy derived 41
from evidence-based research, including, without limitation, discrete 42
trial training, early intensive behavioral intervention, intensive 43
intervention programs, pivotal response training and verbal behavior 44

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provided by a licensed psychologist, licensed behavior analyst, 1
licensed assistant behavior analyst or registered behavior technician. 2
(d) “Evidence-based research” means research that applies 3
rigorous, systematic and objective procedures to obtain valid 4
knowledge relevant to autism spectrum disorders. 5
(e) “Habilitative or rehabilitative care” means counseling, 6
guidance and professional services and treatment programs, 7
including, without limitation, applied behavior analysis, that are 8
necessary to develop, maintain and restore, to the maximu m extent 9
practicable, the functioning of a person. 10
(f) “Licensed assistant behavior analyst” has the meaning 11
ascribed to the term “assistant behavior analyst” in NRS 641D.020. 12
(g) “Licensed behavior analyst” has the meaning ascribed to the 13
term “behavior analyst” in NRS 641D.030. 14
(h) “Medically necessary” means any care, treatment, 15
intervention, service or item which will or is reasonably expected 16
to: 17
(1) Prevent the onset of an illness, condition, injury, disease 18
or disability; 19
(2) Reduce or amelior ate the physical, mental or 20
developmental effects of an illness, condition, injury, disease or 21
disability; or 22
(3) Assist a person to achieve or maintain maximum 23
function in performing daily activities. 24
(i) “Prescription care” means medications prescribe d by a 25
licensed physician and any health-related services deemed medically 26
necessary to determine the need or effectiveness of the medications. 27
[(i)] (j) “Psychiatric care” means direct or consultative services 28
provided by a psychiatrist licensed in the s tate in which the 29
psychiatrist practices. 30
[(j)] (k) “Psychological care” means direct or consultative 31
services provided by a psychologist licensed in the state in which 32
the psychologist practices. 33
[(k)] (l) “Registered behavior technician” has the meanin g 34
ascribed to it in NRS 641D.100. 35
[(l)] (m) “Screening for autism spectrum disorders” means 36
medically necessary assessments, evaluations or tests to screen and 37
diagnose whether a person has an autism spectrum disorder. 38
[(m)] (n) “Therapeutic care” means services provided by 39
licensed or certified speech -language pathologists, occupational 40
therapists and physical therapists. 41
[(n)] (o) “Treatment plan” means a plan to treat an autism 42
spectrum disorder that is prescribed by a licensed physician or 43
licensed p sychologist and may be developed pursuant to a 44

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comprehensive evaluation in coordination with a licensed behavior 1
analyst. 2
Sec. 40. NRS 695F.440 is hereby amended to read as follows: 3
695F.440 1. An organization shall not, when considering 4
eligibility for coverage or making payments under any evidence of 5
coverage, consider the availability of, or eligibility of a person for [, 6
medical] : 7
(a) Medical assistance under Medicaid [.] ; or 8
(b) Any other governmental program that may be used to pay 9
for or reimburse any of the costs of health care services , 10
including, without limitation, Medicare and any program to 11
provide benefits under the Social Security Act. 12
2. To the extent that payment has been made by Medicaid for 13
health care, a prepaid limited health service organization: 14
(a) Shall treat Medicaid as having a valid and enforceable 15
assignment of benefits due a subscriber or claimant under the 16
subscriber regardless of any exclusion of Medicaid or the absence of 17
a written assignment; and 18
(b) May, as otherwise allowed by its evidence of coverage or 19
contract and applicable law or regulation concerning subrogation, 20
seek to enforce any rights of a recipient of Medicaid against any 21
other liable party if: 22
(1) It is so authori zed pursuant to a contract with Medicaid 23
for managed care; or 24
(2) It has reimbursed Medicaid in full for the health care 25
provided by Medicaid to its subscriber. 26
3. If a state agency is assigned any rights of a person who is: 27
(a) Eligible for medical assistance under Medicaid; and 28
(b) Covered by any evidence of coverage, 29
 the prepaid limited health service organization that issued the 30
evidence of coverage shall not impose any requirements upon the 31
state agency except requirements it imposes upon the a gents or 32
assignees of other persons covered by any evidence of coverage. 33
4. If a state agency is assigned any rights of a subscriber who is 34
eligible for medical assistance under Medicaid, a prepaid limited 35
health service organization shall: 36
(a) Upon request of the state agency, provide to the state agency 37
information regarding the subscriber to determine: 38
(1) Any period during which the subscriber, the spouse or a 39
dependent of the subscriber may be or may have been covered by 40
the organization; and 41
(2) The nature of the coverage that is or was provided by the 42
organization, including, without limitation, the name and address of 43
the subscriber and the identifying number of the evidence of 44
coverage; 45

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(b) Respond to any inquiry by the state agency regarding a claim 1
for payment for the provision of any medical item or service not 2
later than 3 years after the date of the provision of the medical item 3
or service; and 4
(c) Agree not to deny a claim submitted by the state agency 5
solely on the basis of the date of submission of the claim, the type or 6
format of the claim form or failure to present proper documentation 7
at the point of sale that is the basis for the claim if: 8
(1) The claim is submitted by the state agency not later than 9
3 years after the date of the provision of the medical item or service; 10
and 11
(2) Any action by the state agency to enforce its rights with 12
respect to such claim is commenced not later than 6 years after the 13
submission of the claim. 14
Sec. 41. Chapter 695G of NRS is hereby amended by adding 15
thereto a new section to read as follows: 16
A managed care organization shall not, when considering 17
eligibility for coverage or making payments under a health care 18
plan, consider the availability of, or eligibility of a person for: 19
1. Medical assistance under Medicaid; or 20
2. Any other governmental program that may be used to pay 21
for or reimburse any of the costs of health care services , 22
including, without limitation, Medicare and any program to 23
provide benefits under the Social Security Act. 24
Sec. 42. NRS 695G.053 is hereby amended to read as follows: 25
695G.053 “Medical or scientific evidence” means evidence 26
found in the following sources: 27
1. Peer-reviewed scientific studies published in or accepted for 28
publication by medical journals that meet nationally recognized 29
requirements for scientific manuscripts and that submit most of their 30
published articles for review by experts who are not part of the 31
editorial staff; 32
2. Peer-reviewed medical literature, including literature 33
relating to therapies reviewed and approved by a qualified 34
institutional review board, biomedical compendia and other medical 35
literature that meet the criteria of the National Library of Medicine 36
of the Nati onal Institutes of Health for indexing in Index Medicus 37
(MEDLINE) and Elsevier for indexing in Excerpta Medica 38
(EMBASE); 39
3. Medical journals recognized by the Secretary of Health and 40
Human Services pursuant to section 1861(t)(2) of the Social 41
Security Act, 42 U.S.C. § 1395x; 42
4. The following standard reference compendia: 43
(a) AHFS Drug Information published by the American Society 44
of Health-System Pharmacists; 45

