AB 290 — Revises provisions relating to prior authorization for medical or dental care under health insurance plans. (BDR 57-861)

Section 2120 of this bill requires thea Directornonprofit ofhospital theand Departmentmedical ofor Healthdental andservice Humancorporation Services to administercomply thewith governingsections Medicaid.2-17.

SectionsSection 22,21 23 and 44 of this bill requirerequires plansthe ofDirector self-ns insurance for employees of local governments, the PublicDepartment Employees’of BenefitsHealth Program and plansHuman ofServices self-insurance for private employers, respectively, to complyadminister with the requirementsprovisions of sections 2-1926-41 of this bill toin the extentsame applicable.manner as other provisions governing Medicaid.

SectionSections 2522, provides23 thatand a44 managedof carethis organizationbill thatrequire providesplans services to recipients of Medicaidself- orProgram theand Children’splans Healthof Insuranceself-insurance Programfor isprivate notemployers, subjectrespectively, to sectionscomply 26-with andthe proceduresrequirements forof coveragesections for2-19 prescriptionof drugsthis underbill Medicaid to complythe withiciesextent sectionsapplicable. 26-41.

THESections PEOPLE12.2 OFand THE34 STATEof OFthis NEVADA,bill REPRESENTEDprovide INthat SENATEa ANDmanaged ASSEMBLY,care DOorganization ENACTthat ASprovides FOLLOWS:services to recipients of Medicaid or the Children’s Health Insurance Program is subject to the requirements of sections 26-41, and is not required to comply with sections 2-19.

Section 42 of this bill requires the policies and procedures for coverage for prescription drugs under Medicaid to comply with sections 26-41.

Section 47.5 of this bill repeals provisions establishing certain requirements relating to prior authorization for dental care which sections 2-19 make redundant.

- *AB290_R1* – 4 – THE PEOPLE OF THE STATE OF NEVADA, REPRESENTED IN SENATE AND ASSEMBLY, DO ENACT AS FOLLOWS:

“Adverse determination” means a determination by a health carrier that an admission,admission availability of care, continued stay or other medical care or dental care that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier’s requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, and the requested care or service or payment for the care or service is therefore denied,denied. reduced or terminated.

- *AB290* – 4 – 2.

Serious jeopardy to the health of ana unbornfetus child of the insured;

Sec.The term additionally includes a utilization review orgSec.

“Individually(Deleted identifiableby healthamendment.)5G.085. information” means information relating to the provision of health care to an insured:

1.

That specifically identifies the insured;

or 2.

For which there is a reasonable basis to believe that the information can be used to identify the insured.

“Insured” means a policyholder, subscriber, enrollee or other person covered by a policy or contract of health insurance issued by a health carrier.

“Network”(Deleted means a defined set of providers of health care who are under contract with a health carrier to provide health care services pursuant to a network plan offered or issued by theamendment.) healthSec. carrier.

Sec.

“Network(Deleted plan” means a contract or policy of insurance offered by aamendment.) healthSec. carrier under which the financing and delivery of medical or dental care is provided, in whole or in part, through a defined set of providers under contract with the health carrier.

Sec.

- *AB290_R1* – 5 – 1.

12.2.

NRS 687B.225 and sections 2 to 17, inclusive, of this act, do not apply to a health maintenance organization or other managed care organization that enters into a contract with the Department of Health and Human Services or the Division of Health Care Financing and Policy of the Department pursuant to NRS 422.273 to provide health care services to recipients of Medicaid under the State Plan for Medicaid or insurance under the Children’s Health Insurance Program to the extent that the organization is providing such services.

Sec.

12.5.

1.

If a health carrier utilizes an artificial intelligence system or automated decision tool to process requests for prior authorization, the health carrier shall make available, in a place that is readily accessible and conspicuous to insureds and the public:

(a) A statement that the health carrier utilizes an artificial intelligence system or automated decision tool to process requests for prior authorization;

(b) A general description of how the artificial intelligence system or automated decision tool works;

and (c) A description of the specific types of information or data utilized by the artificial intelligence system or automated decision tool to generate an outcome.

2.

Except as otherwise provided in subsection 3, a health carrier shall not utilize or employ an artificial intelligence system or automated decision tool to:

(a) Make an adverse determination on a request for prior authorization;

or (b) Terminate, reduce or modify coverage for medical or dental care that was previously approved by the health carrier.

3.

A health carrier may utilize or employ an artificial intelligence system or automated decision tool for a purpose described in subsection 2 if, when the artificial intelligence system or automated decision tool generates an outcome on a request for prior authorization, the request is independently reviewed by a physician or, for a request involving dental care, a dentist, who meets the requirements set forth in paragraph (a) of subsection 1 of section 13 of this act.

- *AB290_R1* – 6 – 4.

As used in this section:

(a) “Artificial intelligence system” means a machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations or decisions influencing real or virtual environments.

(b) “Automated decision tool” means an automated or computerized system that is specifically developed or modified to make, or be a controlling factor in making, consequential decisions.

Sec.

-and *AB290*(2) –Has 5knowledge –or (2)training Isregarding of the sametreatment orof similarthe specialtymedical as a physician or dentist,dental ascondition applicable,involved whoin typicallythe managesrequest or treatshas theexperience medicaltreating or dentalmanaging condition or provides the healthmedical or dental carecondition involved in the request;

and (3) Has experience treating or managing the medical or dental condition involved in the request;

(1) TheA medical director of the health carrier or a similar employee who is in charge of the medical operations of the health carrier;

(a) ImmediatelyNotify notify the provider of health care who submitted the requestrequest, or the person designated by the provider of health care to manage requests for prior authorization, that the medical necessity of the requested care is being questioned by the health carrier;

and (b) Offer the provider of health care who submitted the request, or a colleague of that provider of health care who has the knowledge and ability to provide additional information with respect to the request, an opportunity to speak with the physician or dentist, as applicable, over the telephone or by videoconference - *AB290_R1* – 7 – to discuss the clinical issues involved in the request before the physician or dentist renders an initial determination on the request.

