Nevada Revised Statutes 695C.163 – Effect of eligibility for medical assistance under Medicaid; assignment of rights to state agency
1. A health maintenance organization shall not, when considering eligibility for coverage or making payments under a health care plan, consider the availability of, or eligibility of a person for, medical assistance under Medicaid.
Terms Used In Nevada Revised Statutes 695C.163
- Contract: A legal written agreement that becomes binding when signed.
- Dependent: A person dependent for support upon another.
- Enrollee: means a natural person who has been voluntarily enrolled in a health care plan. See Nevada Revised Statutes 695C.030
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Health care plan: means any arrangement whereby any person undertakes to provide, arrange for, pay for or reimburse any part of the cost of any health care services and at least part of the arrangement consists of arranging for or the provision of health care services paid for by or on behalf of the enrollee on a periodic prepaid basis. See Nevada Revised Statutes 695C.030
- Health maintenance organization: means any person which provides or arranges for provision of a health care service or services and is responsible for the availability and accessibility of such service or services to its enrollees, which services are paid for or on behalf of the enrollees on a periodic prepaid basis without regard to the dates health services are rendered and without regard to the extent of services actually furnished to the enrollees, except that supplementing the fixed prepayments by nominal additional payments for services in accordance with regulations adopted by the Commissioner shall not be deemed to render the arrangement not to be on a prepaid basis. See Nevada Revised Statutes 695C.030
- person: means a natural person, any form of business or social organization and any other nongovernmental legal entity including, but not limited to, a corporation, partnership, association, trust or unincorporated organization. See Nevada Revised Statutes 0.039
2. To the extent that payment has been made by Medicaid for health care, a health maintenance organization:
(a) Shall treat Medicaid as having a valid and enforceable assignment of benefits due an enrollee or claimant under the enrollee regardless of any exclusion of Medicaid or the absence of a written assignment; and
(b) May, as otherwise allowed by its plan, evidence of coverage or contract and applicable law or regulation concerning subrogation, seek to enforce any rights of a recipient of Medicaid to reimbursement against any other liable party if:
(1) It is so authorized pursuant to a contract with Medicaid for managed care; or
(2) It has reimbursed Medicaid in full for the health care provided by Medicaid to its enrollee.
3. If a state agency is assigned any rights of a person who is:
(a) Eligible for medical assistance under Medicaid; and
(b) Covered by a health care plan, the organization responsible for the health care plan shall not impose any requirements upon the state agency except requirements it imposes upon the agents or assignees of other persons covered by the same plan.
4. If a state agency is assigned any rights of an enrollee who is eligible for medical assistance under Medicaid, a health maintenance organization shall:
(a) Upon request of the state agency, provide to the state agency information regarding the enrollee to determine:
(1) Any period during which the enrollee, the spouse or a dependent of the enrollee may be or may have been covered by the health care plan; and
(2) The nature of the coverage that is or was provided by the organization, including, without limitation, the name and address of the enrollee and the identifying number of the health care plan;
(b) Respond to any inquiry by the state agency regarding a claim for payment for the provision of any medical item or service not later than 3 years after the date of the provision of the medical item or service; and
(c) Agree not to deny a claim submitted by the state agency solely on the basis of the date of submission of the claim, the type or format of the claim form or failure to present proper documentation at the point of sale that is the basis for the claim if:
‘ (1) The claim is submitted by the state agency not later than 3 years after the date of the provision of the medical item or service; and
(2) Any action by the state agency to enforce its rights with respect to such claim is commenced not later than 6 years after the submission of the claim.