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- *SB398*
(b) Drug Facts and Comparisons published by Wolter Kluwers 1
Health; 2
(c) Accepted Dental Therapeutics published by the American 3
Dental Association; [and] 4
(d) The United States Pharmacopoeia’s Drug Quality and 5
Information Program; and 6
(e) The Diagnostic and Statistical Manual of Mental Disorders 7
published by the American Psychiatric Association; 8
5. Findings, studies or research conducted by or under the 9
auspices of the Federal Government and nationally recognized 10
federal research institutes, including, without limitation: 11
(a) The Agency for Healthcare Research and Quality; 12
(b) The National Institutes of Health; 13
(c) The National Cancer Institute; 14
(d) The National Academy of Sciences of the National 15
Academies; 16
(e) The Centers for Medicare and Medicaid Services; 17
(f) The Food and Drug Administration; and 18
(g) Any national board recognized by the National Institutes of 19
Health for the purpose of evaluating the medical value of health care 20
services; or 21
6. Any other source of medical or scientific evidence that is 22
comparable to the sources listed in subsections 1 to 5, inclusive. 23
Sec. 43. NRS 695G.1645 is hereby amended to read as 24
follows: 25
695G.1645 1. A health care plan issued by a managed care 26
organization for group coverage must provide coverage for 27
screening for and diagnosis of autism spectrum disorders and for 28
treatment of autism spectrum disorders to persons covered by the 29
health care plan under t he age of [18] 27 years . [or, if enrolled in 30
high school, until the person reaches the age of 22 years.] 31
2. A health care plan issued by a managed care organization for 32
individual coverage must provide an option for coverage for 33
screening for and diagno sis of autism spectrum disorders and 34
for treatment of autism spectrum disorders to persons covered by the 35
health care plan under the age of [18] 27 years . [or, if enrolled in 36
high school, until the person reaches the age of 22 years.] 37
3. Coverage provided under this section is subject to [: 38
(a) A maximum benefit of the actuarial equivalent of $72,000 39
per year for applied behavior analysis treatment; and 40
(b) Copayment,] copayment, deductible and coinsurance 41
provisions and any other general exclusion or limitation of a health 42
care plan to the same extent as other medical services or prescription 43
drugs covered by the plan. 44

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4. A managed care organization [that offers or issues a health 1
care plan which provides coverage for outpatient care] shall not: 2
(a) Require an insured to pay a higher deductible, copayment or 3
coinsurance or require a longer waiting period for coverage for 4
[outpatient] care related to autism spectrum disorders than is 5
required for other [outpatient] care covered by the plan; [or] 6
(b) Refuse to issue a health care plan or cancel a health care plan 7
[solely] because the person applying for or covered by the plan uses 8
or may use in the future any of the services listed in subsection 1 [.] 9
; or 10
(c) Except as authorized by subsection 8, exclude coverage for 11
medically necessary care related to autism spectrum disorders 12
because the care is provided in a school or other educational 13
setting. 14
5. [Except as otherwise provided in subsections 1, 2 and 3, a] A 15
managed care organization shall not limit the number of visits an 16
insured may make to any person, entity or group for treatment of 17
autism spectrum disorders. 18
6. Treatment of autism spectrum disorders [must] may be 19
identified in a treatment plan and [may] must include medically 20
necessary h abilitative or rehabilitative care, prescription care, 21
psychiatric care, psychological care, behavioral therapy , applied 22
behavior analysis therapy or therapeutic care that is: 23
(a) Prescribed for a person diagnosed with an autism spectrum 24
disorder by a licensed physician or licensed psychologist; and 25
(b) Provided for a person diagnosed with an autism spectrum 26
disorder by a licensed physician, licensed psychologist, licensed 27
behavior analyst or other provider that is supervised by the licensed 28
physician, psychologist or behavior analyst. 29
 A managed care organization may request a copy of and review a 30
treatment plan that may be created pursuant to this subsection. 31
7. An evidence of coverage subject to the provisions of this 32
chapter that is delivered, issued for delivery or renewed on or after 33
January 1, [2011,] 2026, has the legal effect of including the 34
coverage required by subsection 1, and any provision of the 35
evidence of coverage or the renewal which is in conflict with 36
subsection 1 or 3 is void. 37
8. Nothing in this section shall be construed as requiring a 38
managed care organization to provide reimbursement to a school for 39
services delivered through school services. 40
9. As used in this section: 41
(a) “Applied behavior analysis” [means the design, 42
implementation and evaluation of environmental modifications 43
using behavioral stimuli and consequences to produce socially 44
significant improvement in human behavior , including, without 45

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limitation, the use of direct observation, measurement and 1
functional analysis of the relations between environment and 2
behavior.] has the meaning ascribed to the term “practice of 3
applied behavior analysis” in NRS 641D.080. 4
(b) “Autism spectrum disorder” has the meaning ascribed to it in 5
NRS 427A.875. 6
(c) “Behavioral therapy” means any interactive therapy derived 7
from evidence-based research, including, without limitation, discrete 8
trial training, early intensive behavioral intervent ion, intensive 9
intervention programs, pivotal response training and verbal behavior 10
provided by a licensed psychologist, licensed behavior analyst, 11
licensed assistant behavior analyst or registered behavior technician. 12
(d) “Evidence-based research” means research that applies 13
rigorous, systematic and objective procedures to obtain valid 14
knowledge relevant to autism spectrum disorders. 15
(e) “Habilitative or rehabilitative care” means counseling, 16
guidance and professional services and treatment programs, 17
including, without limitation, applied behavior analysis, that are 18
necessary to develop, maintain and restore, to the maximum extent 19
practicable, the functioning of a person. 20
(f) “Licensed assistant behavior analyst” has the meaning 21
ascribed to the term “assistant behavior analyst” in NRS 641D.020. 22
(g) “Licensed behavior analyst” has the meaning ascribed to the 23
term “behavior analyst” in NRS 641D.030. 24
(h) “Medically necessary” means any care, treatment, 25
intervention, service or item which will or is reasona bly expected 26
to: 27
(1) Prevent the onset of an illness, condition, injury, disease 28
or disability; 29
(2) Reduce or ameliorate the physical, mental or 30
developmental effects of an illness, condition, injury, disease or 31
disability; or 32
(3) Assist a person to achieve or maintain maximum 33
function in performing daily activities. 34
(i) “Prescription care” means medications prescribed by a 35
licensed physician and any health-related services deemed medically 36
necessary to determine the need or effectiveness of the medications. 37
[(i)] (j) “Psychiatric care” means direct or consultative services 38
provided by a psychiatrist licensed in the state in which the 39
psychiatrist practices. 40
[(j)] (k) “Psychological care” means direct or consultative 41
services provided by a psycholog ist licensed in the state in which 42
the psychologist practices. 43
[(k)] (l) “Registered behavior technician” has the meaning 44
ascribed to it in NRS 641D.100. 45