(d) Instructions, written in clear language that is understandable to an ordinary layperson, describing how the - *AB290* – 6 – insured can appeal the adverse determination through the process established pursuant to subsection 4;

(b) EvaluatesHas andknowledge treatsor patientstraining regarding the treatment of the medical or dental condition involved in histhe request or herhas capacityexperience astreating anor activelymanaging practicingthe physicianmedical or dentist,dental ascondition applicable;involved in the request;

(c) IsWas ofnot theinvolved samein ormaking similar specialty as a physician or dentist, as applicable, who typically manages or treats the medicaladverse ordetermination dentalthat conditionis or provides the medicalsubject orof dental care involved in the request;appeal;

(d) HasConsiders experienceall treatingknown orclinical managingaspects of the medical or dental conditioncare involved in the request;

and (e) WasIs notemployed involvedby inor makingcontracted thewith adverse determination that is the subjecthealth ofcarrier: the appeal;

(f)(1) ConsidersTo allparticipate knownin clinicalthe aspectsnetwork of the medicalhealth carrier in his or dentalher carecapacity involvedas ina thepracticing request;physician or dentist, as applicable;

andor (g)- Is*AB290_R1* employed– by8 or– contracted(2) withPrimarily theto healthmake carrierdeterminations to:on reviews or appeals of adverse determinations.

(1)6. Participate in the network of the health carrier in his or her capacity as a practicing physician or dentist, as applicable;

orAs (2)used Solelyin makethis determinationssection: on reviews or appeals of adverse determinations.

(a) “Network” means a defined set of providers of health care who are under contract with a health carrier to provide health care services pursuant to a network plan offered or issued by the health carrier.

(b) “Network plan” means a contract or policy of insurance offered by a health carrier under which the financing and delivery of medical or dental care is provided, in whole or in part, through a defined set of providers under contract with the health carrier.

IfExcept as otherwise provided in subsection 2, if a health carrier approves a request for prior authorization,authorization and the process to provide the approved medical or dental care has been initiated, the approval remains valid until 126 months after the date on which the request is approved.

AExcept as otherwise provided in this this subsection, if a health carrier shallapproves nota revokerequest orfor imposeprior anauthorization additionalfor limit,a conditioncontinuous orcourse restrictionof ontreatment that relates to a chronic or long- term condition which is specifically identified in the request for prior authorizationauthorization, thatthe approval remains valid until 12 months after the healthdate carrieron haswhich previouslythe health carrier approved unless:the request.

(a)A Thehealth carrier may require additional prior authorization for medical or dental care atthat issuerepresents ina substantial deviation from the requestcourse wasof nottreatment providedindicated toin the insuredprevious withinrequest 90for businessprior daysauthorization afterthat thewas healthapproved carrierby received the request;health carrier.

(b) The health carrier determines that an insured or a provider of health care procured the approval by fraud or material misrepresentation;

or - *AB290* – 7 – (c) The health carrier determines that the care at issue in the request was not covered by the health carrier at the time the care was provided.

A health carrier that has approved a request for prior authorization shall not denyrevoke or refuseimpose toan promptlyadditional paylimit, acondition claim for the approved medical or dentalrestriction careon unlessa therequest healthfor carrierprior determinesauthorization that the insured or provider of health carecarrier procuredhas thepreviously priorapproved authorizationunless: by fraud or material misrepresentation.

(a) The claim must be paid at the same rate that the health carrier isdetermines contractuallythat obligatedan toinsured or would ordinarily pay a provider of health care forprocured providing the specificapproval typeby offraud careor thatmaterial wasmisrepresentation; approved and provided to the insured.

(b) The health carrier determines that the care at issue in the request was not covered by the health carrier at the time the care was provided;

or (c) The coverage period of the policy or contract of insurance under which the insured was covered at the time of the approval has ended and the insured is currently covered under a different policy or contract of insurance which imposes a lower cost- sharing obligation for the relevant medical or dental care.

A health carrier that has approved a request for prior authorization shall not deny or refuse to promptly pay a claim for the approved medical or dental care unless the health carrier determines that the insured or provider of health care procured the prior authorization by fraud or material misrepresentation.

- *AB290_R1* – 9 – 5.

(a) The approval was issued within the 126 months immediately preceding the first day of the coverage period under the current contract or policy of insurance;

and (b) The specificinsured medical or dentalhis careor includedher withinprovider theof requesthealth iscare notfurnishes affirmativelythe excludedhealth undercarrier thewith termscomplete anddocumentation conditionswith ofrespect to the contractprior orapproval policyin ofa insurancetimely issuedmanner, byif the health carrier.carrier requests such documentation;

5.and (c) The specific medical or dental care included within the request is not affirmatively excluded under the terms and conditions of the contract or policy of insurance issued by the health carrier.

6.

Nothing in this section shall be construed to prohibit a health carrier from subsequently reducing or eliminating a cost- sharing obligation imposed against an insured for medical or dental care for which the health carrier has previously granted prior authorization.

7.

3.

A health carrier shall not deny coverage for emergency services covered by the health carrier that are medically necessary.

Emergency services are presumed to be medically necessary if, within 72 hours after an insured is admitted to receive emergency services, the insured’s provider of health care transmits to the health carrier a certification, in writing, that the condition of the - *AB290* – 8 – insured required emergency services.

The health carrier may rebut that presumption by establishing, by clear and convincing evidence, that the emergency services were not medically necessary.

4.

A health carrier shall make all determinations for whether emergency services are medically necessary without regard to whether a provider of health care that provided or billed for those services participates in the network of the health carrier.

If a health carrier violates NRS 687B.225 or section 12.5, 13, 14 or 15 of this act with respect to a particular request for prior authorization, the request shall be deemed approved.

Nothing in NRS 687B.225 or sectionsections 13,12.5 14to or15, 15inclusive, of this act shall be construed to require a health carrier to provide coverage:

- *AB290_R1* – 10 – (a) For medical or dental care that, regardless of whether such care is medically necessary, would not be a covered benefit under the terms and conditions of the contract or policy of insurance;

On or before March 1 of each calendar year, a health carrier that requires insureds to obtain prior authorization for medical or dental care shall compile and transmit to the Commissioner, in a form prescribed by the Commissioner, and publish on an Internet website maintained by the health carrier in an easily accessible format the following information for the immediately preceding calendarplan year, in aggregated form for all requests for prior authorization received by the insurerhealth carrier during the immediately preceding plan year for urgent and non- urgent care and disaggregated in accordance with subsection 2:

(a) The percentagenumber of initial requests for prior authorization for medical or dental care in this State that were approved upon initial review;

(b) The percentagenumber of initial requests for prior authorization for medical or dental care in this State that resulted in an adverse determination upon initial review;

(c) The percentagenumber of the adverse determinations described in paragraph (b) that were appealed;

(d) The percentagenumber of appeals of adverse determinations described in paragraph (c) that resulted in a reversal of the adverse determination;

and - *AB290* – 9 – (f) The average time betweenbetween: a request for prior authorization for medical or dental care in this State and the resolution of the request.

