Nevada Administrative Code Chapter 695C - Health Maintenance Organizations; Provider-Sponsored Organizations Nevada Administra
Here’s a refined summary of Nevada Administrative Code Chapter 695C – Health Maintenance Organizations & Provider‑Sponsored Organizations (effective through Dec 31, 2024):
① General Provisions (§ 695C.010–.060)
Defines HMO and provider‑sponsored organization terms, applicability, and public nature of applications, filings, and reports (§ 695C.105). (law.cornell.edu, casetext.com)
② Certificates of Authority (§ 695C.111–.129)
Establishes licensing requirements:
Application must be verified by an officer and include organizational, financial, governance, and marketing details (§ 695C.115) (law.cornell.edu)
Includes contracts with providers, complaint procedures, geographic service area, and financial statements/3‑year projections.
③ Financial Requirements (§ 695C.130–.137)
HMOs must meet minimum capital and reserves, carry insurance or reinsurance, and maintain proven financial stability. Revisions in 2022 removed some reserve requirements (§ 695C.135/137). (law.cornell.edu)
④ Sale of Health Plans (§ 695C.140–.150)
Sets standards for marketing and enrollment, ensuring clarity and compliance with plan type and cost-sharing rules.
⑤ Services & Benefits (§ 695C.160–.185)
HMOs must clearly define covered services and cost–sharing terms in plan documents; in-network copays may not exceed 50 % of charges (§ 695C.215) (leg.state.nv.us, law.cornell.edu)
⑥ Provider Agreements (§ 695C.190–.215)
Provider contracts must:
Clearly allocate responsibilities
Protect enrollees from balance billing
Last at least one year
Ensure quality standards
Cover all medically necessary services
Include malpractice coverage and, if a physician departs, records transfer provisions (law.cornell.edu)
⑦ Organization Administration (§ 695C.217–.295)
Fully describes systems for:
Enrollee grievance and complaint processes, with annual reporting due June 1 (§ 695C.235) (regulations.justia.com)
Data reporting, compliance systems, governance, broker licensing, and other operational standards.
⑧ Examinations (§ 695C.300–.345)
Commissioner may conduct financial, administrative, and market exams. HMOs are responsible for exam costs, including provider‑sponsored organizations (§ 695C.340). (casetext.com)
⑨ Provider‑Sponsored Organization (PSO) Special Rules (§ 695C.350–.380)
Additional PSO requirements—financial oversight, governance structure, reimbursement flows, and administrative policies—layered over the HMO framework.
⑩ Quality Assurance (§ 695C.400–.430)
Mandates QA programs covering utilization review, credentialing, provider performance monitoring, data collection, and quality improvement initiatives.
⑪ Delivery System Intermediary (§ 695C.500–.550)
Defines governance, contracts, financial criteria, and reporting for DSIs—entities managing care delivery networks on behalf of HMOs.
✅ Summary Table
Topic
Highlights
Definitions (§ 010–060)
Establish key terms; applications are public (§ 105)
Licensing (§ 111–129)
Officer-verified apps with governance & finance details (§ 115)
Finance (§ 130–137)
Minimum capital, reserves/reinsurance; updates removed some reserves
Plan Sales (§ 140–150)
Marketing and enrollment standards
Services & Cost-sharing (§ 160–185)
Copays ≤ 50 % in-network (§ 215)
Provider Contracts (§ 190–215)
Protect enrollees; service obligations; malpractice insurance
Administration (§ 217–295)
Complaints, governance, broker rules
Examinations (§ 300–345)
Exams at insurer expense (§ 340)
PSO Provisions (§ 350–380)
Added oversight for provider-run orgs
Quality Programs (§ 400–430)
Utilization review, credentialing, QA
DSI Rules (§ 500–550)
Structure and governance for network intermediaries
📌 Key Takeaway
Chapter 695C establishes a comprehensive regulatory framework for HMOs and PSOs in Nevada—from licensing and financial stability, to quality care, provider agreements, and grievance systems. The standards ensure enrollees receive transparent, quality coverage through monitored networks and robust oversight.
RELATED Blog
0 comments