Text of NV SB 163 (2023)

S.B. 163 - *SB163* SENATE BILL NO. 163–SENATORS SCHEIBLE, D. HARRIS AND SPEARMAN FEBRUARY 15, 2023 ____________ JOINT SPONSOR: ASSEMBLYWOMAN GONZÁLEZ ____________ Referred to Committee on Commerce and Labor SUMMARY—Requires certain health insurance to cover treatment of certain conditions relating to gender dysphoria, gender incongruence and other disorders of sexual development. (BDR 57-129) FISCAL NOTE: Effect on Local Government: May have Fiscal Impact. Effect on the State: Yes. CONTAINS UNFUNDED MANDATE (§§ 13, 14) (NOT REQUESTED BY AFFECTED LOCAL GOVERNMENT) ~ EXPLANATION – Matter in bolded italics is new; matter between brackets [omitted material] is material to be omitted. AN ACT relating to insurance; requiring certain health insurance to include coverage for the treatment of conditions relating to gender dysphoria, gender incongruence and other disorders of sexual development; and providing other matters properly relating thereto. Legislative Counsel’s Digest: Existing law requires public and private policies of health insurance regulated 1 under Nevada law to include certain coverage. (NRS 287.010, 287.04335, 2 422.2712-422.27241, 689A.04033-689A.0465, 689B.0303-689B.0379, 689C.1655- 3 689C.169, 689C.194, 689C.1945, 689C.195, 695A.184-695A.1875, 695B.1901- 4 695B.1948, 695C.1691-695C.176, 695G.162-695G.177) Existing law also requires 5 employers to provide certain benefits for health care to employees, including the 6 coverage required of health insurers, if the employer provides health benefits for its 7 employees. (NRS 608.1555) Sections 1, 3, 4, 6-8, 11 and 13-15 of this bill: (1) 8 require certain public and private policies of health insurance and health care plans, 9 including Medicaid, to cover the treatment of conditions relating to gender 10 dysphoria, gender incongruence and other disorders of sexual development; and (2) 11 authorize those policies and plans to prescribe requirements that must be satisfied 12 before the insurer will cover surgical treatment for conditions relating to gender 13 dysphoria, gender incongruence and other disorders of sexual development for 14 – 2 – - *SB163* persons who are less than 17 years of age. Sections 2, 5, 9 and 12 of this bill make 15 conforming changes to indicate the proper placement of sections 1, 4, 8 and 15 in 16 the Nevada Revised Statutes. 17 Section 10 of this bill authorizes the Commissioner of Insurance to suspend or 18 revoke the certificate of a health maintenance organization that fails to comply with 19 the requirements of section 8 to provide coverage for the treatment of conditions 20 relating to gender dysphoria, gender incongruence and other disorders of sexual 21 development. The Commissioner would also be authorized to take such action 22 against other health insurers who fail to comply with the requirements of sections 23 1, 3, 4, 6, 7 and 11 of this bill. (NRS 680A.200) 24 THE PEOPLE OF THE STATE OF NEVADA, REPRESENTED IN SENATE AND ASSEMBLY, DO ENACT AS FOLLOWS: Section 1. Chapter 689A of NRS is hereby amended by 1 adding thereto a new section to read as follows: 2 1. An insurer that issues a policy of health insurance shall 3 include in the policy coverage for the medically necessary 4 treatment of conditions relating to gender dysphoria, gender 5 incongruence and other disorders of sexual development. Such 6 coverage must include, without limitation, coverage of medically 7 necessary psychosocial and surgical intervention and any other 8 medically necessary treatment for such disorders provided by: 9 (a) Endocrinologists; 10 (b) Pediatric endocrinologists; 11 (c) Social workers; 12 (d) Psychiatrists; 13 (e) Psychologists; 14 (f) Gynecologists; 15 (g) Plastic surgeons; and 16 (h) Any other providers of medically necessary services for the 17 treatment of gender dysphoria, gender incongruence and other 18 disorders of sexual development. 19 2. An insurer that issues a policy of health insurance may 20 prescribe requirements that must be satisfied before the insurer 21 covers surgical treatment of conditions relating to gender 22 dysphoria, gender incongruence and other disorders of sexual 23 development for an insured who is less than 17 years of age. Such 24 requirements may include, without limitation, requirements that: 25 (a) The treatment must be recommended by a psychologist, 26 psychiatrist or other mental health professional; 27 (b) The treatment must be recommended by a physician; 28 (c) The insured must provide a written expression of the desire 29 of the insured to undergo the treatment; and 30 (d) A written plan for treatment that covers at least 1 year must 31 be developed and approved by at least two providers of health care. 32 – 3 – - *SB163* 3. An insurer shall make a reasonable effort to ensure that 1 the benefits required by subsection 1 are made available to an 2 insured through a provider of health care who participates in the 3 network plan of the insurer. If, after a reasonable effort, the 4 insurer is unable to make such benefits available through such a 5 provider of health care, the insurer must cover the benefits when 6 provided to an insured through a provider of health care who does 7 not participate in the network plan of the insurer. 8 4. A policy of health insurance subject to the provisions of 9 this chapter that is delivered, issued for delivery or renewed on or 10 after July 1, 2023, has the legal effect of including the coverage 11 required by subsection 1, and any provision of the policy or the 12 renewal which is in conflict with this section is void. 13 5. As used in this section: 14 (a) “Gender dysphoria” means distress or impairment in 15 social, occupational or other areas of functioning caused by a 16 marked difference between the gender identity or expression of a 17 person and the sex assigned to the person at birth which lasts at 18 least 6 months and is shown by at least two of the following: 19 (1) A marked difference between gender identity or 20 expression and primary or secondary sex characteristics or 21 anticipated secondary sex characteristics in young adolescents. 22 (2) A strong desire to be rid of primary or secondary sex 23 characteristics because of a marked difference between such sex 24 characteristics and gender identity or expression or a desire to 25 prevent the development of anticipated secondary sex 26 characteristics in young adolescents. 27 (3) A strong desire for the primary or secondary sex 28 characteristics of the gender opposite from the sex assigned at 29 birth. 30 (4) A strong desire to be of the opposite gender or a gender 31 different from the sex assigned at birth. 32 (5) A strong desire to be treated as the opposite gender or a 33 gender different from the sex assigned at birth. 34 (6) A strong conviction of experiencing typical feelings and 35 reactions of the opposite gender or a gender different from the sex 36 assigned at birth. 37 (b) “Medically necessary” means health care services or 38 products that a prudent provider of health care would provide to a 39 patient to prevent, diagnose or treat an illness, injury or disease, or 40 any symptoms thereof, that are necessary and: 41 (1) Provided in accordance with generally accepted 42 standards of medical practice; 43 (2) Clinically appropriate with regard to type, frequency, 44 extent, location and duration; 45 – 4 – - *SB163* (3) Not provided primarily for the convenience of the 1 patient or provider of health care; 2 (4) Required to improve a specific health condition of a 3 patient or to preserve the existing state of health of the patient; 4 and 5 (5) The most clinically appropriate level of health care that 6 may be safely provided to the patient. 7  A provider of health care prescribing, ordering, recommending 8 or approving a health care service or product does not, by itself, 9 make that health care service or product medically necessary. 10 (c) “Network plan” means a policy of health insurance offered 11 by an insurer under which the financing and delivery of medical 12 care, including items and services paid for as medical care, are 13 provided, in whole or in part, through a defined set of providers 14 under contract with the insurer. The term does not include an 15 arrangement for the financing of premiums. 16 (d) “Provider of health care” has the meaning ascribed to it in 17 NRS 629.031. 18 Sec. 2. NRS 689A.330 is hereby amended to read as follows: 19 689A.330 If any policy is issued by a domestic insurer for 20 delivery to a person residing in another state, and if the insurance 21 commissioner or corresponding public officer of that other state has 22 informed the Commissioner that the policy is not subject to approval 23 or disapproval by that officer, the Commissioner may by ruling 24 require that the policy meet the standards set forth in NRS 689A.030 25 to 689A.320, inclusive [.] , and section 1 of this act. 26 Sec. 3. Chapter 689B of NRS is hereby amended by adding 27 thereto a new section to read as follows: 28 1. An insurer that issues a policy of group health insurance 29 shall include in the policy coverage for the medically necessary 30 treatment of conditions relating to gender dysphoria, gender 31 incongruence and other disorders of sexual development. Such 32 coverage must include, without limitation, coverage of medically 33 necessary psychosocial and surgical intervention and any other 34 medically necessary treatment for such disorders provided by: 35 (a) Endocrinologists; 36 (b) Pediatric endocrinologists; 37 (c) Social workers; 38 (d) Psychiatrists; 39 (e) Psychologists; 40 (f) Gynecologists; 41 (g) Plastic surgeons; and 42 (h) Any other providers of medically necessary services for the 43 treatment of gender dysphoria, gender incongruence and other 44 disorders of sexual development. 45 – 5 – - *SB163* 2. An insurer that issues a policy of group health insurance 1 may prescribe requirements that must be satisfied before the 2 insurer covers surgical treatment of conditions relating to gender 3 dysphoria, gender incongruence and other disorders of sexual 4 development for an insured who is less than 17 years of age. Such 5 requirements may include, without limitation, requirements that: 6 (a) The treatment must be recommended by a psychologist, 7 psychiatrist or other mental health professional; 8 (b) The treatment must be recommended by a physician; 9 (c) The insured must provide a written expression of the desire 10 of the insured to undergo the treatment; and 11 (d) A written plan for treatment that covers at least 1 year must 12 be developed and approved by at least two providers of health care. 13 3. An insurer shall make a reasonable effort to ensure that 14 the benefits required by subsection 1 are made available to an 15 insured through a provider of health care who participates in the 16 network plan of the insurer. If, after a reasonable effort, the 17 insurer is unable to make such benefits available through such a 18 provider of health care, the insurer must cover the benefits when 19 provided to an insured through a provider of health care who does 20 not participate in the network plan of the insurer. 21 4. A policy of group health insurance subject to the 22 provisions of this chapter that is delivered, issued for delivery or 23 renewed on or after July 1, 2023, has the legal effect of including 24 the coverage required by subsection 1, and any provision of the 25 policy or renewal which is in conflict with the provisions of this 26 section is void. 27 5. As used in this section: 28 (a) “Gender dysphoria” means distress or impairment in 29 social, occupational or other areas of functioning caused by a 30 marked difference between the gender identity or expression of a 31 person and the sex assigned to the person at birth which lasts at 32 least 6 months and is shown by at least two of the following: 33 (1) A marked difference between gender identity or 34 expression and primary or secondary sex characteristics or 35 anticipated secondary sex characteristics in young adolescents. 36 (2) A strong desire to be rid of primary or secondary sex 37 characteristics because of a marked difference between such sex 38 characteristics and gender identity or expression or a desire to 39 prevent the development of anticipated secondary sex 40 characteristics in young adolescents. 41 (3) A strong desire for the primary or secondary sex 42 characteristics of the gender opposite from the sex assigned at 43 birth. 44 – 6 – - *SB163* (4) A strong desire to be of the opposite gender or a gender 1 different from the sex assigned at birth. 2 (5) A strong desire to be treated as the opposite gender or a 3 gender different from the sex assigned at birth. 4 (6) A strong conviction of experiencing typical feelings and 5 reactions of the opposite gender or a gender different from the sex 6 assigned at birth. 