(1) The submission of an initial request for prior authorization for medical or dental care in this State and the response to the request;

and (2) The submission of an appeal of an adverse determination on a request for prior authorization for medical or dental care in this State and the resolution of the appeal.

(a) TheRequests specialtyfor ofurgent the provider of health care whoand submittednon-urgent ahealth requestcare; for prior authorization;

and- *AB290_R1* – 11 – (b) The typesspecialty of healththe orprovider dentalof health care atwho issuesubmitted ina the request for prior authorization,authorization; including the specific types of prescription drugs, procedures or diagnostic tests involved in the requests.

and (c) The types of medical or dental care at issue in the request for prior authorization, including the specific types of prescription drugs, procedures or diagnostic tests involved in the requests.

Sec.4.

18.

1.

On or before March 1 of each calendar year, a health carrier shall compile and transmit to the Commissioner, in a form prescribed by the Commissioner, and publish on an Internet website maintained by the health carrier a report containing the following information:

(a) The specific goods and services for which the health carrier requires prior authorization and, for each good or service:

(1) The date on which prior authorization for that good or service became required for contracts or policies issued or delivered in this State and the date on which that requirement was listed on the Internet website of the health carrier pursuant to subsection 6 of NRS 687B.225;

(2) The number of requests for prior authorization received by the health carrier during the immediately preceding calendar year for the provision of the good or service to insureds in this State;

(3) The number and percentage of the requests listed pursuant to subparagraph (2) that were approved;

(4) The number and percentage of the requests listed pursuant to subparagraph (2) that resulted in adverse determinations;

and (5) The number of appeals from adverse determinations during the immediately preceding calendar year and the percentage of those appeals that were reversed on appeal by the health carrier.

(b) For all requests for prior authorization for non-urgent health or dental care received by the health carrier during the immediately preceding calendar year, the average and median time between:

(1) The health carrier receiving a request for prior authorization and the health carrier approving or making an adverse determination on the request;

and - *AB290* – 10 – (2) The submission of an appeal of an adverse determination on a request for prior authorization and the resolution of the appeal.

(c) For all requests for prior authorization for urgent health care received by the health carrier during the immediately preceding calendar year, the average and median time between:

(1) The health carrier receiving a request for prior authorization and the health carrier approving or making an adverse determination on the request;

and (2) The submission of an appeal of an adverse determination on a request for prior authorization and the resolution of the appeal.

2.

3.5.

AAs healthused carrierin shallthis notsection, include“individually individually identifiable health information” means information inrelating ato reportthe publishedprovision pursuantof medical or dental care to subsectionan 1.insured:

(a) That specifically identifies the insured;

or (b) For which there is a reasonable basis to believe that the information can be used to identify the insured.

18.

(Deleted by amendment.) Sec.

The - *AB290**AB290_R1* – 1112 – insurer or organization] health carrier in a manner consistent with this section and sections 2 to 18, inclusive, of this act.

(a) File its procedure for obtaining [approval of care] prior authorization pursuant to this section , including, without limitation, a list of the specificitems goods and services for which the health carrier requires prior authorization and the clinical review criteria used by the health carrier to evaluate requests for prior authorization, for approval by the Commissioner .

and] (b) Unless a shorter time period is prescribed by a specific statute, including, without limitation, NRS 689A.0446, 689B.0361, 689C.1688, 695A.1859, 695B.19087, 695C.16932 and 695G.1703, [respond to] and except as otherwise provided by paragraph (c), approve or make an adverse determination on any request for [approval by the insured or member] prior authorization submitted by or on behalf of the insured pursuant to this section [within 20 days after it receives the request.] and notify the insured and his or her provider of health care, or the person designated by the provider of health care to manage requests for prior authorization, of the approval or adverse determination:

(1) For non-urgent medical or dental care, within 57 days after receiving the request.

(2) For urgent health care, within 2448 hours after receiving the request.

(1) Notify the insured and the provider of health care who submitted the requestrequest, or the person designated by the provider of health care to manage requests for prior authorization, within the applicable amount of time described in paragraph (b) that additional information is required to evaluate the request;

(I) For non-urgent medical or dental care, within 57 days after receiving the information.

(II) For urgent health care, within 2448 hours after receiving the information.

- *AB290_R1* – 13 – 4.

IfA a health carrier seeksshall topublish amend its procedureprocedures for obtaining prior authorization, including, without limitation, -the *AB290*clinical –review 12criteria –and changing the goodslist of items and services for which the health carrier requires prior authorization orand changingthe dates on which the clinicalhealth reviewcarrier criteriabegan usedrequiring byprior theauthorization healthin carrier,this theState healthfor carrier:each item or service, on its Internet website:

(a) Must file a request to amend the procedure for approval by the Commissioner.

(b) May not allow the amended procedure to take effect until:

(1) The Commissioner notifies the health carrier that the request is approved;

and (2) The health carrier satisfies the requirements of subsection 5 after the health carrier receives a notice of approval from the Commissioner.

5.

A change to a health carrier’s procedure for obtaining prior authorization may not take effect until:

(a) The health carrier transmits a notice that contains a summary of the changes to the procedure to each of its insureds and providers of health care who participate in the network of the health carrier;

(b) The health carrier updates the information published on its Internet website pursuant to subsection 6 to reflect the amended procedure for obtaining prior authorization and the date on which the amended procedure takes effect;

and (c) At least 60 days have passed after the later of:

(1) The date on which the health carrier transmitted the notice to its insureds and providers of health care who participate in the network of the health carrier pursuant to paragraph (a);

or (2) The date on which the health carrier updated the information published on its Internet website pursuant to paragraph (b).

6.

A health carrier shall publish its procedures for obtaining prior authorization, including, without limitation, the clinical review criteria, on its Internet website:

7.5.

8.6.

As used in this section, “clinical review criteria” means any written screening procedure, decision abstract, clinical protocol or practice guideline used by the health carrier to - *AB290* – 13 – determine the necessity and appropriateness of medical or dental care.