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[(l)] (m) “Screening for autism spectrum disorders” means 1
medically necessary assessments, evaluations or tests to screen and 2
diagnose whether a person has an autism spectrum disorder. 3
[(m)] (n) “Therapeutic care” means services provided by 4
licensed or certified speech -language pathologists, occupational 5
therapists and physical therapists. 6
[(n)] (o) “Treatment plan” means a plan to treat an autism 7
spectrum disorder that is prescribed by a licensed physician or 8
licensed psychologist and may be developed pursuant to a 9
comprehensive evaluation in coordination with a licensed behavior 10
analyst. 11
Sec. 44. NRS 232.320 is hereby amended to read as follows: 12
232.320 1. The Director: 13
(a) Shall appoint, with the consent of the Governor, 14
administrators of the divisions of the Department, who are 15
respectively designated as follows: 16
(1) The Administrator of the Aging and Disability Services 17
Division; 18
(2) The Administrator of the Division of Welfare and 19
Supportive Services; 20
(3) The Administrator of the Division of Child and Family 21
Services; 22
(4) The Administrator of the Division of Health Care 23
Financing and Policy; and 24
(5) The Administrator of the Division of Public and 25
Behavioral Health. 26
(b) Shall administer, through the divisions of the Department, 27
the provisions of chapters 63, 424, 425, 427A, 432A to 442, 28
inclusive, 446 to 450, inclusive, 458A and 656A of NRS, NRS 29
127.220 to 127.310, inclusive, 422.001 to 422.410, inclusive, and 30
sections 48 to 68, inclusive, of this act, 422.580, 432.010 to 31
432.133, inclusive, 432B.6201 to 432B.626, inclusive, 444.002 to 32
444.430, inclusive, and 445A.010 to 445A.055, inclusive, and a ll 33
other provisions of law relating to the functions of the divisions of 34
the Department, but is not responsible for the clinical activities of 35
the Division of Public and Behavioral Health or the professional line 36
activities of the other divisions. 37
(c) Shall administer any state program for persons with 38
developmental disabilities established pursuant to the 39
Developmental Disabilities Assistance and Bill of Rights Act of 40
2000, 42 U.S.C. §§ 15001 et seq. 41
(d) Shall, after considering advice from agencies of l ocal 42
governments and nonprofit organizations which provide social 43
services, adopt a master plan for the provision of human services in 44
this State. The Director shall revise the plan biennially and deliver a 45

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copy of the plan to the Governor and the Legislat ure at the 1
beginning of each regular session. The plan must: 2
(1) Identify and assess the plans and programs of the 3
Department for the provision of human services, and any 4
duplication of those services by federal, state and local agencies; 5
(2) Set forth priorities for the provision of those services; 6
(3) Provide for communication and the coordination of those 7
services among nonprofit organizations, agencies of local 8
government, the State and the Federal Government; 9
(4) Identify the sources of funding for services provided by 10
the Department and the allocation of that funding; 11
(5) Set forth sufficient information to assist the Department 12
in providing those services and in the planning and budgeting for the 13
future provision of those services; and 14
(6) Contain any other information necessary for the 15
Department to communicate effectively with the Federal 16
Government concerning demographic trends, formulas for the 17
distribution of federal money and any need for the modification of 18
programs administered by the Department. 19
(e) May, by regulation, require nonprofit organizations and state 20
and local governmental agencies to provide information regarding 21
the programs of those organizations and agencies, excluding 22
detailed information relating to their budgets and payrolls, which the 23
Director deems necessary for the performance of the duties imposed 24
upon him or her pursuant to this section. 25
(f) Has such other powers and duties as are provided by law. 26
2. Notwithstanding any other provision of law, the Director, or 27
the Director’s designee, is responsible for appointing and removing 28
subordinate officers and employees of the Department. 29
Sec. 45. NRS 287.010 is hereby amended to read as follows: 30
287.010 1. The governing body of any county, school 31
district, municipal corporation, political subdivision, public 32
corporation or other local governmental agency of the State of 33
Nevada may: 34
(a) Adopt and carry into effect a system of group life, accident 35
or health insurance, or any combination thereof, for the benefit of its 36
officers and employees, and the dependents of officers and 37
employees who elect to accept the insurance and who, where 38
necessary, have authorized the governing body to make deductions 39
from their compensation for the payme nt of premiums on the 40
insurance. 41
(b) Purchase group policies of life, accident or health insurance, 42
or any combination thereof, for the benefit of such officers and 43
employees, and the dependents of such officers and employees, as 44
have authorized the purch ase, from insurance companies authorized 45

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to transact the business of such insurance in the State of Nevada, 1
and, where necessary, deduct from the compensation of officers and 2
employees the premiums upon insurance and pay the deductions 3
upon the premiums. 4
(c) Provide group life, accident or health coverage through a 5
self-insurance reserve fund and, where necessary, deduct 6
contributions to the maintenance of the fund from the compensation 7
of officers and employees and pay the deductions into the fund. The 8
money accumulated for this purpose through deductions from the 9
compensation of officers and employees and contributions of the 10
governing body must be maintained as an internal service fund as 11
defined by NRS 354.543. The money must be deposited in a state or 12
national bank or credit union authorized to transact business in the 13
State of Nevada. Any independent administrator of a fund created 14
under this section is subject to the licensing requirements of chapter 15
683A of NRS, and must be a resident of this State. Any contract 16
with an independent administrator must be approved by the 17
Commissioner of Insurance as to the reasonableness of 18
administrative charges in relation to contributions collected and 19
benefits provided. The provisions of NRS 439.581 to 439.597, 20
inclusive, 686A.135, paragraphs (b), (c) and (d) of subsection 2 of 21
NRS 687B.225, subsections 1, 3 and 5 to 8, inclusive, of NRS 22
687B.225, NRS 687B.352, 687B.408, 687B.692, 687B.723, 23
687B.725, 687B.805, 689B.030 to 689B.0317, inclusive, paragraphs 24
(b) and (c) of subsection 1 of NRS 689B.0319, subsections 2, 4, 6 25
and 7 of NRS 689B.0319, 689B.033 to 689B.0369, inclusive, 26
689B.0375 to 689B.050, inclusive, 689B.0675, 689B.265, 689B.287 27
and 689B.500 and sections 2 to 24, inclusive, of this act apply to 28
coverage provided pursuant to this paragraph, except that the 29
provisions of NRS 689B.0378, 689B.03785 and 689B.500 only 30
apply to coverage for active officers and emplo yees of the 31
governing body, or the dependents of such officers and employees. 32
(d) Defray part or all of the cost of maintenance of a self -33
insurance fund or of the premiums upon insurance. The money for 34
contributions must be budgeted for in accordance with the laws 35
governing the county, school district, municipal corporation, 36
political subdivision, public corporation or other local governmental 37
agency of the State of Nevada. 38
2. If a school district offers group insurance to its officers and 39
employees pursuant to this section, members of the board of trustees 40
of the school district must not be excluded from participating in the 41
group insurance. If the amount of the deductions from compensation 42
required to pay for the group insurance exceeds the compensation to 43
which a trustee is entitled, the difference must be paid by the trustee. 44

