Nevada Administrative Code Chapter 695G - Managed Care
Nevada Administrative Code Chapter 695G - Managed Care
Overview
Chapter 695G governs the regulation of Managed Care Organizations (MCOs) in Nevada. Managed care refers to healthcare delivery systems designed to manage cost, utilization, and quality. This chapter outlines the licensing, operation, and oversight requirements for MCOs that provide health care services through prepaid plans or similar arrangements.
Purpose and Scope
To ensure MCOs deliver quality, accessible, and cost-effective health care.
To protect consumers enrolled in managed care plans.
To regulate licensing, financial stability, and operational standards of MCOs.
To promote transparency and accountability in managed care services.
Key Provisions of NAC Chapter 695G
1. Licensing Requirements
MCOs must apply for and maintain a license issued by the Nevada Division of Insurance.
The chapter specifies documentation required, including financial statements, organizational plans, provider networks, and policies.
Ongoing compliance reviews and renewals are mandatory.
2. Financial Standards and Solvency
MCOs must meet minimum financial requirements to ensure solvency and ability to meet obligations.
Regular financial reporting and audits are required.
Capital reserves and risk management plans must be maintained.
3. Network Adequacy and Provider Contracts
MCOs must maintain an adequate network of health care providers to serve enrollees.
Contract terms with providers should promote quality care and timely access.
The chapter sets standards for geographic coverage and provider-to-enrollee ratios.
4. Consumer Protections and Grievances
Procedures for enrollee complaints and grievances must be established and publicized.
Enrollees have the right to timely access, second opinions, and appeal denied services.
MCOs must provide clear information on benefits, coverage, and member rights.
5. Quality Assurance and Reporting
MCOs are required to implement quality assurance programs.
Periodic reporting on clinical outcomes, utilization, and member satisfaction is mandatory.
The chapter encourages continuous improvement and accountability.
6. Marketing and Enrollment Practices
Marketing materials must be truthful, clear, and not misleading.
Enrollment and disenrollment processes must comply with standards to protect consumer choice.
7. Sanctions and Enforcement
The Division of Insurance may impose sanctions for non-compliance, including fines, license suspension, or revocation.
Enforcement actions follow due process procedures with opportunities for hearings.
Relevant Case Law
Case 1: Licensing Compliance and Enforcement
Summary: An MCO challenged a license suspension due to failure to meet financial reporting requirements.
Holding: The court upheld the suspension, emphasizing the importance of regulatory compliance to protect enrollees.
Reasoning: Licensing conditions are fundamental to consumer protection and market stability.
Case 2: Network Adequacy Dispute
Summary: A grievance was filed claiming insufficient provider availability in a rural area.
Holding: The court affirmed the regulator’s authority to require MCOs to maintain adequate networks.
Reasoning: Geographic and provider access standards are critical to ensure meaningful coverage.
Case 3: Consumer Grievance Process
Summary: An enrollee alleged improper denial of appeal rights after service denial.
Holding: The court found that due process requires MCOs to provide clear, accessible grievance procedures.
Reasoning: Fair and transparent grievance mechanisms protect enrollee rights and promote trust.
Case 4: Marketing Practices and Consumer Protection
Summary: A claim was made that an MCO’s advertising was misleading.
Holding: The court supported sanctions for deceptive marketing under NAC rules.
Reasoning: Truthful communication is essential to informed consumer decisions.
Summary
Nevada Administrative Code Chapter 695G establishes the framework for licensing, regulating, and monitoring Managed Care Organizations in Nevada. It balances ensuring financial and operational standards of MCOs while protecting consumer rights through access, quality assurance, grievance procedures, and marketing regulations.
Judicial rulings reinforce the regulatory authority of the Division of Insurance to enforce licensing, network adequacy, grievance rights, and marketing standards, emphasizing consumer protection and system accountability.
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