- *AB290_R1* – 14 – (2) The Administrator of the Division of Welfare and Supportive Services;

- *AB290* – 14 – (c) Shall administer any state program for persons with developmental disabilities established pursuant to the Developmental Disabilities Assistance and Bill of Rights Act of 2000, 42 U.S.C.

and (6) Contain any other information necessary for the Department to communicate effectively with the Federal Government concerning demographic trends, formulas for the - *AB290_R1* – 15 – distribution of federal money and any need for the modification of programs administered by the Department.

(a) Adopt and carry into effect a system of group life, accident or health insurance, or any combination thereof, for the benefit of its officers and employees, and the dependents of officers and - *AB290* – 15 – employees who elect to accept the insurance and who, where necessary, have authorized the governing body to make deductions from their compensation for the payment of premiums on the insurance.

Any contract with an independent administrator must be approved by the - *AB290_R1* – 16 – Commissioner of Insurance as to the reasonableness of administrative charges in relation to contributions collected and benefits provided.

The provisions of NRS 439.581 to 439.597, inclusive, 686A.135, paragraphs (b) and (c) of subsection 2 and subsections 1, 3, 5,4 6 and 75 of NRS 687B.225, 687B.352, 687B.408, 687B.692, 687B.723,[687B.723,] 687B.725, 687B.805, 689B.030 to 689B.0317, inclusive, paragraphs (b) and (c) of subsection 1 of NRS 689B.0319, subsections 2, 4, 6 and 7 of NRS 689B.0319, 689B.033 to 689B.0369, inclusive, 689B.0375 to 689B.050, inclusive, 689B.0675, 689B.265, 689B.287 and 689B.500 and sections 2 to 18, inclusive, of this act apply to coverage provided pursuant to this paragraph, except that the provisions of NRS 689B.0378, 689B.03785 and 689B.500 only apply to coverage for active officers and employees of the governing body, or the dependents of such officers and employees.

The money for contributions must be budgeted for in accordance with the laws governing the county, school district, municipal corporation, - *AB290* – 16 – political subdivision, public corporation or other local governmental agency of the State of Nevada.

(a) Shall be deemed, solely for the purposes of this section, to be officers and employees of the county, school district, municipal corporation, political subdivision, public corporation or other local - *AB290_R1* – 17 – governmental agency with which the legal services organization has contracted;

287.04335 If the Board provides health insurance through a plan of self-insurance, it shall comply with the provisions of - *AB290* – 17 – NRS 439.581 to 439.597, inclusive, 686A.135, paragraphs (b) and (c) of subsection 2 and subsections 1, 3, 5,4 6 and 75 of NRS 687B.225, 687B.352, 687B.409, 687B.692, 687B.723,[687B.723,] 687B.725, 687B.805, 689B.0353, 689B.255, 695C.1723, 695G.150, 695G.155, 695G.160, 695G.162, 695G.1635, 695G.164, 695G.1645, 695G.1665, 695G.167, 695G.1675, 695G.170 to 695G.1712, inclusive, 695G.1714 to 695G.174, inclusive, 695G.176, 695G.177, 695G.200 to 695G.230, inclusive, 695G.241 to 695G.310, inclusive, 695G.405 and 695G.415, and sections 2 to 18, inclusive, of this act in the same manner as an insurer that is licensed pursuant to title 57 of NRS is required to comply with those provisions.

1.(Deleted by amendment.) Sec.

The provisions of sections 26 to 41, inclusive, of this act and any policies developed pursuant thereto do not apply to the delivery of services to recipients of Medicaid or the Children’s Health Insurance Program through managed care in accordance with NRS 422.273.

2.

A health maintenance organization or other managed care organization that enters into a contract with the Department or the Division pursuant to NRS 422.273 to provide health care services to recipients of Medicaid under the State Plan for Medicaid or the Children’s Health Insurance Program shall comply with NRS 687B.225 and sections 2 to 18, inclusive, of this act.

Sec.

“Adverse determination” means a determination by the Department thator ana admission,Medicaid availabilitymanaged ofcare care,entity continuedthat stayan admission or other medical care or dental care that is a covered benefit has been reviewed and, based upon the information provided, does not meet the Department’srelevant requirements for medical necessity, appropriateness, health care setting, level of care or - *AB290_R1* – 18 – effectiveness, and the requested care or service or payment for the care or service is therefore denied,denied. reduced or terminated.

“Emergency(Deleted services” means health care services that are provided by aamendment.) providerSec. of health care to screen and to stabilize a recipient after the sudden onset of a medical condition that manifests itself by symptoms of such sufficient severity that a prudent person would believe that the absence of immediate medical attention could result in:

1.

Serious jeopardy to the health of the recipient;

- *AB290* – 18 – 2.

Serious jeopardy to the health of an unborn child of the recipient;

3.

Serious impairment of a bodily function of the recipient;

or 4.

Serious dysfunction of any bodily organ or part of the recipient.

Sec.

29.5.

“Medicaid managed care entity” means:

1.

A health maintenance organization or other managed care organization that enters into a contract with the Department or the Division pursuant to NRS 422.273 to provide health care services to recipients of Medicaid under the State Plan for Medicaid or the Children’s Health Insurance Program;

or 2.

A utilization review organization, as defined in NRS 695G.085, that conducts utilization reviews for the Department or a health maintenance organization or managed care organization described in subsection 1 with respect to Medicaid or the Children’s Health Insurance Program.

Sec.

“Medically1. necessary” has the meaning ascribed to it in NRS 695G.055.

Except as otherwise provided in subsection 2 or where otherwise required by federal law, “medically necessary” has the meaning ascribed to it in NRS 695G.055.

2.

If federal law or regulations define “medically necessary” for purposes related to Medicaid or the Children’s Health Insurance Program differently from the manner in which that term is defined in subsection 1, the Department may, by regulation, adopt the definition established by federal law or regulations.

Any such definition supersedes the definition established in subsection 1.

“Provider of health care” hasmeans a person who participates in the meaningState ascribedPlan tofor itMedicaid inor NRSthe 695G.070.Children’s Health Insurance Program as a provider of items or services.

“Urgent(Deleted healthby care”:amendment.) Sec.

1.

Means health care that, in the opinion of a provider of health care with knowledge of a recipient’s medical condition, if not rendered to the recipient within 48 hours could:

(a) Seriously jeopardize the life or health of the recipient or the ability of the recipient to regain maximum function;

or (b) Subject the recipient to severe pain that cannot be adequately managed without receiving such care.