7 (b) “Medically necessary” means health care services or 8 products that a prudent provider of health care would provide to a 9 patient to prevent, diagnose or treat an illness, injury or disease, or 10 any symptoms thereof, that are necessary and: 11 (1) Provided in accordance with generally accepted 12 standards of medical practice; 13 (2) Clinically appropriate with regard to type, frequency, 14 extent, location and duration; 15 (3) Not provided primarily for the convenience of the 16 patient or provider of health care; 17 (4) Required to improve a specific health condition of a 18 patient or to preserve the existing state of health of the patient; 19 and 20 (5) The most clinically appropriate level of health care that 21 may be safely provided to the patient. 22  A provider of health care prescribing, ordering, recommending 23 or approving a health care service or product does not, by itself, 24 make that health care service or product medically necessary. 25 (c) “Network plan” means a policy of group health insurance 26 offered by an insurer under which the financing and delivery of 27 medical care, including items and services paid for as medical 28 care, are provided, in whole or in part, through a defined set of 29 providers under contract with the insurer. The term does not 30 include an arrangement for the financing of premiums. 31 (d) “Provider of health care” has the meaning ascribed to it in 32 NRS 629.031. 33 Sec. 4. Chapter 689C of NRS is hereby amended by adding 34 thereto a new section to read as follows: 35 1. A carrier that issues a health benefit plan shall include in 36 the health benefit plan coverage for the medically necessary 37 treatment of conditions relating to gender dysphoria, gender 38 incongruence and other disorders of sexual development. Such 39 coverage must include, without limitation, coverage of medically 40 necessary psychosocial and surgical intervention and any other 41 medically necessary treatment for such disorders provided by: 42 (a) Endocrinologists; 43 (b) Pediatric endocrinologists; 44 (c) Social workers; 45 – 7 – - *SB163* (d) Psychiatrists; 1 (e) Psychologists; 2 (f) Gynecologists; 3 (g) Plastic surgeons; and 4 (h) Any other providers of medically necessary services for the 5 treatment of gender dysphoria, gender incongruence and other 6 disorders of sexual development. 7 2. A carrier that issues a health benefit plan may prescribe 8 requirements that must be satisfied before the carrier covers 9 surgical treatment of conditions relating to gender dysphoria, 10 gender incongruence and other disorders of sexual development 11 for an insured who is less than 17 years of age. Such requirements 12 may include, without limitation, requirements that: 13 (a) The treatment must be recommended by a psychologist, 14 psychiatrist or other mental health professional; 15 (b) The treatment must be recommended by a physician; 16 (c) The insured must provide a written expression of the desire 17 of the insured to undergo the treatment; and 18 (d) A written plan for treatment that covers at least 1 year must 19 be developed and approved by at least two providers of health care. 20 3. A carrier shall make a reasonable effort to ensure that the 21 benefits required by subsection 1 are made available to an insured 22 through a provider of health care who participates in the network 23 plan of the carrier. If, after a reasonable effort, the carrier is 24 unable to make such benefits available through such a provider of 25 health care, the carrier must cover the benefits when provided to 26 an insured through a provider of health care who does not 27 participate in the network plan of the carrier. 28 4. A health benefit plan subject to the provisions of this 29 chapter that is delivered, issued for delivery or renewed on or after 30 July 1, 2023, has the legal effect of including the coverage 31 required by subsection 1, and any provision of the plan or renewal 32 which is in conflict with the provisions of this section is void. 33 5. As used in this section: 34 (a) “Gender dysphoria” means distress or impairment in 35 social, occupational or other areas of functioning caused by a 36 marked difference between the gender identity or expression of a 37 person and the sex assigned to the person at birth which lasts at 38 least 6 months and is shown by at least two of the following: 39 (1) A marked difference between gender identity or 40 expression and primary or secondary sex characteristics or 41 anticipated secondary sex characteristics in young adolescents. 42 (2) A strong desire to be rid of primary or secondary sex 43 characteristics because of a marked difference between such sex 44 characteristics and gender identity or expression or a desire to 45 – 8 – - *SB163* prevent the development of anticipated secondary sex 1 characteristics in young adolescents. 2 (3) A strong desire for the primary or secondary sex 3 characteristics of the gender opposite from the sex assigned at 4 birth. 5 (4) A strong desire to be of the opposite gender or a gender 6 different from the sex assigned at birth. 7 (5) A strong desire to be treated as the opposite gender or a 8 gender different from the sex assigned at birth. 9 (6) A strong conviction of experiencing typical feelings and 10 reactions of the opposite gender or a gender different from the sex 11 assigned at birth. 12 (b) “Medically necessary” means health care services or 13 products that a prudent provider of health care would provide to a 14 patient to prevent, diagnose or treat an illness, injury or disease, or 15 any symptoms thereof, that are necessary and: 16 (1) Provided in accordance with generally accepted 17 standards of medical practice; 18 (2) Clinically appropriate with regard to type, frequency, 19 extent, location and duration; 20 (3) Not provided primarily for the convenience of the 21 patient or provider of health care; 22 (4) Required to improve a specific health condition of a 23 patient or to preserve the existing state of health of the patient; 24 and 25 (5) The most clinically appropriate level of health care that 26 may be safely provided to the patient. 27  A provider of health care prescribing, ordering, recommending 28 or approving a health care service or product does not, by itself, 29 make that health care service or product medically necessary. 30 (c) “Network plan” means a health benefit plan offered by a 31 carrier under which the financing and delivery of medical care, 32 including items and services paid for as medical care, are 33 provided, in whole or in part, through a defined set of providers 34 under contract with the carrier. The term does not include an 35 arrangement for the financing of premiums. 36 (d) “Provider of health care” has the meaning ascribed to it in 37 NRS 629.031. 38 Sec. 5. NRS 689C.425 is hereby amended to read as follows: 39 689C.425 A voluntary purchasing group and any contract 40 issued to such a group pursuant to NRS 689C.360 to 689C.600, 41 inclusive, are subject to the provisions of NRS 689C.015 to 42 689C.355, inclusive, and section 4 of this act, to the extent 43 applicable and not in conflict with the express provisions of NRS 44 687B.408 and 689C.360 to 689C.600, inclusive. 45 – 9 – - *SB163* Sec. 6. Chapter 695A of NRS is hereby amended by adding 1 thereto a new section to read as follows: 2 1. A society that issues a benefit contract shall include in the 3 benefit contract coverage for the medically necessary treatment of 4 conditions relating to gender dysphoria, gender incongruence and 5 other disorders of sexual development. Such coverage must 6 include, without limitation, coverage of medically necessary 7 psychosocial and surgical intervention and any other medically 8 necessary treatment for such disorders provided by: 9 (a) Endocrinologists; 10 (b) Pediatric endocrinologists; 11 (c) Social workers; 12 (d) Psychiatrists; 13 (e) Psychologists; 14 (f) Gynecologists; 15 (g) Plastic surgeons; and 16 (h) Any other providers of medically necessary services for the 17 treatment of gender dysphoria, gender incongruence and other 18 disorders of sexual development. 19 2. A society that issues a benefit contract may prescribe 20 requirements that must be satisfied before the society covers 21 surgical treatment of conditions relating to gender dysphoria, 22 gender incongruence and other disorders of sexual development 23 for an insured who is less than 17 years of age. Such requirements 24 may include, without limitation, requirements that: 25 (a) The treatment must be recommended by a psychologist, 26 psychiatrist or other mental health professional; 27 (b) The treatment must be recommended by a physician; 28 (c) The insured must provide a written expression of the desire 29 of the insured to undergo the treatment; and 30 (d) A written plan for treatment that covers at least 1 year must 31 be developed and approved by at least two providers of health care. 32 3. A society shall make a reasonable effort to ensure that the 33 benefits required by subsection 1 are made available to an insured 34 through a provider of health care who participates in the network 35 plan of the society. If, after a reasonable effort, the society is 36 unable to make such benefits available through such a provider of 37 health care, the society must cover the benefits when provided to 38 an insured through a provider of health care who does not 39 participate in the network plan of the society. 40 4. A benefit contract subject to the provisions of this chapter 41 that is delivered, issued for delivery or renewed on or after July 1, 42 2023, has the legal effect of including the coverage required by 43 subsection 1, and any provision of the benefit contract or renewal 44 which is in conflict with the provisions of this section is void. 45 – 10 – - *SB163* 5. As used in this section: 1 (a) “Gender dysphoria” means distress or impairment in 2 social, occupational or other areas of functioning caused by a 3 marked difference between the gender identity or expression of a 4 person and the sex assigned to the person at birth which lasts at 5 least 6 months and is shown by at least two of the following: 6 (1) A marked difference between gender identity or 7 expression and primary or secondary sex characteristics or 8 anticipated secondary sex characteristics in young adolescents. 9 (2) A strong desire to be rid of primary or secondary sex 10 characteristics because of a marked difference between such sex 11 characteristics and gender identity or expression or a desire to 12 prevent the development of anticipated secondary sex 13 characteristics in young adolescents. 14 (3) A strong desire for the primary or secondary sex 15 characteristics of the gender opposite from the sex assigned at 16 birth. 17 (4) A strong desire to be of the opposite gender or a gender 18 different from the sex assigned at birth. 19 (5) A strong desire to be treated as the opposite gender or a 20 gender different from the sex assigned at birth. 21 (6) A strong conviction of experiencing typical feelings and 22 reactions of the opposite gender or a gender different from the sex 23 assigned at birth. 24 (b) “Medically necessary” means health care services or 25 products that a prudent provider of health care would provide to a 26 patient to prevent, diagnose or treat an illness, injury or disease, or 27 any symptoms thereof, that are necessary and: 28 (1) Provided in accordance with generally accepted 29 standards of medical practice; 30 (2) Clinically appropriate with regard to type, frequency, 31 extent, location and duration; 32 (3) Not provided primarily for the convenience of the 33 patient or provider of health care; 34 (4) Required to improve a specific health condition of a 35 patient or to preserve the existing state of health of the patient; 36 and 37 (5) The most clinically appropriate level of health care that 38 may be safely provided to the patient. 39  A provider of health care prescribing, ordering, recommending 40 or approving a health care service or product does not, by itself, 41 make that health care service or product medically necessary. 42 (c) “Network plan” means a benefit contract offered by a 43 society under which the financing and delivery of medical care, 44 including items and services paid for as medical care, are 45 – 11 – - *SB163* provided, in whole or in part, through a defined set of providers 1 under contract with the society. The term does not include an 2 arrangement for the financing of premiums. 3 (d) “Provider of health care” has the meaning ascribed to it in 4 NRS 629.031. 