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3. In any county in which a legal services organization exists, 1
the governing body of the county, or of any school district, 2
municipal corporation, political subdivision, public corporation or 3
other local governmental agency of the State of Nevada in the 4
county, may enter into a contract with the legal services 5
organization pursuant to which the officers and employees of the 6
legal services organization, and the dependents of thos e officers and 7
employees, are eligible for any life, accident or health insurance 8
provided pursuant to this section to the officers and employees, and 9
the dependents of the officers and employees, of the county, school 10
district, municipal corporation, poli tical subdivision, public 11
corporation or other local governmental agency. 12
4. If a contract is entered into pursuant to subsection 3, the 13
officers and employees of the legal services organization: 14
(a) Shall be deemed, solely for the purposes of this section, to be 15
officers and employees of the county, school district, municipal 16
corporation, political subdivision, public corporation or other local 17
governmental agency with which the legal services organization has 18
contracted; and 19
(b) Must be required by th e contract to pay the premiums or 20
contributions for all insurance which they elect to accept or of which 21
they authorize the purchase. 22
5. A contract that is entered into pursuant to subsection 3: 23
(a) Must be submitted to the Commissioner of Insurance for 24
approval not less than 30 days before the date on which the contract 25
is to become effective. 26
(b) Does not become effective unless approved by the 27
Commissioner. 28
(c) Shall be deemed to be approved if not disapproved by the 29
Commissioner within 30 days after its submission. 30
6. As used in this section, “legal services organization” means 31
an organization that operates a program for legal aid and receives 32
money pursuant to NRS 19.031. 33
Sec. 46. NRS 287.04335 is hereby amended to read as 34
follows: 35
287.04335 If the Board provides health insurance through a 36
plan of self -insurance, it shall comply with the provisions of NRS 37
439.581 to 439.597, inclusive, 686A.135, paragraphs (b), (c) and 38
(d) of subsection 2 of NRS 687B.225, subsections 1, 3 and 5 to 8, 39
inclusive, of NRS 687B.225, NRS 687B.352, 687B.409, 687B.692, 40
687B.723, 687B.725, 687B.805, 689B.0353, 689B.255, 695C.1723, 41
695G.150, 695G.155, 695G.160, 695G.162, 695G.1635, 695G.164, 42
695G.1645, 695G.1665, 695G.167, 695G.1675, 695G. 170 to 43
695G.1712, inclusive, 695G.1714 to 695G.174, inclusive, 44
695G.176, 695G.177, 695G.200 to 695G.230, inclusive, 695G.241 45

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to 695G.310, inclusive, 695G.405 and 695G.415, and sections 2 to 1
24, inclusive, of this act in the same manner as an insurer that is 2
licensed pursuant to title 57 of NRS is required to comply with those 3
provisions. 4
Sec. 47. Chapter 422 of NRS is hereby amended by adding 5
thereto the provisions set forth as sections 48 to 68, inclusive, of this 6
act. 7
Sec. 48. 1. The provisions of sections 49 to 68, inclusive, of 8
this act and any policies developed pursuant thereto do not apply 9
to the deli very of services to recipients of Medicaid or the 10
Children’s Health Insurance Program through managed care in 11
accordance with NRS 422.273. 12
2. A health maintenance organization or other managed care 13
organization that enters into a contract with the Department or the 14
Division pursuant to NRS 422.273 to provide health care services 15
to recipients of Medicaid under the State Plan for Medicaid or the 16
Children’s Health Insurance Program shall comply with NRS 17
687B.225 and sections 2 to 24, inclusive, of this act. 18
Sec. 49. As used in sections 49 to 68, inclusive, of this act, 19
unless the context otherwise requires, the words and terms defined 20
in sections 50 to 55, inclusive, of this act have the meanings 21
ascribed to them in those sections. 22
Sec. 50. “Adverse determination” means a determination by 23
the Department that an admission, availability of c are, continued 24
stay or other medical care or dental care that is a covered benefit 25
has been reviewed and, based upon the information provided, does 26
not meet the Department’s requirements for medical necessity, 27
appropriateness, health care setting, level of care or effectiveness, 28
and the requested care or service or payment for the care or 29
service is therefore denied, reduced or terminated. 30
Sec. 51. “Emergency services” means health care services 31
that are provided by a provider of health care to screen and to 32
stabilize a recipient after the sudden onset of a medical condition 33
that manifests itself by symptoms of such sufficient severity that a 34
prudent person would believe that the absence of immediate 35
medical attention could result in: 36
1. Serious jeopardy to the health of the recipient; 37
2. Serious jeopardy to the health of an unborn child of the 38
recipient; 39
3. Serious impairment of a bodily function of the recipient; or 40
4. Serious dysfunction of any bodily organ or part of the 41
recipient. 42
Sec. 52. “Individually identifiable health information” 43
means information relating to the provision of medical or dental 44
care to a recipient: 45

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1. That specifically identifies the recipient; or 1
2. For which there is a reasonable basis to believe that the 2
information can be used to identify the recipient. 3
Sec. 53. “Medically necessary” has the meaning ascribed to 4
it in NRS 695G.055. 5
Sec. 54. “Provider of health care” has the meaning ascribed 6
to it in NRS 695G.070. 7
Sec. 55. “Recipient” means a natural person who receives 8
benefits through Medicaid or the Children’s Health Insurance 9
Program, as applicable. 10
Sec. 56. 1. The Department, with respect to Medicaid and 11
the Children’s Health Insurance Program, shall establish written 12
procedures for obtaining prior authorization for medical or dental 13
care which must include, without limitation: 14
(a) A list of the specific goods and services for which the 15
Department requires prior authorization; and 16
(b) A description of the clinical review criteria used by the 17
Department. 18
2. The Department shall publish the written procedures for 19
obtaining prior authorization established by the Department 20
pursuant to subsection 1, including, without limitation, the clinical 21
review criteria, on an Internet website maintained by the 22
Department: 23
(a) Using clear language that is understandable to an ordinary 24
layperson, where practicable; and 25
(b) In a place that is readily accessible and conspicuous to 26
recipients and the public. 27
3. If the Department amends the procedure for obtaining 28
prior authorization established pursuant to subsection 1, 29
including, without limitation, changing the goods and services for 30
which the Department requires prior authorization or changing 31
the clinical review criteria used by the Department, the 32
Department shall: 33
(a) Transmit a notice containing a summary of the c hanges 34
made to the procedure to each recipient and each provider of 35
goods or services under Medicaid or the Children’s Health 36
Insurance Program, as applicable; and 37
(b) Update the information published on its Internet website 38
pursuant to subsection 2 to re flect the amended procedure for 39
obtaining prior authorization and the date on which the amended 40
procedure takes effect. 41
4. A change to the Department’s procedure for obtaining 42
prior authorization may not take effect until 60 days have passed 43
after the later of: 44

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(a) The date on which the Department transmitted the notice to 1
recipients and providers of goods or services under Medicaid or 2
the Children’s Health Insurance Program, as applicable, pursuant 3
to paragraph (a) of subsection 3; or 4
(b) The date on w hich the Department updated the 5
information published on its Internet website pursuant to 6
paragraph (b) of subsection 3. 7
5. The Department shall not deny a claim based on the 8
failure of a recipient to obtain prior authorization for medical or 9
dental care if the procedure for obtaining prior authorization 10
established by the Department pursuant to this section did not 11
require the recipient to obtain prior authorization for that medical 12
or dental care on the date that the medical or dental care was 13
provided to the recipient. 14
6. As used in this section, “clinical review criteria” means 15
any written screening procedure, formulary decision abstract, 16
clinical protocol , practice guideline or other criteria used by the 17
Department to determine the necessity and app ropriateness of 18
medical or dental care. 19
Sec. 57. 1. When determining whether to approve or make 20
an adverse determination on a request for prior authorization, the 21
Department shall determine whether the purported recipient is: 22
(a) Currently covered by Medicaid or the Children’s Health 23
Insurance Program; and 24
(b) Eligible to receive coverage for the goods or services to 25
which the request pertains. 26
2. Unless a shorter time period is prescribed by a specific 27
statute, and exc ept as otherwise provided in subsection 3, the 28
Department, with respect to Medicaid and the Children’s Health 29
Insurance Program, shall approve or make an adverse 30
determination on a request for prior authorization submitted by or 31
on behalf of a recipient an d notify the recipient and his or her 32
provider of health care of the approval or adverse determination: 33
(a) For non -urgent medical or dental care, within 48 hours 34
after receiving the request. 35
(b) For urgent health care, within 24 hours after receiving th e 36
request. 37
3. If the Department requires additional, medically relevant 38
information or documentation , including, without limitation, an 39
in-person evaluation of the recipient or a second opinion from a 40
different provider of health care, in order to adequately evaluate a 41
request for prior authorization, the Department shall: 42
(a) Notify the recipient and the provider of health care who 43
submitted the request within the applicable amount of time 44