2.

Does not include emergency services.

Sec.

The Department, with respect to Medicaid and the Children’s Health Insurance Program, shall establish written procedures for obtaining prior authorization for medical or dental care whichwhich: must include, without limitation:

(a) AApply listto the delivery of themedical specificor goodsdental andcare servicesto forrecipients whichof Medicaid or the DepartmentChildren’s requiresHealth priorInsurance authorization;Program:

and(1) (b)Directly A description of the clinical review criteria used by the Department.Department;

and - *AB290_R1* – 19 – (2) Through managed care in accordance with NRS 422.273;

and (b) Must include, without limitation:

(1) A list of the items and services for which the Department requires prior authorization;

and (2) A description of the clinical review criteria used by the Department.

The Department and each Medicaid managed care entity shall publish the written procedures for obtaining prior authorization established by the Department pursuant to subsection 1, including, without limitation, the clinical review criteria, on an Internet website maintained by the Department:Department or the Medicaid managed care entity, as applicable:

- *AB290* – 19 – 3.

If the Department amends the procedure for obtaining prior authorization adopted pursuant to subsection 1, including, without limitation, changing the goodsitems and services for which the Department requires prior authorization or changing the clinical review criteria used by the Department, the Department shall:and each Medicaid managed care entity shall update the information published on its Internet website pursuant to subsection 2 to reflect the amended procedure for obtaining prior authorization and the date on which the amended procedure takes effect.

(a) Transmit a notice containing a summary of the changes made to the procedure to each recipient and each provider of goods or services under Medicaid or the Children’s Health Insurance Program, as applicable;

and (b) Update the information published on its Internet website pursuant to subsection 2 to reflect the amended procedure for obtaining prior authorization and the date on which the amended procedure takes effect.

A change to the Department’s procedure for obtaining prior authorization may not take effect until 60the daysdate haveon passedwhich afterthe Department updated the laterinformation of:published on its Internet website pursuant to subsection 3.

(a) The date on which the Department transmitted the notice to recipients and providers of goods or services under Medicaid or the Children’s Health Insurance Program, as applicable, pursuant to paragraph (a) of subsection 3;

or (b) The date on which the Department updated the information published on its Internet website pursuant to paragraph (b) of subsection 3.

The Department or a Medicaid managed care entity shall not deny a claim based on the failure of a recipient to obtain prior authorization for medical or dental care if the procedure for obtaining prior authorization established by the Department pursuant to this section did not require the recipient to obtain prior authorization for that medical or dental care on the date that the medical or dental care was provided to the recipient.

Unless a shorter time period is prescribed by a specific statute, and except as otherwise provided in subsectionsubsections 2,2 and 3, the Department,Department or a Medicaid managed care entity, with - *AB290_R1* – 20 – respect to Medicaid and the Children’s Health Insurance Program, shall approve or make an adverse determination on a request for prior authorization submitted by or on behalf of a recipient and notify the recipient and his or her provider of health care, or the person designated by the provider of health care to manage requests for prior authorization, of the approval or adverse determination:determination within 7 days after receiving the request.

(a) For non-urgent medical or dental care, within 5 days after receiving the request.

- *AB290* – 20 – (b) For urgent health care, within 24 hours after receiving the request.

If the Department or Medicaid managed care entity requires additional, medically relevant information or documentation in order to adequately evaluate a request for prior authorization, the Department or Medicaid managed care entity, as applicable, shall:

(a) Notify the recipient and the provider of health care who submitted the requestrequest, withinor the applicableperson amountdesignated by the provider of timehealth describedcare into subsectionmanage 1requests for prior authorization, within 7 days after receiving the request that additional information is required to evaluate the request;

(b) Include within the notification sent pursuant to paragraph (a) a description, with reasonable specificity, of the information that the Department or Medicaid managed care entity, as applicable, requires to make a determination on the request for prior authorization;

and (c) Approve or make an adverse determination on the request:request within 7 days after receiving the information.

(1)3. For non-urgent medical or dental care, within 5 days after receiving the information.

(2)The Forprovisions urgentof healththis care,section withindo 24not hoursapply afterto receivingrequests thefor information.prior authorization for prescription drugs, for personal care services or for services which are provided under Medicaid pursuant to 42 U.S.C.

§ 1396n(i) or a waiver granted pursuant to 42 U.S.C.

§ 1396n(c) by the Secretary of Health and Human Services.

The Department,Department or a Medicaid managed care entity, with respect to Medicaid and the Children’s Health Insurance Program, shall not make an adverse determination on a request for prior authorization unless the adverse determination is made by a physicianphysician, a pharmacist or, for a request relating to dental care, a dentist, who:

(a) Holds an unrestricted license to practice medicinemedicine, pharmacy or dentistry, as applicable, in any state or territory of the United States;

and (b) Is acting within the scope of his or her practice with respect to evaluating the particular medical or dental care involved in the request and, to the extent practicable, is of the same or similar specialty as a physicianphysician, pharmacist or dentist, as applicable, who typically manages or treats the medical or dental condition or provides the medical or dental care involved in the request;request.

and- (c)*AB290_R1* Has– experience21 treating– or2. managing the medical or dental condition involved in the request.

2.Upon rendering an adverse determination on a request for prior authorization, the Department or a Medicaid managed care entity, as applicable, shall immediately transmit to the recipient to whom the request pertains a written notice that contains:

If(a) aA physicianspecific ordescription dentistof describedall inreasons subsection 1 is considering making an adverse determination on a request for prior authorization on the basis that the medicalDepartment or dentalMedicaid managed care involvedentity, inas theapplicable, requestmade is not medically necessary, the Departmentadverse shall:determination;

(a)(b) ImmediatelyA notifydescription of any documentation that the Department or Medicaid managed care entity, as applicable, requested from the recipient or a provider of health care whoof submitted the requestrecipient thatand thedid medicalnot necessityreceive ofor deemed insufficient, if the requestedfailure careto isreceive beingsufficient questioneddocumentation bycontributed to the Department;adverse determination;

and (b) Offer the provider of health care an opportunity to speak with the physician or dentist, as applicable, over the telephone or by videoconference to discuss the clinical issues involved in the request before the physician or dentist renders an initial determination on the request.

- *AB290* – 21 – 3.

