Nevada Administrative Code Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations Nevada Administra
1. Purpose of NAC Chapter 695C
Chapter 695C sets rules for Health Maintenance Organizations (HMOs) and Provider-Sponsored Organizations (PSOs) in Nevada. It ensures that these organizations:
Operate legally and ethically
Protect members who enroll in health plans
Meet financial and service-quality standards
Follow professional and administrative regulations
2. Key Definitions
Health Maintenance Organization (HMO): An organization that provides or arranges healthcare services on a prepaid basis, ensuring access to covered services for enrolled members.
Provider-Sponsored Organization (PSO): A healthcare organization typically owned by providers (hospitals, doctors) that offers managed care services and meets specific federal and state requirements.
Subscriber: An individual or employer who purchases a health plan.
Delivery System Intermediary: A legal entity that contracts with the organization to provide healthcare services.
3. Certificate of Authority
Before operating in Nevada, an HMO or PSO must obtain a certificate of authority from the state Commissioner of Insurance. Requirements include:
Detailed application and supporting documents
Demonstration of financial stability
Adherence to operational and reporting standards
Without this certificate, the organization cannot sell or manage health plans in Nevada.
4. Financial Requirements
HMOs and PSOs must maintain:
Minimum net worth to ensure financial stability
Annual audited financial statements prepared by independent accountants
Periodic reports on financial condition and operations to the Commissioner
Failure to meet these requirements can result in fines, suspension, or revocation of the certificate of authority.
5. Sale and Advertising of Plans
Health plans offered by these organizations must:
Clearly disclose benefits, limitations, and exclusions
Avoid misleading or false advertising
Not solicit customers door-to-door without authorization
Clearly indicate any waiting periods or restrictions
This ensures transparency and protects consumers from deceptive practices.
6. Services and Benefits
HMOs and PSOs must provide comprehensive medically necessary services, including:
Physician services
Hospital care (inpatient and outpatient)
Emergency services
Optional services like dental, vision, and pharmaceuticals (for additional cost if offered)
Members must have access to these services through preselected providers or networks.
7. Provider Contracts
Contracts with healthcare providers must:
Detail provider duties and responsibilities
Ensure medically necessary care is provided
Include minimum contract terms (usually one year)
Protect members from personal liability for covered services
Providers are expected to maintain professional standards and adequate insurance coverage.
8. Administration and Member Rights
Organizations must:
Maintain records of complaints and resolutions
Report complaint statistics annually
Ensure quick resolution of minor issues (within one business day)
Members have rights to fair treatment, access to services, and clear information about their coverage.
9. Prohibited Practices
HMOs and PSOs must:
Avoid misleading advertising
Not use terms like “insurance” or “mutual” unless licensed accordingly
Operate only after certification under Chapter 695C
These rules prevent consumer confusion and maintain professional integrity.
10. Quality Assurance Programs
Organizations must implement programs to monitor care quality, including:
Reviewing outcomes of medical services
Maintaining written procedures for quality assurance
Establishing a committee of healthcare professionals to oversee and improve care
Correcting issues identified in reviews
This ensures that members receive safe and effective healthcare.
Summary
NAC Chapter 695C ensures that HMOs and PSOs in Nevada:
Operate responsibly and ethically
Provide medically necessary care
Maintain financial stability
Follow strict reporting and quality standards
Protect members from unfair practices
It is a comprehensive framework that governs both the financial and operational aspects of healthcare organizations, while safeguarding the rights of patients and ensuring the quality of care.
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