5 Sec. 7. Chapter 695B of NRS is hereby amended by adding 6 thereto a new section to read as follows: 7 1. A hospital or medical services corporation that issues a 8 policy of health insurance shall include in the policy coverage for 9 the medically necessary treatment of conditions relating to gender 10 dysphoria, gender incongruence and other disorders of sexual 11 development. Such coverage must include, without limitation, 12 coverage of medically necessary psychosocial and surgical 13 intervention and any other medically necessary treatment for such 14 disorders provided by: 15 (a) Endocrinologists; 16 (b) Pediatric endocrinologists; 17 (c) Social workers; 18 (d) Psychiatrists; 19 (e) Psychologists; 20 (f) Gynecologists; 21 (g) Plastic surgeons; and 22 (h) Any other providers of medically necessary services for the 23 treatment of gender dysphoria, gender incongruence and other 24 disorders of sexual development. 25 2. A hospital or medical services corporation that issues a 26 policy of health insurance may prescribe requirements that must 27 be satisfied before the hospital or medical services corporation 28 covers surgical treatment of conditions relating to gender 29 dysphoria, gender incongruence and other disorders of sexual 30 development for an insured who is less than 17 years of age. Such 31 requirements may include, without limitation, requirements that: 32 (a) The treatment must be recommended by a psychologist, 33 psychiatrist or other mental health professional; 34 (b) The treatment must be recommended by a physician; 35 (c) The insured must provide a written expression of the desire 36 of the insured to undergo the treatment; and 37 (d) A written plan for treatment that covers at least 1 year must 38 be developed and approved by at least two providers of health care. 39 3. A hospital or medical services corporation shall make a 40 reasonable effort to ensure that the benefits required by subsection 41 1 are made available to an insured through a provider of health 42 care who participates in the network plan of the hospital or 43 medical services corporation. If, after a reasonable effort, the 44 hospital or medical services corporation is unable to make such 45 – 12 – - *SB163* benefits available through such a provider of health care, the 1 hospital or medical services corporation must cover the benefits 2 when provided to an insured through a provider of health care 3 who does not participate in the network plan of the hospital or 4 medical services corporation. 5 4. A policy of health insurance subject to the provisions of 6 this chapter that is delivered, issued for delivery or renewed on or 7 after July 1, 2023, has the legal effect of including the coverage 8 required by subsection 1, and any provision of the policy or 9 renewal which is in conflict with the provisions of this section is 10 void. 11 5. As used in this section: 12 (a) “Gender dysphoria” means distress or impairment in 13 social, occupational or other areas of functioning caused by a 14 marked difference between the gender identity or expression of a 15 person and the sex assigned to the person at birth which lasts at 16 least 6 months and is shown by at least two of the following: 17 (1) A marked difference between gender identity or 18 expression and primary or secondary sex characteristics or 19 anticipated secondary sex characteristics in young adolescents. 20 (2) A strong desire to be rid of primary or secondary sex 21 characteristics because of a marked difference between such sex 22 characteristics and gender identity or expression or a desire to 23 prevent the development of anticipated secondary sex 24 characteristics in young adolescents. 25 (3) A strong desire for the primary or secondary sex 26 characteristics of the gender opposite from the sex assigned at 27 birth. 28 (4) A strong desire to be of the opposite gender or a gender 29 different from the sex assigned at birth. 30 (5) A strong desire to be treated as the opposite gender or a 31 gender different from the sex assigned at birth. 32 (6) A strong conviction of experiencing typical feelings and 33 reactions of the opposite gender or a gender different from the sex 34 assigned at birth. 35 (b) “Medically necessary” means health care services or 36 products that a prudent provider of health care would provide to a 37 patient to prevent, diagnose or treat an illness, injury or disease, or 38 any symptoms thereof, that are necessary and: 39 (1) Provided in accordance with generally accepted 40 standards of medical practice; 41 (2) Clinically appropriate with regard to type, frequency, 42 extent, location and duration; 43 (3) Not provided primarily for the convenience of the 44 patient or provider of health care; 45 – 13 – - *SB163* (4) Required to improve a specific health condition of a 1 patient or to preserve the existing state of health of the patient; 2 and 3 (5) The most clinically appropriate level of health care that 4 may be safely provided to the patient. 5  A provider of health care prescribing, ordering, recommending 6 or approving a health care service or product does not, by itself, 7 make that health care service or product medically necessary. 8 (c) “Network plan” means a policy of health insurance offered 9 by a hospital or medical services corporation under which the 10 financing and delivery of medical care, including items and 11 services paid for as medical care, are provided, in whole or in part, 12 through a defined set of providers under contract with the hospital 13 or medical services corporation. The term does not include an 14 arrangement for the financing of premiums. 15 (d) “Provider of health care” has the meaning ascribed to it in 16 NRS 629.031. 17 Sec. 8. Chapter 695C of NRS is hereby amended by adding 18 thereto a new section to read as follows: 19 1. A health maintenance organization that issues a health 20 care plan shall include in the health care plan coverage for the 21 medically necessary treatment of conditions relating to gender 22 dysphoria, gender incongruence and other disorders of sexual 23 development. Such coverage must include, without limitation, 24 coverage of medically necessary psychosocial and surgical 25 intervention and any other medically necessary treatment for such 26 disorders provided by: 27 (a) Endocrinologists; 28 (b) Pediatric endocrinologists; 29 (c) Social workers; 30 (d) Psychiatrists; 31 (e) Psychologists; 32 (f) Gynecologists; 33 (g) Plastic surgeons; and 34 (h) Any other providers of medically necessary services for the 35 treatment of gender dysphoria, gender incongruence and other 36 disorders of sexual development. 37 2. A health maintenance organization that issues a health 38 care plan may prescribe requirements that must be satisfied before 39 the health maintenance organization covers surgical treatment of 40 conditions relating to gender dysphoria, gender incongruence and 41 other disorders of sexual development for an enrollee who is less 42 than 17 years of age. Such requirements may include, without 43 limitation, requirements that: 44 – 14 – - *SB163* (a) The treatment must be recommended by a psychologist, 1 psychiatrist or other mental health professional; 2 (b) The treatment must be recommended by a physician; 3 (c) The enrollee must provide a written expression of the desire 4 of the enrollee to undergo the treatment; and 5 (d) A written plan for treatment that covers at least 1 year must 6 be developed and approved by at least two providers of health care. 7 3. A health maintenance organization shall make a 8 reasonable effort to ensure that the benefits required by subsection 9 1 are made available to an enrollee through a provider of health 10 care who participates in the network plan of the 11 health maintenance organization. If, after a reasonable effort, the 12 health maintenance organization is unable to make such benefits 13 available through such a provider of health care, the health 14 maintenance organization must cover the benefits when provided 15 to an enrollee through a provider of health care who does not 16 participate in the network plan of the health maintenance 17 organization. 18 4. A health care plan subject to the provisions of this chapter 19 that is delivered, issued for delivery or renewed on or after July 1, 20 2023, has the legal effect of including the coverage required by 21 subsection 1, and any provision of the plan or renewal which is in 22 conflict with the provisions of this section is void. 23 5. As used in this section: 24 (a) “Gender dysphoria” means distress or impairment in 25 social, occupational or other areas of functioning caused by a 26 marked difference between the gender identity or expression of a 27 person and the sex assigned to the person at birth which lasts at 28 least 6 months and is shown by at least two of the following: 29 (1) A marked difference between gender identity or 30 expression and primary or secondary sex characteristics or 31 anticipated secondary sex characteristics in young adolescents. 32 (2) A strong desire to be rid of primary or secondary sex 33 characteristics because of a marked difference between such sex 34 characteristics and gender identity or expression or a desire to 35 prevent the development of anticipated secondary sex 36 characteristics in young adolescents. 37 (3) A strong desire for the primary or secondary sex 38 characteristics of the gender opposite from the sex assigned at 39 birth. 40 (4) A strong desire to be of the opposite gender or a gender 41 different from the sex assigned at birth. 42 (5) A strong desire to be treated as the opposite gender or a 43 gender different from the sex assigned at birth. 44 – 15 – - *SB163* (6) A strong conviction of experiencing typical feelings and 1 reactions of the opposite gender or a gender different from the sex 2 assigned at birth. 3 (b) “Medically necessary” means health care services or 4 products that a prudent provider of health care would provide to a 5 patient to prevent, diagnose or treat an illness, injury or disease, or 6 any symptoms thereof, that are necessary and: 7 (1) Provided in accordance with generally accepted 8 standards of medical practice; 9 (2) Clinically appropriate with regard to type, frequency, 10 extent, location and duration; 11 (3) Not provided primarily for the convenience of the 12 patient or provider of health care; 13 (4) Required to improve a specific health condition of a 14 patient or to preserve the existing state of health of the patient; 15 and 16 (5) The most clinically appropriate level of health care that 17 may be safely provided to the patient. 18  A provider of health care prescribing, ordering, recommending 19 or approving a health care service or product does not, by itself, 20 make that health care service or product medically necessary. 21 (c) “Network plan” means a health care plan offered by a 22 health maintenance organization under which the financing and 23 delivery of medical care, including items and services paid for as 24 medical care, are provided, in whole or in part, through a defined 25 set of providers under contract with the health maintenance 26 organization. The term does not include an arrangement for the 27 financing of premiums. 28 (d) “Provider of health care” has the meaning ascribed to it in 29 NRS 629.031. 30 Sec. 9. NRS 695C.050 is hereby amended to read as follows: 31 695C.050 1. Except as otherwise provided in this chapter or 32 in specific provisions of this title, the provisions of this title are not 33 applicable to any health maintenance organization granted a 34 certificate of authority under this chapter. This provision does not 35 apply to an insurer licensed and regulated pursuant to this title 36 except with respect to its activities as a health maintenance 37 organization authorized and regulated pursuant to this chapter. 38 2. Solicitation of enrollees by a health maintenance 39 organization granted a certificate of authority, or its representatives, 40 must not be construed to violate any provision of law relating to 41 solicitation or advertising by practitioners of a healing art. 42 3. Any health maintenance organization authorized under this 43 chapter shall not be deemed to be practicing medicine and is exempt 44 from the provisions of chapter 630 of NRS. 45 – 16 – - *SB163* 4. The provisions of NRS 695C.110, 695C.125, 695C.1691, 1 695C.1693, 695C.170, 695C.1703, 695C.1705, 695C.1709 to 2 695C.173, inclusive, 695C.1733, 695C.17335, 695C.1734, 3 695C.1751, 695C.1755, 695C.1759, 695C.176 to 695C.200, 4 inclusive, and 695C.265 do not apply to a health maintenance 5 organization that provides health care services through managed 6 care to recipients of Medicaid under the State Plan for Medicaid or 7 insurance pursuant to the Children’s Health Insurance Program 8 pursuant to a contract with the Division of Health Care Financing 9 and Policy of the Department of Health and Human Services. This 10 subsection does not exempt a health maintenance organization from 11 any provision of this chapter for services provided pursuant to any 12 other contract. 