Upon rendering an adverse determination on a request for prior authorization, the Department shall immediately transmit to the recipient to whom the request pertains a written notice that contains:

(a) A specific description of all reasons that the Department made the adverse determination;

(b) A description of any documentation that the Department requested from the recipient or a provider of health care of the recipient and did not receive or deemed insufficient, if the failure to receive sufficient documentation contributed to the adverse determination;

(d) Instructions, written in clear language that is understandable to an ordinary layperson, describing how the recipient can appeal the adverse determination through the process for appeals established pursuant to subsection 4;3;

4.3.

The processDepartment mustmay allowelect forto utilize the clearprocedures resolutionfor hearings established for appeals of eachdenials appealof withinclaims aof reasonablebenefits time.under Medicaid pursuant to NRS 422.275 to 422.280, inclusive, to satisfy that requirement.

5.If the Department utilizes such procedures for that purpose, the Department shall, upon the request of a hearing officer, make available to the hearing officer a licensed medical professional, which may include the Medical Director for Medicaid, as available, to provide clinical input and expertise which may be necessary to evaluate the appeal of an adverse determination.

The4. Department shall not uphold on appeal an adverse determination pertaining to a request for prior authorization unless the decision on the appeal is made by a physician, or, for an appeal relating to dental care, a dentist, who:

(a)Notwithstanding Holdsthe anprovisions unrestrictedof licensesubsection to3, practicea medicineMedicaid ormanaged dentistry,care asentity applicable,may inestablish anya stateseparate orprocess territorythat ofallows thea Unitedrecipient States;to appeal an adverse determination on a request for prior authorization.

(b)If Evaluatesthe andMedicaid treatsmanaged patientscare inentity hisdoes ornot herreverse capacitythe asadverse andetermination activelyafter practicingthe physicianexhaustion orof dentist,that asprocess, applicable;the recipient my appeal to the Department pursuant to subsection 3.

(c)Sec. Is of the same or similar specialty as a physician or dentist, as applicable, who typically manages or treats the medical or dental condition or provides the medical or dental care involved in the request;

(d) Has experience treating or managing the medical or dental condition involved in the request;

(e) Was not involved in making the adverse determination that is the subject of the appeal;

(f) Considers all known clinical aspects of the medical or dental care involved in the request;

and (g) Is employed by or contracted with the Department solely to make determinations on appeals of adverse determinations.

- *AB290* – 22 – Sec.

If the Department or a Medicaid managed care entity approves a request for prior authorization, the approval remains valid until 12 months after the date on which the request is approved.approved or, if federal law establishes a different amount of time for which a request for prior authorization is required to remain valid, the amount of time established by the federal law.

- *AB290_R1* – 22 – 2.

The Department or a Medicaid managed care entity shall not revoke or impose an additional limit, condition or restriction on a request for prior authorization that the Department or Medicaid managed care entity, as applicable, has previously approved unless:

(a) The care at issue in the request was not provided to the recipient within 90 business days after the Department or Medicaid managed care entity, as applicable, received the request;

(b) The Department or Medicaid managed care entity, as applicable, determines that a recipient or a provider of health care procured the approval by fraud or material misrepresentation;

or (c) The Department or Medicaid managed care entity, as applicable, determines that the care at issue in the request was not covered by Medicaid or the Children’s Health Insurance Program, as applicable, at the time the care was provided.

If the Department or a Medicaid managed care entity has approved a request for prior authorization, the Department or Medicaid managed care entity, as applicable, shall not deny or refuse to promptly pay a clean claim for the approved medical or dental care unlessunless: the Department determines that the recipient or provider of health care procured the prior authorization by fraud or material misrepresentation.

(a) The claim must be paid at the same rate that the Department is contractuallynot obligatedtimely tosubmitted; or would ordinarily pay a provider of health care for providing the specific type of care that was approved and provided to the recipient.

(b) The claim is not submitted in accordance with the requirements of the Department or the Federal Government;

or (c) The Department or Medicaid managed care entity, as applicable, determines that the recipient or provider of health care procured the prior authorization by fraud or material misrepresentation.

WithinIf the firstDepartment 90or daysa thatMedicaid managed care entity does not deny a recipientclean isclaim enrolledfor inapproved Medicaidmedical or dental care pursuant to subsection 3, the Children’sDepartment Healthor InsuranceMedicaid Program,managed care entity, as applicable, shall pay the Departmentclaim shallat honorthe asame requestrate forthat priorthe authorizationDepartment thator hasMedicaid beenmanaged approvedcare byentity, aas healthapplicable, carrieris orcontractually otherobligated entityto thator previouslywould providedordinarily thepay recipienta withprovider coverageof health care for medicalproviding orthe dentalspecific type of care if:that was approved and provided to the recipient.

(a) The approval was issued within the 12 months immediately preceding the first day of the enrollment of the recipient;

and (b) The specific medical or dental care included within the request is not affirmatively excluded under the terms and conditions of Medicaid or the Children’s Health Insurance Program, as applicable.

As used in this section, “health“clean carrier”claim” has the meaning ascribed to it in NRS42 695G.024C.F.R. and includes, without limitation, an organization for dental care.

§ 447.45.

The Department,Department or a Medicaid managed care entity, with respect to Medicaid and the Children’s Health Insurance Program, shall not require prior authorization for covered emergency services, including, where applicable, transportation by ambulance to a hospital or other medical facility.

- *AB290* – 23 – 2.

If the Department or a Medicaid managed care entity requires a recipient or his or her provider of health care to notify - *AB290_R1* – 23 – the Department or Medicaid managed care entity, as applicable, that the recipient has been admitted to a hospital to receive emergency services or has received emergency services, the Department or Medicaid managed care entity, as applicable, shall not require a recipient or a provider of health care to transmit such a notice earlier than the end of the business day immediately following the day after the date on which the recipient was admitted or the emergency services were provided, as applicable.

The Department or a Medicaid managed care entity shall not deny coverage for emergency services covered by Medicaid or the Children’s Health Insurance Program that are medically necessary.

Emergency services are presumed to be medically necessary if, within 72 hours after a recipient is admitted to receive emergency services, the recipient’s provider of health care transmits to the Department or Medicaid managed care entity, as applicable, a certification, in writing, that the condition of the recipient required emergency services.

The Department or Medicaid managed care entity may rebut that presumption by establishing, by clear and convincing evidence, that the emergency services were not medically necessary.