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described in subsection 2 that additional information is required to 1
evaluate the request; 2
(b) Include within the notification sent pursuant to paragraph 3
(a) a description, with reasonable specificity, of the information 4
that the Department requires to make a determination on the 5
request for prior authorization; and 6
(c) Approve or make an adverse determination on the request: 7
(1) For non-urgent medical or dental care, within 48 hours 8
after receiving the information. 9
(2) For urgent health care, within 24 hours after receiving 10
the information. 11
4. As used in this section, “urgent health care”: 12
(a) Means health care that, in the opinion of a provider of 13
health care with knowledge of a recipient’s medical condition, if 14
not rendered to the recipient within 48 hours could: 15
(1) Seriously jeopardize the life or health of the recipient or 16
the ability of the recipient to regain maximum function; or 17
(2) Subject the recipient to severe pain that cannot be 18
adequately managed without receiving such care. 19
(b) Does not include emergency services. 20
Sec. 58. 1. The Department, with respect to Medicaid and 21
the Children’s Health Insurance Program, shall not make an 22
adverse determination on a request for prior authorization unless 23
the adverse determination is made by a physician or, for a request 24
relating to dental care, a dentist, who: 25
(a) Holds an unrestricted license to practice medicine or 26
dentistry, as applicable, in any state or territory of the United 27
States; 28
(b) Is of the same or similar specialty as a physician or dentist, 29
as applicable, who typically manages or treats the medical or 30
dental condition or provides the medical or dental care involved in 31
the request; and 32
(c) Has experience treating or managing the medical or dental 33
condition involved in the request. 34
2. If a physician or dentist described in subsection 1 is 35
considering making an adverse determination on a request for 36
prior authorization on the basis that the medical or dental care 37
involved in the request is not medically necessary, the Department 38
shall: 39
(a) Immediately notify the provider of health care who 40
submitted the request that the medical necessity of the requested 41
care is being questioned by the Department; and 42
(b) Offer the provider of health care an opportunity to speak 43
with the physician or dentist, as applicable, over the telephone or 44
by videoconference to discuss the clinical issues involved in the 45

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request before the physician or dentist renders an initial 1
determination on the request. 2
3. Upon rendering an adverse determination on a requ est for 3
prior authorization, the Department shall immediately transmit to 4
the recipient to whom the request pertains a written notice that 5
contains: 6
(a) A specific description of all reasons that the Department 7
made the adverse determination; 8
(b) A descr iption of any documentation that the Department 9
requested from the recipient or a provider of health care of the 10
recipient and did not receive or deemed insufficient, if the failure 11
to receive sufficient documentation contributed to the adverse 12
determination; 13
(c) A statement that the recipient has the right to appeal the 14
adverse determination; 15
(d) Instructions, written in clear language that is 16
understandable to an ordinary layperson, describing how the 17
recipient can appeal the adverse determination throu gh the 18
process established pursuant to subsection 4; and 19
(e) A description of any documentation that may be necessary 20
or pertinent to a potential appeal. 21
4. The Department shall establish a process that allows a 22
recipient to appeal an adverse determination on a request for prior 23
authorization. The process must allow for the clear resolution of 24
each appeal within a reasonable time. 25
5. The Department shall not uphold on appeal an adverse 26
determination pertaining to a request for prior authorization 27
unless the decision on the appeal is made by a physician or, for an 28
appeal relating to dental care, a dentist, who: 29
(a) Holds an unrestricted license to practice medicine or 30
dentistry, as applicable, in any state or territory of the United 31
States; 32
(b) Is acti vely practicing medicine or dentistry, as applicable, 33
within the same or similar specialty as a physician or dentist, as 34
applicable, who typically manages or treats the medical or dental 35
condition or provides the medical or dental care involved in the 36
request and has been actively practicing in such specialty for at 37
least 5 consecutive years preceding the date on which the 38
physician or dentist, as applicable, makes the determination on the 39
appeal; 40
(c) Is knowledgeable of and has experience treating or 41
managing the medical or dental condition involved in the request; 42
(d) Was not involved in making the adverse determination that 43
is the subject of the appeal; 44

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(e) Has no financial interest in the outcome of the request for 1
prior authorization that is the subject of the appeal; 2
(f) Is not employed by or contracted with the Department or 3
any administrator contracted by the Department except: 4
(1) To participate in Medicaid as a provider of services; 5
(2) To make determinations on appeals of adverse 6
determinations; or 7
(3) For the purposes described in both subparagraph s (1) 8
and (2); and 9
(g) Considers all known clinical aspects of the medical or 10
dental care involved in the request, including, without limitation: 11
(1) The medical records of the recipient that are provided 12
or accessible to the Department, including those records provided 13
to the Department by the recipient or a provider of health care of 14
the recipient; 15
(2) The clinical review criteria adopted by the Department 16
pursuant to section 56 of this act; and 17
(3) Medical or scientific evidence provided to the 18
Department by the provider of health care who requested prior 19
authorization for the care at issue. 20
6. As used in this section: 21
(a) “Administrator” has the meaning ascribed to it in 22
NRS 683A.025. 23
(b) “Medical or scientific evidence” has the meaning ascribed 24
to it in NRS 695G.053. 25
Sec. 59. 1. If the Department approves a request for prior 26
authorization, the Department shall not revoke, limit, condition or 27
restrict the approval due to a subsequent change in the coverage 28
under Medicaid or the criteria under which the approval was 29
initially issued. 30
2. If the Department approves a request for prior 31
authorization that relates to a chronic or long -term condition that 32
is specifically identified in the request, the approval remains valid 33
for the entire length of the treatment , subject to the provisions of 34
section 60 of this act. The Department shall not require a recipient 35
who receives an approval pursuant to this subsection to obtain 36
additional prior aut horization for the same care so long as the 37
recipient is covered by Medicaid or the Children’s Health 38
Insurance Program. 39
3. Within the first 90 days that a recipient is enrolled in 40
Medicaid or the Children’s Health Insurance Program, as 41
applicable, the D epartment shall honor a request for prior 42
authorization that has been approved by a health carrier or other 43
entity that previously provided the recipient with coverage for 44
medical or dental care if: 45