13 5. The provisions of NRS 695C.1694 to 695C.1698, inclusive, 14 695C.1701, 695C.1708, 695C.1728, 695C.1731, 695C.17333, 15 695C.17345, 695C.17347, 695C.1735, 695C.1737, 695C.1743, 16 695C.1745 and 695C.1757 and section 8 of this act apply to a 17 health maintenance organization that provides health care services 18 through managed care to recipients of Medicaid under the State Plan 19 for Medicaid. 20 Sec. 10. NRS 695C.330 is hereby amended to read as follows: 21 695C.330 1. The Commissioner may suspend or revoke any 22 certificate of authority issued to a health maintenance organization 23 pursuant to the provisions of this chapter if the Commissioner finds 24 that any of the following conditions exist: 25 (a) The health maintenance organization is operating 26 significantly in contravention of its basic organizational document, 27 its health care plan or in a manner contrary to that described in and 28 reasonably inferred from any other information submitted pursuant 29 to NRS 695C.060, 695C.070 and 695C.140, unless any amendments 30 to those submissions have been filed with and approved by the 31 Commissioner; 32 (b) The health maintenance organization issues evidence of 33 coverage or uses a schedule of charges for health care services 34 which do not comply with the requirements of NRS 695C.1691 to 35 695C.200, inclusive, or 695C.207 [;] or section 8 of this act; 36 (c) The health care plan does not furnish comprehensive health 37 care services as provided for in NRS 695C.060; 38 (d) The Commissioner certifies that the health maintenance 39 organization: 40 (1) Does not meet the requirements of subsection 1 of NRS 41 695C.080; or 42 (2) Is unable to fulfill its obligations to furnish health care 43 services as required under its health care plan; 44 – 17 – - *SB163* (e) The health maintenance organization is no longer financially 1 responsible and may reasonably be expected to be unable to meet its 2 obligations to enrollees or prospective enrollees; 3 (f) The health maintenance organization has failed to put into 4 effect a mechanism affording the enrollees an opportunity to 5 participate in matters relating to the content of programs pursuant to 6 NRS 695C.110; 7 (g) The health maintenance organization has failed to put into 8 effect the system required by NRS 695C.260 for: 9 (1) Resolving complaints in a manner reasonably to dispose 10 of valid complaints; and 11 (2) Conducting external reviews of adverse determinations 12 that comply with the provisions of NRS 695G.241 to 695G.310, 13 inclusive; 14 (h) The health maintenance organization or any person on its 15 behalf has advertised or merchandised its services in an untrue, 16 misrepresentative, misleading, deceptive or unfair manner; 17 (i) The continued operation of the health maintenance 18 organization would be hazardous to its enrollees or creditors or to 19 the general public; 20 (j) The health maintenance organization fails to provide the 21 coverage required by NRS 695C.1691; or 22 (k) The health maintenance organization has otherwise failed to 23 comply substantially with the provisions of this chapter. 24 2. A certificate of authority must be suspended or revoked only 25 after compliance with the requirements of NRS 695C.340. 26 3. If the certificate of authority of a health maintenance 27 organization is suspended, the health maintenance organization shall 28 not, during the period of that suspension, enroll any additional 29 groups or new individual contracts, unless those groups or persons 30 were contracted for before the date of suspension. 31 4. If the certificate of authority of a health maintenance 32 organization is revoked, the organization shall proceed, immediately 33 following the effective date of the order of revocation, to wind up its 34 affairs and shall conduct no further business except as may be 35 essential to the orderly conclusion of the affairs of the organization. 36 It shall engage in no further advertising or solicitation of any kind. 37 The Commissioner may, by written order, permit such further 38 operation of the organization as the Commissioner may find to be in 39 the best interest of enrollees to the end that enrollees are afforded 40 the greatest practical opportunity to obtain continuing coverage for 41 health care. 42 – 18 – - *SB163* Sec. 11. Chapter 695G of NRS is hereby amended by adding 1 thereto a new section to read as follows: 2 1. A managed care organization that issues a health care 3 plan shall include in the health care plan coverage for the 4 medically necessary treatment of conditions relating to gender 5 dysphoria, gender incongruence and other disorders of sexual 6 development. Such coverage must include, without limitation, 7 coverage of medically necessary psychosocial and surgical 8 intervention and any other medically necessary treatment for such 9 disorders provided by: 10 (a) Endocrinologists; 11 (b) Pediatric endocrinologists; 12 (c) Social workers; 13 (d) Psychiatrists; 14 (e) Psychologists; 15 (f) Gynecologists; 16 (g) Plastic surgeons; and 17 (h) Any other providers of medically necessary services for the 18 treatment of gender dysphoria, gender incongruence and other 19 disorders of sexual development. 20 2. A managed care organization that issues a health care 21 plan may prescribe requirements that must be satisfied before the 22 managed care organization covers surgical treatment of 23 conditions relating to gender dysphoria, gender incongruence and 24 other disorders of sexual development for an insured who is less 25 than 17 years of age. Such requirements may include, without 26 limitation, requirements that: 27 (a) The treatment must be recommended by a psychologist, 28 psychiatrist or other mental health professional; 29 (b) The treatment must be recommended by a physician; 30 (c) The insured must provide a written expression of the desire 31 of the insured to undergo the treatment; and 32 (d) A written plan for treatment that covers at least 1 year must 33 be developed and approved by at least two providers of health care. 34 3. A managed care organization shall make a reasonable 35 effort to ensure that the benefits required by subsection 1 are 36 made available to an insured through a provider of health care 37 who participates in the network plan of the managed 38 care organization. If, after a reasonable effort, the managed care 39 organization is unable to make such benefits available through 40 such a provider of health care, the managed care organization 41 must cover the benefits when provided to an insured through a 42 provider of health care who does not participate in the network 43 plan of the managed care organization. 44 – 19 – - *SB163* 4. Evidence of coverage subject to the provisions of this 1 chapter that is delivered, issued for delivery or renewed on or after 2 July 1, 2023, has the legal effect of including the coverage 3 required by subsection 1, and any provision of the plan or renewal 4 which is in conflict with the provisions of this section is void. 5 5. As used in this section: 6 (a) “Gender dysphoria” means distress or impairment in 7 social, occupational or other areas of functioning caused by a 8 marked difference between the gender identity or expression of a 9 person and the sex assigned to the person at birth which lasts at 10 least 6 months and is shown by at least two of the following: 11 (1) A marked difference between gender identity or 12 expression and primary or secondary sex characteristics or 13 anticipated secondary sex characteristics in young adolescents. 14 (2) A strong desire to be rid of primary or secondary sex 15 characteristics because of a marked difference between such sex 16 characteristics and gender identity or expression or a desire to 17 prevent the development of anticipated secondary sex 18 characteristics in young adolescents. 19 (3) A strong desire for the primary or secondary sex 20 characteristics of the gender opposite from the sex assigned at 21 birth. 22 (4) A strong desire to be of the opposite gender or a gender 23 different from the sex assigned at birth. 24 (5) A strong desire to be treated as the opposite gender or a 25 gender different from the sex assigned at birth. 26 (6) A strong conviction of experiencing typical feelings and 27 reactions of the opposite gender or a gender different from the sex 28 assigned at birth. 29 (b) “Medically necessary” means health care services or 30 products that a prudent provider of health care would provide to a 31 patient to prevent, diagnose or treat an illness, injury or disease, or 32 any symptoms thereof, that are necessary and: 33 (1) Provided in accordance with generally accepted 34 standards of medical practice; 35 (2) Clinically appropriate with regard to type, frequency, 36 extent, location and duration; 37 (3) Not provided primarily for the convenience of the 38 patient or provider of health care; 39 (4) Required to improve a specific health condition of a 40 patient or to preserve the existing state of health of the patient; 41 and 42 (5) The most clinically appropriate level of health care that 43 may be safely provided to the patient. 44 – 20 – - *SB163*  A provider of health care prescribing, ordering, recommending 1 or approving a health care service or product does not, by itself, 2 make that health care service or product medically necessary. 3 (c) “Network plan” means a health care plan offered by a 4 managed care organization under which the financing and 5 delivery of medical care, including items and services paid for as 6 medical care, are provided, in whole or in part, through a defined 7 set of providers under contract with the managed care 8 organization. The term does not include an arrangement for the 9 financing of premiums. 10 (d) “Provider of health care” has the meaning ascribed to it in 11 NRS 629.031. 12 Sec. 12. NRS 232.320 is hereby amended to read as follows: 13 232.320 1. The Director: 14 (a) Shall appoint, with the consent of the Governor, 15 administrators of the divisions of the Department, who are 16 respectively designated as follows: 17 (1) The Administrator of the Aging and Disability Services 18 Division; 19 (2) The Administrator of the Division of Welfare and 20 Supportive Services; 21 (3) The Administrator of the Division of Child and Family 22 Services; 23 (4) The Administrator of the Division of Health Care 24 Financing and Policy; and 25 (5) The Administrator of the Division of Public and 26 Behavioral Health. 27 (b) Shall administer, through the divisions of the Department, 28 the provisions of chapters 63, 424, 425, 427A, 432A to 442, 29 inclusive, 446 to 450, inclusive, 458A and 656A of NRS, NRS 30 127.220 to 127.310, inclusive, 422.001 to 422.410, inclusive, and 31 section 15 of this act, 422.580, 432.010 to 432.133, inclusive, 32 432B.6201 to 432B.626, inclusive, 444.002 to 444.430, inclusive, 33 and 445A.010 to 445A.055, inclusive, and all other provisions of 34 law relating to the functions of the divisions of the Department, but 35 is not responsible for the clinical activities of the Division of Public 36 and Behavioral Health or the professional line activities of the other 37 divisions. 38 (c) Shall administer any state program for persons with 39 developmental disabilities established pursuant to the 40 Developmental Disabilities Assistance and Bill of Rights Act of 41 2000, 42 U.S.C. §§ 15001 et seq. 42 (d) Shall, after considering advice from agencies of local 43 governments and nonprofit organizations which provide social 44 services, adopt a master plan for the provision of human services in 45 – 21 – - *SB163* this State. The Director shall revise the plan biennially and deliver a 1 copy of the plan to the Governor and the Legislature at the 2 beginning of each regular session. The plan must: 3 (1) Identify and assess the plans and programs of the 4 Department for the provision of human services, and any 5 duplication of those services by federal, state and local agencies; 6 (2) Set forth priorities for the provision of those services; 7 (3) Provide for communication and the coordination of those 8 services among nonprofit organizations, agencies of local 9 government, the State and the Federal Government; 10 (4) Identify the sources of funding for services provided by 11 the Department and the allocation of that funding; 12 (5) Set forth sufficient information to assist the Department 13 in providing those services and in the planning and budgeting for the 14 future provision of those services; and 15 (6) Contain any other information necessary for the 16 Department to communicate effectively with the Federal 17 Government concerning demographic trends, formulas for the 18 distribution of federal money and any need for the modification of 19 programs administered by the Department. 20 (e) May, by regulation, require nonprofit organizations and state 21 and local governmental agencies to provide information regarding 22 the programs of those organizations and agencies, excluding 23 detailed information relating to their budgets and payrolls, which the 24 Director deems necessary for the performance of the duties imposed 25 upon him or her pursuant to this section. 