1.  A health maintenance organization that issues a health care plan shall include in the plan coverage for:

Terms Used In Nevada Revised Statutes 695C.1728

  • 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 care services: means any services included in the furnishing to any natural person of medical or dental care or hospitalization or incident to the furnishing of such care or hospitalization, as well as the furnishing to any person of any other services for the purpose of preventing, alleviating, curing or healing human illness or injury. 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
  • Provider: means any physician, hospital or other person who is licensed or otherwise authorized in this state to furnish health care services. See Nevada Revised Statutes 695C.030

(a) Necessary case management services for an enrollee who has been diagnosed with sickle cell disease and its variants; and

(b) Medically necessary care for an enrollee who has been diagnosed with sickle cell disease and its variants.

2.  A health maintenance organization that issues a health care plan which provides coverage for prescription drugs shall include in the plan coverage for medically necessary prescription drugs to treat sickle cell disease and its variants.

3.  A health maintenance organization shall establish a plan for each enrollee under 18 years of age who has been diagnosed with sickle cell disease and its variants to transition the enrollee from pediatric care to adult care when the enrollee reaches 18 years of age.

4.  A health maintenance organization may use medical management techniques, including, without limitation, any available clinical evidence, to determine the frequency of or treatment relating to any benefit required by this section or the type of provider of health care to use for such treatment.

5.  As used in this section:

(a) ’Case management services’ means medical or other health care management services to assist patients and providers of health care, including, without limitation, identifying and facilitating additional resources and treatments, providing information about treatment options and facilitating communication between providers of services to a patient.

(b) ’Medical management technique’ means a practice which is used to control the cost or utilization of health care services. The term includes, without limitation, the use of step therapy, prior authorization or categorizing drugs and devices based on cost, type or method of administration.

(c) ’Medically necessary’ has the meaning ascribed to it in NRS 695G.055.

(d) ’Sickle cell disease and its variants’ has the meaning ascribed to it in NRS 439.4927.

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