4.

As used in this section, “emergency services” means health care services that are provided by a provider of health care to screen and to stabilize a recipient after the sudden onset of a medical condition that manifests itself by symptoms of such sufficient severity that a prudent person would believe that the absence of immediate medical attention could result in:

(a) Serious jeopardy to the health of the recipient;

(b) Serious jeopardy to the health of a fetus of the recipient;

(c) Serious impairment of a bodily function of the recipient;

or (d) Serious dysfunction of any bodily organ or part of the recipient.

Nothing in sections 34 to 38, inclusive, of this act shall be construed to require the Department or a Medicaid managed care entity to provide coverage:

IfFor themedical Departmentor violatesdental sectionscare 34that, toregardless 38,of inclusive,whether ofsuch thiscare actis withmedically respectnecessary, towould not be a particularcovered requestbenefit forunder priorthe authorization,terms and conditions of Medicaid or the requestChildren’s shallHealth beInsurance deemedProgram, approved.as applicable;

or 2.

NothingTo ina sectionsperson 34who tois 38,not inclusive,a ofrecipient thisor actis shallnot beotherwise construedeligible to requirereceive coverage under Medicaid or the DepartmentChildren’s Health Insurance Program, as applicable, on the date on which medical or dental care is provided to providethe coverage:person.

(a) For medical or dental care that, regardless of whether such care is medically necessary, would not be a covered benefit under the terms and conditions of Medicaid or the Children’s Health Insurance Program, as applicable;

or (b) To a person who is not a recipient or is not otherwise eligible to receive coverage under Medicaid or the Children’s Health Insurance Program, as applicable, on the date on which medical or dental care is provided to the person.

On or before March 1 of each calendar year, the Department and each Medicaid managed care entity shall publish on an Internet website maintained by the Department or Medicaid - *AB290_R1* – 24 – managed care entity, as applicable, in an easily accessible format the following information for the immediately preceding calendar year, in aggregated form for all requests for prior authorization received by the insurerDepartment or Medicaid managed care entity, as applicable, during the immediately preceding year and disaggregated in accordance with subsection 2:

(a) The percentagenumber of initial requests for prior authorization for medical or dental care that were approved upon initial review;

(b) The percentagenumber of initial requests for prior authorization for medical or dental care that resulted in an adverse determination upon initial review;

(c) The percentagenumber of the adverse determinations described in paragraph (b) that were appealed;

- *AB290* – 24 – (d) The percentagenumber of appeals of adverse determinations described in paragraph (c) that resulted in a reversal of the adverse determination;

and (f) The average time betweenbetween: a request for prior authorization for medical or dental care in this State and the resolution of the request.

(1) The submission of an initial request for prior authorization for medical or dental care in this State and the response to the request;

and (2) The submission of an appeal of an adverse determination on a request for prior authorization for medical or dental care and the resolution of the appeal.

and (b) The types of healthmedical or dental care at issue in the request for prior authorization, including the specific types of prescription drugs, procedures or diagnostic tests involved in the requests.

The Department or a Medicaid managed care entity shall not include individually identifiable health information in the information published pursuant to subsection 1.

On or before March 1 of each calendar year, the Department and each Medicaid managed care entity shall:

(1) The specificitems goods and services for which the Department or Medicaid managed care entity requires prior authorization and, for each gooditem or service:

(I) The date on which the Department or Medicaid managed care entity began requiring prior authorization for that gooditem or serviceservice; and the date on which that requirement was listed on the Internet website of the Department pursuant to section 34 of this act;

- *AB290_R1* – 25 – (II) The number of requests for prior authorization received by the Department or Medicaid managed care entity during the immediately preceding calendar year for the provision of the gooditem or service;

and (V) The number of appeals from adverse determinations during the immediately preceding calendar year and the percentage of those appeals that were reversed on appeal by the Department;Department or Medicaid managed care entity;

(2) For all requests for prior authorization forreceived non-urgentby healththe Department or dentalMedicaid managed care receivedentity by the Department during the immediately preceding calendar year, the average and median time between:

-(I) *AB290*The –Department 25or –Medicaid (I)managed Thecare Departmententity receiving a request for prior authorization and the Department or Medicaid managed care entity approving or making an adverse determination on the request;

and(b) (3)Post Forthe allreport requestson forthe priorInternet authorizationwebsite formaintained urgent health care received by the Department duringor theMedicaid immediatelymanaged precedingcare calendarentity; year, the average and median time between:

(I) The Department receiving a request for prior authorization and the Department approving or making an adverse determination on the request;

and (II) The submission of an appeal of an adverse determination on a request for prior authorization and the resolution of the appeal;

(b) Post the report on the Internet website maintained by the Department;

The Department or a Medicaid managed care entity shall not include individually identifiable health information in a report published pursuant to subsection 1.

and - *AB290_R1* – 26 – (c) Review and approve, based on clinical evidence and best clinical practice guidelines and without consideration of the cost of the prescription drugs being considered, step therapy protocols used by the Medicaid program for prescription drugs.

(a) The drug has been approved by the Food and Drug Administration with indications for the psychiatric condition of the - *AB290* – 26 – insured or the use of the drug to treat that psychiatric condition is otherwise supported by medical or scientific evidence;

- *AB290_R1* – 27 – Sec.

NRS(Deleted 439B.736by isamendment.) herebySec. amended to read as follows:

439B.736 1.

“Third party” includes, without limitation:

(a) The issuer of a health benefit plan, as defined in NRS 695G.019 ;

[, which provides coverage for medically necessary emergency services;] (b) The Public Employees’ Benefits Program established pursuant to subsection 1 of NRS 287.043;

(c) The Public Option established pursuant to NRS 695K.200;

and - *AB290* – 27 – (d) Any other entity or organization that elects pursuant to NRS 439B.757 for the provisions of NRS 439B.700 to 439B.760, inclusive, to apply to the provision of medically necessary emergency services by out-of-network providers to covered persons.

2.

The term does not include the State Plan for Medicaid, the Children’s Health Insurance Program or a health maintenance organization, as defined in NRS 695C.030, or managed care organization, as defined in NRS 695G.050, when providing health care services through managed care to recipients of Medicaid under the State Plan for Medicaid or insurance pursuant to the Children’s Health Insurance Program pursuant to a contract with the Division of Health Care Financing and Policy of the Department.

Sec.