26 (f) Has such other powers and duties as are provided by law. 27 2. Notwithstanding any other provision of law, the Director, or 28 the Director’s designee, is responsible for appointing and removing 29 subordinate officers and employees of the Department. 30 Sec. 13. NRS 287.010 is hereby amended to read as follows: 31 287.010 1. The governing body of any county, school 32 district, municipal corporation, political subdivision, public 33 corporation or other local governmental agency of the State of 34 Nevada may: 35 (a) Adopt and carry into effect a system of group life, accident 36 or health insurance, or any combination thereof, for the benefit of its 37 officers and employees, and the dependents of officers and 38 employees who elect to accept the insurance and who, where 39 necessary, have authorized the governing body to make deductions 40 from their compensation for the payment of premiums on the 41 insurance. 42 (b) Purchase group policies of life, accident or health insurance, 43 or any combination thereof, for the benefit of such officers and 44 employees, and the dependents of such officers and employees, as 45 – 22 – - *SB163* have authorized the purchase, from insurance companies authorized 1 to transact the business of such insurance in the State of Nevada, 2 and, where necessary, deduct from the compensation of officers and 3 employees the premiums upon insurance and pay the deductions 4 upon the premiums. 5 (c) Provide group life, accident or health coverage through a 6 self-insurance reserve fund and, where necessary, deduct 7 contributions to the maintenance of the fund from the compensation 8 of officers and employees and pay the deductions into the fund. The 9 money accumulated for this purpose through deductions from 10 the compensation of officers and employees and contributions of the 11 governing body must be maintained as an internal service fund as 12 defined by NRS 354.543. The money must be deposited in a state or 13 national bank or credit union authorized to transact business in the 14 State of Nevada. Any independent administrator of a fund created 15 under this section is subject to the licensing requirements of chapter 16 683A of NRS, and must be a resident of this State. Any contract 17 with an independent administrator must be approved by the 18 Commissioner of Insurance as to the reasonableness of 19 administrative charges in relation to contributions collected and 20 benefits provided. The provisions of NRS 686A.135, 687B.352, 21 687B.408, 687B.723, 687B.725, 689B.030 to 689B.050, inclusive, 22 and section 3 of this act, 689B.265, 689B.287 and 689B.500 apply 23 to coverage provided pursuant to this paragraph, except that the 24 provisions of NRS 689B.0378, 689B.03785 and 689B.500 only 25 apply to coverage for active officers and employees of the 26 governing body, or the dependents of such officers and employees. 27 (d) Defray part or all of the cost of maintenance of a self- 28 insurance fund or of the premiums upon insurance. The money for 29 contributions must be budgeted for in accordance with the laws 30 governing the county, school district, municipal corporation, 31 political subdivision, public corporation or other local governmental 32 agency of the State of Nevada. 33 2. If a school district offers group insurance to its officers and 34 employees pursuant to this section, members of the board of trustees 35 of the school district must not be excluded from participating in the 36 group insurance. If the amount of the deductions from compensation 37 required to pay for the group insurance exceeds the compensation to 38 which a trustee is entitled, the difference must be paid by the trustee. 39 3. In any county in which a legal services organization exists, 40 the governing body of the county, or of any school district, 41 municipal corporation, political subdivision, public corporation or 42 other local governmental agency of the State of Nevada in the 43 county, may enter into a contract with the legal services 44 organization pursuant to which the officers and employees of the 45 – 23 – - *SB163* legal services organization, and the dependents of those officers and 1 employees, are eligible for any life, accident or health insurance 2 provided pursuant to this section to the officers and employees, and 3 the dependents of the officers and employees, of the county, school 4 district, municipal corporation, political subdivision, public 5 corporation or other local governmental agency. 6 4. If a contract is entered into pursuant to subsection 3, the 7 officers and employees of the legal services organization: 8 (a) Shall be deemed, solely for the purposes of this section, to be 9 officers and employees of the county, school district, municipal 10 corporation, political subdivision, public corporation or other local 11 governmental agency with which the legal services organization has 12 contracted; and 13 (b) Must be required by the contract to pay the premiums or 14 contributions for all insurance which they elect to accept or of which 15 they authorize the purchase. 16 5. A contract that is entered into pursuant to subsection 3: 17 (a) Must be submitted to the Commissioner of Insurance for 18 approval not less than 30 days before the date on which the contract 19 is to become effective. 20 (b) Does not become effective unless approved by the 21 Commissioner. 22 (c) Shall be deemed to be approved if not disapproved by the 23 Commissioner within 30 days after its submission. 24 6. As used in this section, “legal services organization” means 25 an organization that operates a program for legal aid and receives 26 money pursuant to NRS 19.031. 27 Sec. 14. NRS 287.04335 is hereby amended to read as 28 follows: 29 287.04335 If the Board provides health insurance through a 30 plan of self-insurance, it shall comply with the provisions of NRS 31 686A.135, 687B.352, 687B.409, 687B.723, 687B.725, 689B.0353, 32 689B.255, 695C.1723, 695G.150, 695G.155, 695G.160, 695G.162, 33 695G.1635, 695G.164, 695G.1645, 695G.1665, 695G.167, 34 695G.1675, 695G.170 to 695G.174, inclusive, and section 11 of 35 this act, 695G.176, 695G.177, 695G.200 to 695G.230, inclusive, 36 695G.241 to 695G.310, inclusive, and 695G.405, in the same 37 manner as an insurer that is licensed pursuant to title 57 of NRS is 38 required to comply with those provisions. 39 Sec. 15. Chapter 422 of NRS is hereby amended by adding 40 thereto a new section to read as follows: 41 1. The Director shall include in the State Plan for Medicaid a 42 requirement that the State, to the extent authorized by federal law, 43 must pay the nonfederal share of expenditures incurred for the 44 medically necessary treatment of conditions relating to gender 45 – 24 – - *SB163* dysphoria, gender incongruence and other disorders of sexual 1 development. Such treatment includes, without limitation, 2 medically necessary psychosocial and surgical intervention and 3 any other medically necessary treatment for such disorders 4 provided by: 5 (a) Endocrinologists; 6 (b) Pediatric endocrinologists; 7 (c) Social workers; 8 (d) Psychiatrists; 9 (e) Psychologists; 10 (f) Gynecologists; 11 (g) Plastic surgeons; and 12 (h) Any other providers of medically necessary services for the 13 treatment of gender dysphoria, gender incongruence and other 14 disorders of sexual development. 15 2. As used in this section: 16 (a) “Gender dysphoria” means distress or impairment in 17 social, occupational or other areas of functioning caused by a 18 marked difference between the gender identity or expression of a 19 person and the sex assigned to the person at birth which lasts at 20 least 6 months and is shown by at least two of the following: 21 (1) A marked difference between gender identity or 22 expression and primary or secondary sex characteristics or 23 anticipated secondary sex characteristics in young adolescents. 24 (2) A strong desire to be rid of primary or secondary sex 25 characteristics because of a marked difference between such sex 26 characteristics and gender identity or expression or a desire to 27 prevent the development of anticipated secondary sex 28 characteristics in young adolescents. 29 (3) A strong desire for the primary or secondary sex 30 characteristics of the gender opposite from the sex assigned at 31 birth. 32 (4) A strong desire to be of the opposite gender or a gender 33 different from the sex assigned at birth. 34 (5) A strong desire to be treated as the opposite gender or a 35 gender different from the sex assigned at birth. 36 (6) A strong conviction of experiencing typical feelings and 37 reactions of the opposite gender or a gender different from the sex 38 assigned at birth. 39 (b) “Medically necessary” means health care services or 40 products that a prudent provider of health care would provide to a 41 patient to prevent, diagnose or treat an illness, injury or disease, or 42 any symptoms thereof, that are necessary and: 43 (1) Provided in accordance with generally accepted 44 standards of medical practice; 45 – 25 – - *SB163* (2) Clinically appropriate with regard to type, frequency, 1 extent, location and duration; 2 (3) Not provided primarily for the convenience of the 3 patient or provider of health care; 4 (4) Required to improve a specific health condition of a 5 patient or to preserve the existing state of health of the patient; 6 and 7 (5) The most clinically appropriate level of health care that 8 may be safely provided to the patient. 9  A provider of health care prescribing, ordering, recommending 10 or approving a health care service or product does not, by itself, 11 make that health care service or product medically necessary. 12 (c) “Provider of health care” has the meaning ascribed to it in 13 NRS 629.031. 14 Sec. 16. The provisions of NRS 354.599 do not apply to any 15 additional expenses of a local government that are related to the 16 provisions of this act. 17 Sec. 17. This act becomes effective on July 1, 2023. 18 H

- 82nd Session (2023) Senate Bill No. 163–Senators Scheible, D. Harris and Spearman Joint Sponsor: Assemblywoman González CHAPTER.......... AN ACT relating to insurance; requiring certain health insurance to include coverage for the treatment of conditions relating to gender dysphoria and gender incongruence; prohibiting such insurers from engaging in certain discrimination on the basis of gender identity or expression; making appropriations and authorizing certain expenditures; and providing other matters properly relating thereto. Legislative Counsel’s Digest: Existing law requires public and private policies of health insurance regulated under Nevada law to include certain coverage. (NRS 287.010, 287.04335, 422.2712-422.27241, 689A.04033-689A.0465, 689B.0303-689B.0379, 689C.1655- 689C.169, 689C.194, 689C.1945, 689C.195, 695A.184-695A.1875, 695B.1901- 695B.1948, 695C.1691-695C.176, 695G.162-695G.177) Existing law also requires employers to provide certain benefits for health care to employees, including the coverage required of health insurers, if the employer provides health benefits for its employees. (NRS 608.1555) Sections 1.3, 3, 4, 6, 7, 8, 11, 13, 14 and 15 of this bill: (1) require certain public and private policies of health insurance and health care plans, including Medicaid, to cover the treatment of conditions relating to gender dysphoria and gender incongruence; (2) authorize those policies and plans to prescribe requirements that must be satisfied before the insurer will cover surgical treatment for conditions relating to gender dysphoria or gender incongruence for persons who are less than 18 years of age; and (3) require an insurer to consult with a provider of health care with experience in prescribing or delivering gender-affirming treatment when considering certain appeals of a denial of coverage. Sections 1.6, 3.6, 4.6, 6.6, 7.6, 8.6, 11.6 and 15.6 of this bill prohibit an insurer from engaging in certain discrimination on the basis of gender identity or expression. Sections 2, 5, 9 and 12 of this bill make conforming changes to indicate the proper placement of sections 1.3, 1.6, 4, 4.6, 8, 8.6, 15 and 15.6 in the Nevada Revised Statutes. Section 10 of this bill authorizes the Commissioner of Insurance to suspend or revoke the certificate of a health maintenance organization that fails to comply with the requirements of sections 8 and 8.6. The Commissioner would also be authorized to take such action against other health insurers who fail to comply with the requirements of sections 1.3, 1.6, 3, 3.6, 4, 4.6, 6, 6.6, 7, 7.6, 11 and 11.6. (NRS 680A.200) Sections 16 and 17 of this bill make appropriations to the Division of Health Care Financing and Policy of the Department of Health and Human Services and authorize certain related expenditures for: (1) the costs of providing the coverage under Medicaid required by section 15; and (2) certain other costs associated with carrying out the provisions of this bill. – 2 – - 82nd Session (2023) EXPLANATION – Matter in bolded italics is new; matter between brackets [omitted material] is material to be omitted. THE PEOPLE OF THE STATE OF NEVADA, REPRESENTED IN SENATE AND ASSEMBLY, DO ENACT AS FOLLOWS: Section 1. Chapter 689A of NRS is hereby amended by adding thereto the provisions set forth as sections 1.3 and 1.6 of this act. Sec. 1.3. 