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(a) The approval was issued within the 12 months immedia tely 1
preceding the first day of the enrollment of the recipient; and 2
(b) The specific medical or dental care included within the 3
request is not affirmatively excluded under the terms and 4
conditions of Medicaid or the Children’s Health Insurance 5
Program, as applicable. 6
4. The Department may undertake an independent review of 7
the care approved by the previous health carrier of a recipient 8
which is subject to the requirements of subsection 3 for the 9
purpose of granting its own approval of the care. The Department 10
may not deny approval in violation of subsection 3 as the result of 11
such a review. 12
5. As used in this section, “health carrier” has the meaning 13
ascribed to it in section 6 of this act. 14
Sec. 60. 1. The Department may revoke, limit, condition or 15
restrict an approval granted for a request for prior authorization 16
only if: 17
(a) The care to which the request pertains was not provided 18
within 45 business days after the Department received the request; 19
(b) The Department determines that any of the conditions 20
under which the Department may refuse to pay a claim pursuant 21
to subsection 4, 5 or 6 of section 61 of this act exist; or 22
(c) The Department: 23
(1) Determines that the recipient was not covered by 24
Medicaid or the Children’s Health Insurance Program on the date 25
on which the approved care was provided; and 26
(2) Has satisfied the conditions of subsection 2. 27
2. The Department may revoke, limit, condition or restrict an 28
approval granted for a request for prior authorization pursuant to 29
paragraph (c) of subsection 1 only if , before the care to which the 30
request pertains was provided, the Department provided to the 31
provider of health care who provided the care a mechanism by 32
which the provider of health care could confirm whether the 33
recipient is: 34
(a) Covered by Medicaid or the Children’s Health Insurance 35
Program; and 36
(b) Eligible to receive coverage for the care on the date on 37
which the care is scheduled to be provided, including, without 38
limitation, the length of any approved inpatient stay in a medical 39
facility. 40
3. As used in this section, “medical facility” has the meaning 41
ascribed to it in NRS 449.0151. 42
Sec. 61. If the Department has approved a request for prior 43
authorization, the Department shall not refuse to pay a claim for 44
the medical or dental care approved by the Department or refuse 45

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to pay a provider of health care at the applicable rate for the 1
approved care unless: 2
1. The approval is later revoked, limited, conditioned or 3
restricted pursuant to section 60 of this act in a manner that 4
precludes payment of the claim. 5
2. The medical or dental care at issue was never performed. 6
3. The claim for the medical or dental care was not timely 7
submitted in accordance with the applicable terms and conditions 8
of Medicaid or the Children’s Health Insurance Program, as 9
applicable. 10
4. The medical or dental care at issue was not a covered 11
benefit by Medicaid or the Children’s Health Insurance Program, 12
as applicable, on the date on which the care was provided. 13
5. The Department possess es specific evidence that the 14
recipient to whom the approval pertains or the provider of health 15
care of the recipient made a material or fraudulent represen tation 16
to obtain the approval or fraudulently obtained the approval by 17
other means. 18
6. The provider of health care was not participating in 19
Medicaid as a provider of services on the date on which the care 20
was provided. 21
Sec. 62. 1. The Department shall not require prior 22
authorization for a surgical procedure or other invasive procedure 23
that is related or incidental to, and performed during the course 24
of, a different procedure for which the Department: 25
(a) Has granted prior authorization; or 26
(b) Does not require prior authorization. 27
2. The Department shall not deny a request for prior 28
authorization for a covered prescription drug that is prescribed for 29
the purpose of treating or managing pain if the recipient to whom 30
the request pertains is diagnosed with a terminal condition and the 31
diagnosis of the condition is indicated on the request for prior 32
authorization. 33
3. The Department shall act on a request for prior 34
authorization relating to a course of treatment for a mental, 35
emotional, behavioral or substance use disorder or condition in a 36
manner that is consistent with the manner that the Department 37
would act on a request for prior authorization relating to a course 38
of treatment for any other type of disease or condit ion. The 39
Department shall additionally treat an appeal of an adverse 40
determination on a request for prior authorization relating to a 41
course of treatment for a mental, emotional, behavioral or 42
substance use disorder or condition in the same manner as it 43
would act on any other appeal of an adverse determination. 44

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4. As used in this section , “terminal condition” means an 1
incurable and irreversible condition that, without the 2
administration of life -sustaining treatment, will, in the opinion of 3
the attending physician, physician assistant or attending advanced 4
practice registered nurse, result in death within a relatively short 5
time. 6
Sec. 63. 1. The Department, with respect to Medicaid and 7
the Children’s Health Insurance Program, shall not require prior 8
authorization for covered emergency services, including, where 9
applicable, transportation by ambulance to a hospital or other 10
medical facility. 11
2. If the Department requires a recipient or his or her 12
provider of health ca re to notify the Department that the recipient 13
has been admitted to a hospital to receive emergency services or 14
has received emergency services, the Department shall not require 15
a recipient or a provider of health care to transmit such a notice 16
earlier than the end of the business day immediately following the 17
day on which the recipient was admitted or the emergency services 18
were provided, as applicable. 19
3. The Department shall not deny coverage for emergency 20
services covered by Medicaid or the Children’s Health Insurance 21
Program that are medically necessary. Emergency services are 22
presumed to be medically necessary if, within 72 hours after a 23
recipient is admitted to receive emergency services, the recipient’s 24
provider of health care transmits to the Department a certification, 25
in writing, that the condition of the recipient required emergency 26
services. The Department may rebut that presumption by 27
establishing, by clear and convincing evidence, that the emergency 28
services were not medically necessary. 29
4. If a recipient receives emergency services and must 30
additionally receive post -evaluation or post -stabilization medical 31
care, and the Department requires prior authorization for the post-32
evaluation or post-stabilization medical care, the Department shall 33
approve or make an adverse determination on a request for prior 34
authorization for such care within 60 minutes after receiving the 35
request. 36
Sec. 64. 1. The Department shall exempt a provider of 37
health care from the requirement to obtain prior authorization for 38
a specific good or service if, within the immediately preceding 12 39
months, the Department approved 80 percent or more of the 40
requests for prior authorization for that specific good or service 41
submitted by the provider o f health care. If a provider of health 42
care qualifies for an exemption pursuant to this section, the 43
Department shall: 44

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(a) Automatically grant the exemption without requiring the 1
provider of health care to submit a request for the exemption; and 2
(b) Transmit to the provider of health care after granting the 3
exemption a notice that includes: 4
(1) A statement that the provider of health care has been 5
granted an exemption from the requirement to obtain prior 6
authorization from the Department for the specifi c goods and 7
services listed pursuant to subparagraph (2); 8
(2) A list of goods and services to which the exemption 9
applies; and 10
(3) The date on which the exemption expires, which must 11
not be earlier than 12 months after the date on which the 12
Department granted the exemption. 13
2. The Department shall provide for an annual review of all 14
of the requests for prior authorization submitted by providers of 15
health care during the immediately preceding year to determine 16
whether those providers meet the criteria prescribed by subsection 17
1 for an exemption from the requirement to obtain prior 18
authorization. If a provider of health care is initially determined to 19
be ineligible for an exemption based on such a review, the 20
eligibility of the provider of health care to receive an exemption 21
must be independently determined by a provider of health care 22
who: 23
(a) Is licensed in this State; 24
(b) Is of the same or similar specialty as the provider of health 25
care who is being evaluated for an exemption; and 26
(c) Has experience providing the good or service for which the 27
exemption has been initially denied. 28
3. A provider of health care who is not granted an exemption 29
from the requirement to obtain prior authorization for a particular 30
good or service may, for that specific good or service, request from 31
the Department any evidence that supported the decision of the 32
Department to not grant the exemption for that good or service. A 33
provider of health care may submit a request for supporting 34
evidence pursuant to this subsection not more than once during a 35
single 12 -month period for each good or service for which the 36
provider of health care has not been granted an exemption. 37
4. An exemption from the requirement to obtain prior 38
authorization pursuant to this section applies to the provision of 39
any good or service covered by the exemption which is provided or 40
ordered by the provide r of health care to whom the exception 41
applies. 42
5. The Department shall not deny a claim or reduce the 43
amount of payment paid under a claim for a good or service that is 44
subject to an exemption pursuant to this section unless: 45

