Network Adequacy

With the passage of AB 425 during the 2013 Nevada legislative session, effective January 1, 2014  the Nevada Division of Insurance “Division” assumed the State Board of Health’s responsibility for reviewing provider networks to ensure the adequate delivery of specific health services.  Carriers choosing to market a network plan in Nevada for 2015 will be required to submit documentation to the Division for network adequacy determination. The Federal Plan Management Data Templates will be used to collect the data in a uniform and consistent manner. The data collected will then be run through a comprehensive comparison program that will identify any outliers and deficiencies for each plan network.

The scope of this review imposes technical and analytical demands upon the Division which requires outside assistance to effectively and efficiently carry out the Division’s duties. NRS 687B.490 provides for the expense of any determination made by the Commissioner to be assessed against the carrier. The Division entered into a contract with Examination Resources in March 2014 to provide this support.

Please refer to Bulletin 14-005 for the standards that will be used to determine adequacy for plan year 2015. Additional guidance will be forthcoming in regulation R049-14 to interpret and clarify the provisions of NRS 687B.490 for plan year 2016.

Health Benefit Plans

Every carrier that chooses to market a health benefit plan (network plan) in Nevada for 2015 will be required to complete and provide a Nevada  Declaration Document, Plans and Benefits Template, Network Adequacy Template, ECP Template, Network Template, Service Area Template and the Membership Data Call Spreadsheet. This requirement applies to PPO, HMO and POS networks, individual and small groups. However, the Membership Data Call Spreadsheet should also include large group membership and the HIOS Plan ID field should be left blank. The Declaration Document and Membership Data Call are below. The Templates can be found at www.serff.com/hix.htm and requirements for filing have been added to the Plan Management General Instructions page.

The templates and associated documents must be submitted in a SERFF Binder. A carrier that is participating in the Silver State Health Insurance Exchange (Exchange) will only need to include the Declaration Document, Membership Data Call Spreadsheet and Network Adequacy Template in the “Supporting Documents tab” in the Binder. Carriers that are NOT participating on the Exchange are NOT required to submit validated templates. Unvalidated templates and documents must be submitted under the “Supporting Documents” tab.  This information is due to the Division by September 1, 2014.

NOTE: For plan year 2015, Nevada is requiring five (5) additional provider specialty types to the unvalidated Network Adequacy Template.  

  • 080-Urgent Care
  • 200-Hematology
  • 201-Licenesed Behavior Analyst (LBA)
  • 202-Licensed Assistant Behavior Analyst (LABA)
  • 203-Certified Autism Behavior Interventionist (CABI)

Dental Plans

For plan year 2015, there are no separate network adequacy filing required for standalone dental plans. Division staff will review the carrier’s templates to  insure adequacy. Provider networks must have one (1) general dentist, one (1) pediatric dentist, one (1) oral surgeon, and one (1) orthodontist within the travel standards established by the Silver State Health Insurance Exchange.