1. Except as otherwise provided in this section, an insurer that issues a policy of health insurance shall include in the policy coverage for the medically necessary treatment of conditions relating to gender dysphoria and gender incongruence. Such coverage must include coverage of medically necessary psychosocial and surgical intervention and any other medically necessary treatment for such disorders provided by: (a) Endocrinologists; (b) Pediatric endocrinologists; (c) Social workers; (d) Psychiatrists; (e) Psychologists; (f) Gynecologists; (g) Speech-language pathologists; (h) Primary care physicians; (i) Advanced practice registered nurses; (j) Physician assistants; and (k) Any other providers of medically necessary services for the treatment of gender dysphoria or gender incongruence. 2. This section does not require a policy of health insurance to include coverage for cosmetic surgery performed by a plastic surgeon or reconstructive surgeon that is not medically necessary. 3. An insurer that issues a policy of health insurance shall not categorically refuse to cover medically necessary gender- affirming treatments or procedures or revisions to prior treatments if the policy provides coverage for any such services, procedures or revisions for purposes other than gender transition or affirmation. 4. An insurer that issues a policy of health insurance may prescribe requirements that must be satisfied before the insurer covers surgical treatment of conditions relating to gender dysphoria or gender incongruence for an insured who is less than 18 years of age. Such requirements may include, without limitation, requirements that: – 3 – - 82nd Session (2023) (a) The treatment must be recommended by a psychologist, psychiatrist or other mental health professional; (b) The treatment must be recommended by a physician; (c) The insured must provide a written expression of the desire of the insured to undergo the treatment; (d) A written plan for treatment that covers at least 1 year must be developed and approved by at least two providers of health care; and (e) Parental consent is provided for the insured unless the insured is expressly authorized by law to consent on his or her own behalf. 5. When determining whether treatment is medically necessary for the purposes of this section, an insurer must consider the most recent Standards of Care published by the World Professional Association for Transgender Health, or its successor organization. 6. An insurer shall make a reasonable effort to ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the insurer. If, after a reasonable effort, the insurer is unable to make such benefits available through such a provider of health care, the insurer may treat the treatment that the insurer is unable to make available through such a provider of health care in the same manner as other services provided by a provider of health care who does not participate in the network plan of the insurer. 7. If an insured appeals the denial of a claim or coverage under this section on the grounds that the treatment requested by the insured is not medically necessary, the insurer must consult with a provider of health care who has experience in prescribing or delivering gender-affirming treatment concerning the medical necessity of the treatment requested by the insured when considering the appeal. 8. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2023, has the legal effect of including the coverage required by subsection 1, and any provision of the policy or the renewal which is in conflict with this section is void. 9. As used in this section: (a) “Cosmetic surgery”: (1) Means a surgical procedure that: (I) Does not meaningfully promote the proper function of the body; – 4 – - 82nd Session (2023) (II) Does not prevent or treat illness or disease; and (III) Is primarily directed at improving the appearance of a person. (2) Includes, without limitation, cosmetic surgery directed at preserving beauty. (b) “Gender dysphoria” means distress or impairment in social, occupational or other areas of functioning caused by a marked difference between the gender identity or expression of a person and the sex assigned to the person at birth which lasts at least 6 months and is shown by at least two of the following: (1) A marked difference between gender identity or expression and primary or secondary sex characteristics or anticipated secondary sex characteristics in young adolescents. (2) A strong desire to be rid of primary or secondary sex characteristics because of a marked difference between such sex characteristics and gender identity or expression or a desire to prevent the development of anticipated secondary sex characteristics in young adolescents. (3) A strong desire for the primary or secondary sex characteristics of the gender opposite from the sex assigned at birth. (4) A strong desire to be of the opposite gender or a gender different from the sex assigned at birth. (5) A strong desire to be treated as the opposite gender or a gender different from the sex assigned at birth. (6) A strong conviction of experiencing typical feelings and reactions of the opposite gender or a gender different from the sex assigned at birth. (c) “Medically necessary” means health care services or products that a prudent provider of health care would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that are necessary and: (1) Provided in accordance with generally accepted standards of medical practice; (2) Clinically appropriate with regard to type, frequency, extent, location and duration; (3) Not provided primarily for the convenience of the patient or provider of health care; (4) Required to improve a specific health condition of a patient or to preserve the existing state of health of the patient; and (5) The most clinically appropriate level of health care that may be safely provided to the patient. – 5 – - 82nd Session (2023)  A provider of health care prescribing, ordering, recommending or approving a health care service or product does not, by itself, make that health care service or product medically necessary. (d) “Network plan” means a policy of health insurance offered by an insurer under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the insurer. The term does not include an arrangement for the financing of premiums. (e) “Provider of health care” has the meaning ascribed to it in NRS 629.031. Sec. 1.6. An insurer that issues a policy of health insurance shall not discriminate against any person with respect to participation or coverage under the policy on the basis of actual or perceived gender identity or expression. Prohibited discrimination includes, without limitation: 1. Denying, cancelling, limiting or refusing to issue or renew a policy of health insurance on the basis of the actual or perceived gender identity or expression of a person or a family member of the person; 2. Imposing a payment or premium that is based on the actual or perceived gender identity or expression of an insured or a family member of the insured; 3. Designating the actual or perceived gender identity or expression of a person or a family member of the person as grounds to deny, cancel or limit participation or coverage; and 4. Denying, cancelling or limiting participation or coverage on the basis of actual or perceived gender identity or expression, including, without limitation, by limiting or denying coverage for health care services that are: (a) Related to gender transition, provided that there is coverage under the policy for the services when the services are not related to gender transition; or (b) Ordinarily or exclusively available to persons of any sex. Sec. 2. NRS 689A.330 is hereby amended to read as follows: 689A.330 If any policy is issued by a domestic insurer for delivery to a person residing in another state, and if the insurance commissioner or corresponding public officer of that other state has informed the Commissioner that the policy is not subject to approval or disapproval by that officer, the Commissioner may by ruling require that the policy meet the standards set forth in NRS 689A.030 to 689A.320, inclusive [.] , and sections 1.3 and 1.6 of this act. – 6 – - 82nd Session (2023) Sec. 2.8. Chapter 689B of NRS is hereby amended by adding thereto the provisions set forth as sections 3 and 3.6 of this act. Sec. 3. 1. Except as otherwise provided in this section, an insurer that issues a policy of group health insurance shall include in the policy coverage for the medically necessary treatment of conditions relating to gender dysphoria and gender incongruence. Such coverage must include coverage of medically necessary psychosocial and surgical intervention and any other medically necessary treatment for such disorders provided by: (a) Endocrinologists; (b) Pediatric endocrinologists; (c) Social workers; (d) Psychiatrists; (e) Psychologists; (f) Gynecologists; (g) Speech-language pathologists; (h) Primary care physicians; (i) Advanced practice registered nurses; (j) Physician assistants; and (k) Any other providers of medically necessary services for the treatment of gender dysphoria or gender incongruence. 2. This section does not require a policy of group health insurance to include coverage for cosmetic surgery performed by a plastic surgeon or reconstructive surgeon that is not medically necessary. 3. An insurer that issues a policy of group health insurance shall not categorically refuse to cover medically necessary gender- affirming treatments or procedures or revisions to prior treatments if the policy provides coverage for any such services, procedures or revisions for purposes other than gender transition or affirmation. 4. An insurer that issues a policy of group health insurance may prescribe requirements that must be satisfied before the insurer covers surgical treatment of conditions relating to gender dysphoria or gender incongruence for an insured who is less than 18 years of age. Such requirements may include, without limitation, requirements that: (a) The treatment must be recommended by a psychologist, psychiatrist or other mental health professional; (b) The treatment must be recommended by a physician; (c) The insured must provide a written expression of the desire of the insured to undergo the treatment; – 7 – - 82nd Session (2023) (d) A written plan for treatment that covers at least 1 year must be developed and approved by at least two providers of health care; and (e) Parental consent is provided for the insured unless the insured is expressly authorized by law to consent on his or her own behalf. 5. When determining whether treatment is medically necessary for the purposes of this section, an insurer must consider the most recent Standards of Care published by the World Professional Association for Transgender Health, or its successor organization. 6. An insurer shall make a reasonable effort to ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the insurer. If, after a reasonable effort, the insurer is unable to make such benefits available through such a provider of health care, the insurer may treat the treatment that the insurer is unable to make available through such a provider of health care in the same manner as other services provided by a provider of health care who does not participate in the network plan of the insurer. 7. If an insured appeals the denial of a claim or coverage under this section on the grounds that the treatment requested by the insured is not medically necessary, the insurer must consult with a provider of health care who has experience in prescribing or delivering gender-affirming treatment concerning the medical necessity of the treatment requested by the insured when considering the appeal. 