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(a) The provider of health care who submitted the claim 1
knowingly and materially misrepresented the goods or services 2
actually provided to a recipient, and the provider of health care 3
made the misrepresentation with the specific intent to obtain a 4
payment from the Department to which the provider of health care 5
is not legally or contractually entitled; or 6
(b) The service or good for which payment is sought was not 7
substantially performed or provided, as applicable. 8
Sec. 65. 1. Not more than once du ring a single 12 -month 9
period, the Department may reevaluate the eligibility of a provider 10
of health care to receive an exemption from the requirement to 11
obtain prior authorization pursuant to section 64 of this act. 12
2. The Department may revoke an exemption from the 13
requirement to obtain prior authorization granted to a provider of 14
health care pursuant to subsection 1 only if the Department 15
determines that the provider of health care would not have met the 16
criteria prescribed in subsection 1 of section 64 of this act for the 17
good or service to which the exemption applies based on: 18
(a) A retrospective review of claims submitted by the provider 19
of health care for that good or service during the immediately 20
preceding 3 months; or 21
(b) If the provider of health care did not submit at least 10 22
claims for that good or service during the immediately preceding 3 23
months, a retrospective review of at least the last 10 claims 24
submitted by the provider of health care for that good or service. 25
3. If it is initially determined that a provider of health care 26
meets the criteria prescribed in subsection 2 for the revocation of 27
an exemption based on a review conducted pursuant to that 28
subsection, the satisfaction of those criteria must be independently 29
determined by a provider of health care described in subsecti on 2 30
of section 64 of this act before the Department may revoke the 31
exemption. 32
4. If the Department revokes an exemption from the 33
requirement to obtai n prior authorization pursuant to subsection 34
2, the Department shall transmit to the provider of health care to 35
which the revocation pertains a notice that includes: 36
(a) The information that the Department relied upon when 37
making the determination described in subsection 2; 38
(b) An identification of each good or service to which the 39
revoked exemption applies; 40
(c) The date on which the revocation takes effect, which must 41
not be earlier than 30 days after the date on which the Department 42
transmits the notice; and 43

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(d) A description, written in easily comprehensible language, 1
of how the provider of health care may appeal the revocation 2
pursuant to subsection 5. 3
5. The Department shall adopt a procedure by which a 4
provider of health care may appeal the revocation of an exemption 5
from the requirement to obtain prior authorization. If a provider 6
of health care appeals a revocation of such exemption, the 7
exemption must remain in effect: 8
(a) If the revocation is reversed on appeal, until the next 9
reevaluation pu rsuant to subsection 1 of the eligibility of the 10
provider of health care to continue receiving the exemption. 11
(b) If the revocation is upheld on appeal, until the later of the 12
5th calendar day after the revocation is upheld or the date 13
contained within th e notice sent to the provider of health care 14
pursuant to subsection 4. 15
Sec. 66. 1. If the Department violates sections 56 to 63, 16
inclusive, of this act with respect to a particular request for prior 17
authorization, the request shall be deemed approved. 18
2. Any provision of a contract or agreement that conflicts 19
with this section or sections 56 to 65, inclusive, of this act is 20
against public policy, void and unenforceable. 21
Sec. 67. 1. On or before March 1 of each calendar year, the 22
Department shall publish on an Internet websi te maintained by 23
the Department in an easily accessible format the following 24
information for the immediately preceding calendar year, in 25
aggregated form for all requests for prior authorization received 26
by the Department for medical or dental care provided to 27
recipients during the immediately preceding year and 28
disaggregated in accordance with subsection 2: 29
(a) The percentage of requests for prior authorization for 30
medical or dental care that were approved upon initial review; 31
(b) The percentage of reques ts for prior authorization for 32
medical or dental care that resulted in an adverse determination 33
upon initial review; 34
(c) The percentage of the adverse determinations described in 35
paragraph (b) that were appealed; 36
(d) The percentage of appeals of adverse determinations 37
described in paragraph (c) that resulted in a reversal of the 38
adverse determination; and 39
(e) The average time between a request for prior authorization 40
for medical or dental care and the resolution of the request. 41
2. The information described in subsection 1 must be 42
disaggregated for the following categories: 43
(a) The specialty of the provider of health care who submitted 44
a request for prior authorization; and 45

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(b) The types of medical or dental care at issue in the request 1
for prior authorization, including the specific types of prescription 2
drugs, procedures or diagnostic tests involved in the requests. 3
3. The Department shall not include individually identifiable 4
health information in the information published pursuant to 5
subsection 1. 6
Sec. 68. 1. On or before March 1 of each calendar year, the 7
Department shall: 8
(a) Compile a report containing the following information for 9
Medicaid and the Children’s Health Insurance Program: 10
(1) The specific go ods and services for which the 11
Department requires prior authorization and, for each good or 12
service: 13
(I) The number of requests for prior authorization 14
received by the Department during the immediately preceding 15
calendar year for the provision of the good or service to recipients; 16
(II) The average and median amount of time, in hours, 17
between the Department receiving a request for prior 18
authorization listed pursuant to sub -subparagraph (I), except 19
those requests for which the Department required addit ional 20
information to process the request, and the Department approving 21
or making an adverse determination on the request; 22
(III) The number and percentage of requests for prior 23
authorization listed pursuant to sub -subparagraph (I) that were 24
not included in calculating the times described in sub -25
subparagraph (II); 26
(IV) The number and percentage of the requests listed 27
pursuant to sub-subparagraph (I) that were approved; 28
(V) The number and percentage of the requests listed 29
pursuant to sub -subparagraph (I) that resulted in adverse 30
determinations; 31
(VI) The number of appeals from adverse 32
determinations listed pursuant to sub -subparagraph (V) during 33
the immediately preceding calendar year and the number and 34
percentage of those adverse determinations that were reversed on 35
appeal by the Department; 36
(VII) The number of appeals described in sub -37
subparagraph (VI) processed at each level of the appeals process 38
established by the Department, if applicable; and 39
(VIII) The number and percentage of requests l isted 40
pursuant to sub -subparagraphs (IV) and (V) that were processed 41
by the Department with the assistance of artificial intelligence, 42
machine-learning technology or other similar technologies that 43
are independently capable of generating recommendations fo r or 44
decisions on requests for prior authorization; 45