608.1555 Any employer who provides benefits for health care to his or her employees shall provide the same benefits and pay providers of health care in the same manner as a policy of insurance pursuant to chapters 689A and 689B of NRS, including, without limitation, as required by paragraphs (b) and (c) of subsection 2 and subsections 1, 3, 5,4 6 and 75 of NRS 687B.225, NRS 687B.409,687B.409 687B.723[, 687B.723] and 687B.725 [.] and sections 2 to 18, inclusive, of this act.

(b) To the Department of Health and Human Services or a Medicaid managed care entity, as defined in section 29.5 of this act, before January 1, 2026, for medical or dental care provided to a recipient of Medicaid.Medicaid or insurance under the Children’s Health Insurance Program.

- *AB290* – 28 – additional expenses of a local government that are related to the provisions of this act.

47.

The provisions of NRS 354.599 do not apply to any additional expenses of a local government that are related to the provisions of this act.

Sec.

47.5.

NRS 687B.723 and 695D.2153 are hereby repealed.

Sec.

Sections 1 to 44, inclusive, 4646, 47 and 4747.5 of this act become effective:

(a) Upon passage and approval for the purpose of adopting any regulations, performing any other preparatory administrative tasks that are necessary to carry out the provisions of this act and approving- procedures*AB290_R1* for– obtaining28 prior– authorization pursuant to NRS 687B.225, as amended by section 19 of this act, and section 45 of this act;

HTEXT -OF *AB290*REPEALED SECTIONS administrator of health benefit plan prohibited from denying claim for which prior authorization has been granted;

exceptions.

1.

A health carrier which provides dental coverage or an administrator of a health benefit plan that includes dental coverage shall not refuse to pay a claim for dental care for which the health carrier or administrator, as applicable, has granted prior authorization unless:

(a) A limitation on coverage provided under the applicable health benefit plan, including, without limitation, a limitation on total costs or frequency of services:

(1) Did not apply at the time the prior authorization was granted;

and (2) Applied at the time of the provision of the dental care for which the prior authorization was granted because additional authorization was granted and before the provision of the dental care for which prior authorization was granted;

(b) The documentation provided by the person submitting the claim clearly fails to support the claim for which prior authorization was originally granted;

(c) After the prior authorization was granted, additional dental care was provided to the insured or the condition of the insured otherwise changed such that:

(1) The dental care for which prior authorization was granted is no longer medically necessary;

or (2) The health carrier or administrator, as applicable, would be required to deny prior authorization under the terms and conditions of the applicable health benefit plan that were in effect at the time of the provision of the dental care for which prior authorization was granted;

(d) Another person or entity is responsible for the payment;

covered by the claim;s previously been paid for the procedures - *AB290_R1* – 29 – (f) The claim was fraudulent or the prior authorization was based, in whole or in part, on materially false information provided by the dentist or insured or another person who is not affiliated with the health carrier or administrator, as applicable;

or (g) The insured was not eligible to receive the dental care for which the claim was made on the date that the dental care was provided.

2.

Any provision of a contract that conflicts with this section is against public policy, void and unenforceable.

3.

As used in this section:

(a) “Medically necessary” means dental care that a prudent illness, injury or disease, or any symptoms thereof, that is necessary and:

(1) Provided in accordance with generally accepted standards of dental practice;

(2) Clinically appropriate with regard to type, frequency, extent, location and duration;

(3) Not primarily provided for the convenience of the patient or dentist;

(4) Required to improve a specific dental condition of a patient or to preserve the existing state of oral health of the patient;

and (5) The most clinically appropriate level of dental care that may(b) “Prior authorization” means any communication issued by a health carrier which provides dental coverage or an administrator of a health benefit plan that includes dental coverage in response to a request by a dentist in the form prescribed by the health carrier or administrator, as applicable, which indicates that specific dental care provided to an insured is:

(1) Covered under the health benefit plan issued to the insured;

and (2) Reimbursable in a specific amount, subject to applicable deductibles, copayments and coinsurance.

695D.2153 Claims:

Organization for dental care or administrator prohibited from denying claim for which prior aut1.rizAn organization for dental care or an administrator of a dental plan shall not refuse to pay a claim for dental care for which the organization for dental care or administrator, as applicable, has granted prior authorization unless:

(a) A limitation on coverage provided under the applicable plan for dental care, including, without limitation, a limitation on total costs or frequency of services:

- *AB290_R1* – 30 – (1) Did not apply at the time the prior authorization was granted;

and (2) Applied at the time of the provision of the dental care for which the prior authorization was granted because additional covered dental care was provided to the member after the prior authorization was granted and before the provision of the dental care for which prior authorization was granted;

(b) The documentation provided by the person submitting the claim clearly fails to support the claim for which prior authorization was originally granted;

(c) After the prior authorization was granted, additional dental otherwise changed such that:ber or the condition of the member (1) The dental care for which prior authorization was granted is no longer medically necessary;

or (2) The organization for dental care or administrator, as applicable, would be required to deny prior authorization under the terms and conditions of the applicable plan for dental care that were in effect at the time of the provision of the dental care for which prior authorization was granted;

(d) Another person or entity is responsible for the payment;

(e) The dentist has previously been paid for the procedures covered by the claim;

(f) The claim was fraudulent or the prior authorization was by the dentist or member or another person who is not affiliatedided with the organization for dental care or administrator, as applicable;

or (g) The member was not eligible to receive the dental care for which the claim was made on the date that the dental care was provided.

2.

Any provision of a contract that conflicts with this section is against public policy, void and unenforceable.

3.

As used in this section:

(a) “Medically necessary” means dental care that a prudent dentist would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that is necessary and:

(1) Provided in accordance with generally accepted standards of dental practice;

(2) Clinically appropriate with regard to type, frequency, extent, location and duration;

(3) Not primarily provided for the convenience of the patient or dentist;

- *AB290_R1* – 31 – (4) Required to improve a specific dental condition of a andient or to preserve the existing state of oral health of the patient;

(5) The most clinically appropriate level of dental care that may be safely provided to the patient.

(b) “Prior authorization” means any communication issued by an organization for dental care or the administrator of a dental plan organization for dental care or administrator, as applicable, which indicates that specific dental care provided to a patient is:

(1) Covered under the plan for dental care issued to the member;

and (2) Reimbursable in a specific amount, subject to applicable deductibles, copayments and coinsurance.

H - *AB290_R1*