8. A policy of group health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2023, has the legal effect of including the coverage required by subsection 1, and any provision of the policy or renewal which is in conflict with the provisions of this section is void. 9. As used in this section: (a) “Cosmetic surgery”: (1) Means a surgical procedure that: (I) Does not meaningfully promote the proper function of the body; (II) Does not prevent or treat illness or disease; and (III) Is primarily directed at improving the appearance of a person. – 8 – - 82nd Session (2023) (2) Includes, without limitation, cosmetic surgery directed at preserving beauty. (b) “Gender dysphoria” means distress or impairment in social, occupational or other areas of functioning caused by a marked difference between the gender identity or expression of a person and the sex assigned to the person at birth which lasts at least 6 months and is shown by at least two of the following: (1) A marked difference between gender identity or expression and primary or secondary sex characteristics or anticipated secondary sex characteristics in young adolescents. (2) A strong desire to be rid of primary or secondary sex characteristics because of a marked difference between such sex characteristics and gender identity or expression or a desire to prevent the development of anticipated secondary sex characteristics in young adolescents. (3) A strong desire for the primary or secondary sex characteristics of the gender opposite from the sex assigned at birth. (4) A strong desire to be of the opposite gender or a gender different from the sex assigned at birth. (5) A strong desire to be treated as the opposite gender or a gender different from the sex assigned at birth. (6) A strong conviction of experiencing typical feelings and reactions of the opposite gender or a gender different from the sex assigned at birth. (c) “Medically necessary” means health care services or products that a prudent provider of health care would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that are necessary and: (1) Provided in accordance with generally accepted standards of medical practice; (2) Clinically appropriate with regard to type, frequency, extent, location and duration; (3) Not provided primarily for the convenience of the patient or provider of health care; (4) Required to improve a specific health condition of a patient or to preserve the existing state of health of the patient; and (5) The most clinically appropriate level of health care that may be safely provided to the patient.  A provider of health care prescribing, ordering, recommending or approving a health care service or product does not, by itself, make that health care service or product medically necessary. – 9 – - 82nd Session (2023) (d) “Network plan” means a policy of group health insurance offered by an insurer under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the insurer. The term does not include an arrangement for the financing of premiums. (e) “Provider of health care” has the meaning ascribed to it in NRS 629.031. Sec. 3.6. An insurer that issues a policy of group health insurance shall not discriminate against any person with respect to participation or coverage under the policy on the basis of actual or perceived gender identity or expression. Prohibited discrimination includes, without limitation: 1. Denying, cancelling, limiting or refusing to issue or renew a policy of group health insurance on the basis of the actual or perceived gender identity or expression of a person or a family member of the person; 2. Imposing a payment or premium that is based on the actual or perceived gender identity or expression of an insured or a family member of the insured; 3. Designating the actual or perceived gender identity or expression of a person or a family member of the person as grounds to deny, cancel or limit participation or coverage; and 4. Denying, cancelling or limiting participation or coverage on the basis of actual or perceived gender identity or expression, including, without limitation, by limiting or denying coverage for health care services that are: (a) Related to gender transition, provided that there is coverage under the policy for the services when the services are not related to gender transition; or (b) Ordinarily or exclusively available to persons of any sex. Sec. 3.8. Chapter 689C of NRS is hereby amended by adding thereto the provisions set forth as sections 4 and 4.6 of this act. Sec. 4. 1. Except as otherwise provided in this section, a carrier that issues a health benefit plan shall include in the health benefit plan coverage for the medically necessary treatment of conditions relating to gender dysphoria and gender incongruence. Such coverage must include coverage of medically necessary psychosocial and surgical intervention and any other medically necessary treatment for such disorders provided by: (a) Endocrinologists; (b) Pediatric endocrinologists; (c) Social workers; – 10 – - 82nd Session (2023) (d) Psychiatrists; (e) Psychologists; (f) Gynecologists; (g) Speech-language pathologists; (h) Primary care physicians; (i) Advanced practice registered nurses; (j) Physician assistants; and (k) Any other providers of medically necessary services for the treatment of gender dysphoria or gender incongruence. 2. This section does not require a health benefit plan to include coverage for cosmetic surgery performed by a plastic surgeon or reconstructive surgeon that is not medically necessary. 3. A carrier that issues a health benefit plan shall not categorically refuse to cover medically necessary gender-affirming treatments or procedures or revisions to prior treatments if the plan provides coverage for any such services, procedures or revisions for purposes other than gender transition or affirmation. 4. A carrier that issues a health benefit plan may prescribe requirements that must be satisfied before the carrier covers surgical treatment of conditions relating to gender dysphoria or gender incongruence for an insured who is less than 18 years of age. Such requirements may include, without limitation, requirements that: (a) The treatment must be recommended by a psychologist, psychiatrist or other mental health professional; (b) The treatment must be recommended by a physician; (c) The insured must provide a written expression of the desire of the insured to undergo the treatment; (d) A written plan for treatment that covers at least 1 year must be developed and approved by at least two providers of health care; and (e) Parental consent is provided for the insured unless the insured is expressly authorized by law to consent on his or her own behalf. 5. When determining whether treatment is medically necessary for the purposes of this section, a carrier must consider the most recent Standards of Care published by the World Professional Association for Transgender Health, or its successor organization. 6. A carrier shall make a reasonable effort to ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the carrier. If, after a reasonable effort, the carrier is – 11 – - 82nd Session (2023) unable to make such benefits available through such a provider of health care, the carrier may treat the treatment that the carrier is unable to make available through such a provider of health care in the same manner as other services provided by a provider of health care who does not participate in the network plan of the carrier. 7. If an insured appeals the denial of a claim or coverage under this section on the grounds that the treatment requested by the insured is not medically necessary, the carrier must consult with a provider of health care who has experience in prescribing or delivering gender-affirming treatment concerning the medical necessity of the treatment requested by the insured when considering the appeal 8. A health benefit plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2023, has the legal effect of including the coverage required by subsection 1, and any provision of the plan or renewal which is in conflict with the provisions of this section is void. 9. As used in this section: (a) “Cosmetic surgery”: (1) Means a surgical procedure that: (I) Does not meaningfully promote the proper function of the body; (II) Does not prevent or treat illness or disease; and (III) Is primarily directed at improving the appearance of a person. (2) Includes, without limitation, cosmetic surgery directed at preserving beauty. (b) “Gender dysphoria” means distress or impairment in social, occupational or other areas of functioning caused by a marked difference between the gender identity or expression of a person and the sex assigned to the person at birth which lasts at least 6 months and is shown by at least two of the following: (1) A marked difference between gender identity or expression and primary or secondary sex characteristics or anticipated secondary sex characteristics in young adolescents. (2) A strong desire to be rid of primary or secondary sex characteristics because of a marked difference between such sex characteristics and gender identity or expression or a desire to prevent the development of anticipated secondary sex characteristics in young adolescents. – 12 – - 82nd Session (2023) (3) A strong desire for the primary or secondary sex characteristics of the gender opposite from the sex assigned at birth. (4) A strong desire to be of the opposite gender or a gender different from the sex assigned at birth. (5) A strong desire to be treated as the opposite gender or a gender different from the sex assigned at birth. (6) A strong conviction of experiencing typical feelings and reactions of the opposite gender or a gender different from the sex assigned at birth. (c) “Medically necessary” means health care services or products that a prudent provider of health care would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that are necessary and: (1) Provided in accordance with generally accepted standards of medical practice; (2) Clinically appropriate with regard to type, frequency, extent, location and duration; (3) Not provided primarily for the convenience of the patient or provider of health care; (4) Required to improve a specific health condition of a patient or to preserve the existing state of health of the patient; and (5) The most clinically appropriate level of health care that may be safely provided to the patient.  A provider of health care prescribing, ordering, recommending or approving a health care service or product does not, by itself, make that health care service or product medically necessary. (d) “Network plan” means a health benefit plan offered by a carrier under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the carrier. The term does not include an arrangement for the financing of premiums. (e) “Provider of health care” has the meaning ascribed to it in NRS 629.031. Sec. 4.6. A carrier that issues a health benefit plan shall not discriminate against any person with respect to participation or coverage under the plan on the basis of actual or perceived gender identity or expression. Prohibited discrimination includes, without limitation: 1. Denying, cancelling, limiting or refusing to issue or renew a health benefit plan on the basis of the actual or perceived gender – 13 – - 82nd Session (2023) identity or expression of a person or a family member of the person; 2. Imposing a payment or premium that is based on the actual or perceived gender identity or expression of an insured or a family member of the insured; 3. Designating the actual or perceived gender identity or expression of a person or a family member of the person as grounds to deny, cancel or limit participation or coverage; and 4. Denying, cancelling or limiting participation or coverage on the basis of actual or perceived gender identity or expression, including, without limitation, by limiting or denying coverage for health care services that are: (a) Related to gender transition, provided that there is coverage under the plan for the services when the services are not related to gender transition; or (b) Ordinarily or exclusively available to persons of any sex. Sec. 5. NRS 689C.425 is hereby amended to read as follows: 689C.425 A voluntary purchasing group and any contract issued to such a group pursuant to NRS 689C.360 to 689C.600, inclusive, are subject to the provisions of NRS 689C.015 to 689C.355, inclusive, and sections 4 and 4.6 of this act, to the extent applicable and not in conflict with the express provisions of NRS 687B.408 and 689C.360 to 689C.600, inclusive. Sec. 5.8. Chapter 695A of NRS is hereby amended by adding thereto the provisions set forth as sections 6 and 6.6 of this act. Sec. 6. 1. Except as otherwise provided in this section, a society that issues a benefit contract shall include in the benefit contract coverage for the medically necessary treatment of conditions relating to gender dysphoria and gender incongruence. Such coverage must include coverage of medically necessary psychosocial and surgical intervention and any other medically necessary treatment for such disorders provided by: (a) Endocrinologists; (b) Pediatric endocrinologists; (c) Social workers; (d) Psychiatrists; (e) Psychologists; (f) Gynecologists; (g) Speech-language pathologists; (h) Primary care physicians; (i) Advanced practice registered nurses; (j) Physician assistants; and – 14 – - 82nd Session (2023) (k) Any other providers of medically necessary services for the treatment of gender dysphoria or gender incongruence. 