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(2) The information required pursuant to sub -1
subparagraphs ( I) to (VIII), inclusive, of sub paragraph (1) 2
aggregated for all requests for prior authorization received by the 3
Department during the immediately preceding year; 4
(3) The number of complaints received by the Department 5
from recipients in the immediately preceding calendar year 6
relating to requests for prior authorization or the requirements 7
established by the Department for prior authorization; 8
(4) A description of the type and nature of any technology 9
described in sub-subparagraph (VIII) of subparagraph (1) used by 10
the Department, if applicable, to process requests for prior 11
authorization; 12
(5) A list of each surgical procedure for which th e 13
Department required prior authorization during the immediately 14
preceding calendar year where, in the course of the surgical 15
procedure, the provider of health care performing the procedure 16
determined that an additional or substitute item or service was 17
medically necessary and, for each such surgical procedure, the 18
number of times during the immediately preceding calendar year 19
that: 20
(I) The surgical procedure was performed on a 21
recipient; 22
(II) The provider of health care performing the surgical 23
procedure determined that an additional or substitute item or 24
service was medically necessary; 25
(III) The Department agreed to cover the additional or 26
substitute item or service; 27
(IV) The Department made an adverse determination 28
concerning coverage f or the additional or substitute item or 29
service; 30
(V) Such additional information as the Director may 31
wish to provide; and 32
(6) A list of specific goods and services for which the 33
Department approved requests for prior authorization at a 34
combined rate of 80 percent or more during the immediately 35
preceding year; and 36
(b) Post the report on the Internet website maintained by the 37
Department; and 38
(c) Submit the report to the Director of the Legislative Counsel 39
Bureau for transmittal to the Joint Interim St anding Committee 40
on Health and Human Services. 41
2. The Department shall not include individually identifiable 42
health information in a report published pursuant to this section. 43

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Sec. 69. NRS 422.403 is hereby amended to read as follows: 1
422.403 1. The Department shall, by regulation, establish and 2
manage the use by the Medicaid program of step therapy and prior 3
authorization for prescription drugs. 4
2. The Drug Use Review Board shall: 5
(a) Advise the Department concerning the use by the Medicaid 6
program of step therapy and prior authorization for prescription 7
drugs; 8
(b) Develop step therapy protocols and prior authorization 9
policies and procedures that comply with the provisions of sections 10
49 to 68, inclusive, of this act for use by the Medicaid program for 11
prescription drugs; and 12
(c) Review and approve, based on clinical evidence and best 13
clinical practice guidelines and without consideration of the cost of 14
the prescription drugs being considered, step therapy protocols used 15
by the Medicaid program for prescription drugs. 16
3. The step therapy protocol established pursuant to this section 17
must not apply to a drug approved by the Food and Drug 18
Administration that is prescribed to treat a psychiatric condition of a 19
recipient of Medicaid, if: 20
(a) The drug has been approved by the Food and Drug 21
Administration with indications for the psychiatric condition of the 22
insured or the use of the drug to treat that psychiatric condition is 23
otherwise supported by medical or scientific evidence; 24
(b) The drug is prescribed by: 25
(1) A psychiatrist; 26
(2) A physician assistant under the supervision of a 27
psychiatrist; 28
(3) An advanced practice registered nurse who has the 29
psychiatric training and experience prescribed by the State Board of 30
Nursing pursuant to NRS 632.120; or 31
(4) A primary care provider that is providing care to an 32
insured in consultation with a practitioner listed in subparagraph (1), 33
(2) or (3), if the closest practitioner listed in subparagraph (1), (2) or 34
(3) who participates in Medicaid is located 60 mi les or more from 35
the residence of the recipient; and 36
(c) The practitioner listed in paragraph (b) who prescribed the 37
drug knows, based on the medical history of the recipient, or 38
reasonably expects each alternative drug that is required to be used 39
earlier in the step therapy protocol to be ineffective at treating the 40
psychiatric condition. 41
4. The Department shall accept and respond to any request 42
for prior authorization for a prescription drug through a secure 43
electronic transmission using the National Council for 44

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Prescription Drug Programs SCRIPT standard described in 42 1
C.F.R. § 423.160(b). 2
5. The procedures for prior authorization established 3
pursuant to this section must not apply to prescription drugs 4
ordered as a part of a course of medication -assisted treatment for 5
opioid use disorder, which may include, without limitation: 6
(a) Methadone; 7
(b) Buprenorphine, whether administered alone or in 8
combination with naloxone; and 9
(c) Extended-release injectable naltrexone. 10
6. The Department shall not require the Drug Use Review 11
Board to develop, review or approve prior authorization policies or 12
procedures necessary for the operation of the list of preferred 13
prescription drugs developed pursuant to NRS 422.4025. 14
[5.] 7. The Department shall accept recommendations from the 15
Drug Use Review Board as the basis for developing or revising step 16
therapy protocols and prior authorization policies and procedures 17
used by the Medicaid program for prescription drugs. 18
[6.] 8. As used in this section: 19
(a) “Medical or scientific evidence” has the meaning ascribed to 20
it in NRS 695G.053. 21
(b) “Step therapy protocol” means a procedure that requires a 22
recipient of Medicaid to use a prescription drug or sequence of 23
prescription drugs other than a drug that a practitio ner recommends 24
for treatment of a psychiatric condition of the recipient before 25
Medicaid provides coverage for the recommended drug. 26
Sec. 70. NRS 608.1555 is hereby amended to read as follows: 27
608.1555 Any employer who pr ovides benefits for health care 28
to his or her employees shall provide the same benefits and pay 29
providers of health care in the same manner as a policy of insurance 30
pursuant to chapters 689A and 689B of NRS, including, without 31
limitation, as required by paragraphs (b), (c) and (d) of subsection 32
2 of NRS 687B.225, subsections 1, 3 and 5 to 8, inclusive, of NRS 33
687B.225, NRS 687B.409, 687B.723 and 687B.725 [.] and sections 34
2 to 24, inclusive, of this act. 35
Sec. 71. 1. The amendatory provisions of this act do not 36
apply to a request for prior authorization submitted: 37
(a) Under a contract or policy of health insurance issued before 38
January 1, 2026, but apply to any request for prior authorization 39
submitted under any renewal of such a contract or policy. 40
(b) To the Department of Health and Human Services before 41
January 1, 2026, for medical or dental care provided to a recipient of 42
Medicaid. 43

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2. A health carrier must, in order to continue requiring prior 1
authorization in contracts or pol icies of health insuran ce issued or 2
renewed on or after January 1, 2026: 3
(a) Develop a procedure for obtaining prior authorization that 4
complies with NRS 687B.225, as amended by section 25 of this act, 5
and sections 2 to 24, inclusive, of this act; and 6
(b) Obtain the approval of the Commissioner of Insurance 7
pursuant to NRS 687B.225, as amended by section 25 of this act, for 8
the procedure developed pursuant to paragraph (a). 9
3. As used in this section, “health carrier” has the meaning 10
ascribed to it in section 6 of this act. 11
Sec. 72. The provisions of subsection 1 of NRS 218D.380 do 12
not apply to any provision of this act which adds or revises a 13
requirement to submit a report to the Legislature. 14
Sec. 73. The provisions of NRS 354.599 do not apply to any 15
additional expenses of a local government that are related to the 16
provisions of this act. 17
Sec. 74. 1. This section becomes effective upon passage and 18
approval. 19
2. Sections 1 to 73, inclusive, of this act become effective: 20
(a) Upon passage and approval for the purpose s of adopting any 21
regulations, performing any other preparatory administrative tasks 22
that are necessary to carry out the provisions of this act and 23
approving procedures for obtaining prior authorization pursuant to 24
NRS 687B.225, as amended by section 25 of this act, and section 71 25
of this act; and 26
(b) On January 1, 2026, for all other purposes. 27

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