2. This section does not require a benefit contract to include coverage for cosmetic surgery performed by a plastic surgeon or reconstructive surgeon that is not medically necessary. 3. A society that issues a benefit contract shall not categorically refuse to cover medically necessary gender-affirming treatments or procedures or revisions to prior treatments if the contract provides coverage for any such services, procedures or revisions for purposes other than gender transition or affirmation. 4. A society that issues a benefit contract may prescribe requirements that must be satisfied before the society covers surgical treatment of conditions relating to gender dysphoria or gender incongruence for an insured who is less than 18 years of age. Such requirements may include, without limitation, requirements that: (a) The treatment must be recommended by a psychologist, psychiatrist or other mental health professional; (b) The treatment must be recommended by a physician; (c) The insured must provide a written expression of the desire of the insured to undergo the treatment; (d) A written plan for treatment that covers at least 1 year must be developed and approved by at least two providers of health care; and (e) Parental consent is provided for the insured unless the insured is expressly authorized by law to consent on his or her own behalf. 5. When determining whether treatment is medically necessary for the purposes of this section, a society must consider the most recent Standards of Care published by the World Professional Association for Transgender Health, or its successor organization. 6. A society shall make a reasonable effort to ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the society. If, after a reasonable effort, the society is unable to make such benefits available through such a provider of health care, the society may treat the treatment that the society is unable to make available through such a provider of health care in the same manner as other services provided by a provider of health care who does not participate in the network plan of the society. – 15 – - 82nd Session (2023) 7. If an insured appeals the denial of a claim or coverage under this section on the grounds that the treatment requested by the insured is not medically necessary, the society must consult with a provider of health care who has experience in prescribing or delivering gender-affirming treatment concerning the medical necessity of the treatment requested by the insured when considering the appeal. 8. A benefit contract subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2023, has the legal effect of including the coverage required by subsection 1, and any provision of the benefit contract or renewal which is in conflict with the provisions of this section is void. 9. As used in this section: (a) “Cosmetic surgery”: (1) Means a surgical procedure that: (I) Does not meaningfully promote the proper function of the body; (II) Does not prevent or treat illness or disease; and (III) Is primarily directed at improving the appearance of a person. (2) Includes, without limitation, cosmetic surgery directed at preserving beauty. (b) “Gender dysphoria” means distress or impairment in social, occupational or other areas of functioning caused by a marked difference between the gender identity or expression of a person and the sex assigned to the person at birth which lasts at least 6 months and is shown by at least two of the following: (1) A marked difference between gender identity or expression and primary or secondary sex characteristics or anticipated secondary sex characteristics in young adolescents. (2) A strong desire to be rid of primary or secondary sex characteristics because of a marked difference between such sex characteristics and gender identity or expression or a desire to prevent the development of anticipated secondary sex characteristics in young adolescents. (3) A strong desire for the primary or secondary sex characteristics of the gender opposite from the sex assigned at birth. (4) A strong desire to be of the opposite gender or a gender different from the sex assigned at birth. (5) A strong desire to be treated as the opposite gender or a gender different from the sex assigned at birth. – 16 – - 82nd Session (2023) (6) A strong conviction of experiencing typical feelings and reactions of the opposite gender or a gender different from the sex assigned at birth. (c) “Medically necessary” means health care services or products that a prudent provider of health care would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that are necessary and: (1) Provided in accordance with generally accepted standards of medical practice; (2) Clinically appropriate with regard to type, frequency, extent, location and duration; (3) Not provided primarily for the convenience of the patient or provider of health care; (4) Required to improve a specific health condition of a patient or to preserve the existing state of health of the patient; and (5) The most clinically appropriate level of health care that may be safely provided to the patient.  A provider of health care prescribing, ordering, recommending or approving a health care service or product does not, by itself, make that health care service or product medically necessary. (d) “Network plan” means a benefit contract offered by a society under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the society. The term does not include an arrangement for the financing of premiums. (e) “Provider of health care” has the meaning ascribed to it in NRS 629.031. Sec. 6.6. A society that issues a benefit contract shall not discriminate against any person with respect to participation or coverage under the contract on the basis of actual or perceived gender identity or expression. Prohibited discrimination includes, without limitation: 1. Denying, cancelling, limiting or refusing to issue or renew a benefit contract on the basis of the actual or perceived gender identity or expression of a person or a family member of the person; 2. Imposing a payment or premium that is based on the actual or perceived gender identity or expression of an insured or a family member of the insured; – 17 – - 82nd Session (2023) 3. Designating the actual or perceived gender identity or expression of a person or a family member of the person as grounds to deny, cancel or limit participation or coverage; and 4. Denying, cancelling or limiting participation or coverage on the basis of actual or perceived gender identity or expression, including, without limitation, by limiting or denying coverage for health care services that are: (a) Related to gender transition, provided that there is coverage under the contract for the services when the services are not related to gender transition; or (b) Ordinarily or exclusively available to persons of any sex. Sec. 6.8. Chapter 695B of NRS is hereby amended by adding thereto the provisions set forth as sections 7 and 7.6 of this act. Sec. 7. 1. Except as otherwise provided in this section, a hospital or medical services corporation that issues a policy of health insurance shall include in the policy coverage for the medically necessary treatment of conditions relating to gender dysphoria and gender incongruence. Such coverage must include coverage of medically necessary psychosocial and surgical intervention and any other medically necessary treatment for such disorders provided by: (a) Endocrinologists; (b) Pediatric endocrinologists; (c) Social workers; (d) Psychiatrists; (e) Psychologists; (f) Gynecologists; (g) Speech-language pathologists; (h) Primary care physicians; (i) Advanced practice registered nurses; (j) Physician assistants; and (k) Any other providers of medically necessary services for the treatment of gender dysphoria or gender incongruence. 2. This section does not require a policy of health insurance to include coverage for cosmetic surgery performed by a plastic surgeon or reconstructive surgeon that is not medically necessary. 3. A hospital or medical services corporation that issues a policy of health insurance shall not categorically refuse to cover medically necessary gender-affirming treatments or procedures or revisions to prior treatments if the policy provides coverage for any such services, procedures or revisions for purposes other than gender transition or affirmation. – 18 – - 82nd Session (2023) 4. A hospital or medical services corporation that issues a policy of health insurance may prescribe requirements that must be satisfied before the hospital or medical services corporation covers surgical treatment of conditions relating to gender dysphoria or gender incongruence for an insured who is less than 18 years of age. Such requirements may include, without limitation, requirements that: (a) The treatment must be recommended by a psychologist, psychiatrist or other mental health professional; (b) The treatment must be recommended by a physician; (c) The insured must provide a written expression of the desire of the insured to undergo the treatment; (d) A written plan for treatment that covers at least 1 year must be developed and approved by at least two providers of health care; and (e) Parental consent is provided for the insured unless the insured is expressly authorized by law to consent on his or her own behalf. 5. When determining whether treatment is medically necessary for the purposes of this section, a hospital or medical services corporation must consider the most recent Standards of Care published by the World Professional Association for Transgender Health, or its successor organization. 6. A hospital or medical services corporation shall make a reasonable effort to ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the hospital or medical services corporation. If, after a reasonable effort, the hospital or medical services corporation is unable to make such benefits available through such a provider of health care, the hospital or medical services corporation may treat the treatment that the hospital or medical services corporation is unable to make available through such a provider of health care in the same manner as other services provided by a provider of health care who does not participate in the network plan of the hospital or medical services corporation. 7. If an insured appeals the denial of a claim or coverage under this section on the grounds that the treatment requested by the insured is not medically necessary, the hospital or medical services corporation must consult with a provider of health care who has experience in prescribing or delivering gender-affirming treatment concerning the medical necessity of the treatment requested by the insured when considering the appeal. – 19 – - 82nd Session (2023) 8. A policy of health insurance subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2023, has the legal effect of including the coverage required by subsection 1, and any provision of the policy or renewal which is in conflict with the provisions of this section is void. 9. As used in this section: (a) “Cosmetic surgery”: (1) Means a surgical procedure that: (I) Does not meaningfully promote the proper function of the body; (II) Does not prevent or treat illness or disease; and (III) Is primarily directed at improving the appearance of a person. (2) Includes, without limitation, cosmetic surgery directed at preserving beauty. (b) “Gender dysphoria” means distress or impairment in social, occupational or other areas of functioning caused by a marked difference between the gender identity or expression of a person and the sex assigned to the person at birth which lasts at least 6 months and is shown by at least two of the following: (1) A marked difference between gender identity or expression and primary or secondary sex characteristics or anticipated secondary sex characteristics in young adolescents. (2) A strong desire to be rid of primary or secondary sex characteristics because of a marked difference between such sex characteristics and gender identity or expression or a desire to prevent the development of anticipated secondary sex characteristics in young adolescents. (3) A strong desire for the primary or secondary sex characteristics of the gender opposite from the sex assigned at birth. (4) A strong desire to be of the opposite gender or a gender different from the sex assigned at birth. (5) A strong desire to be treated as the opposite gender or a gender different from the sex assigned at birth. (6) A strong conviction of experiencing typical feelings and reactions of the opposite gender or a gender different from the sex assigned at birth. (c) “Medically necessary” means health care services or products that a prudent provider of health care would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that are necessary and: – 20 – - 82nd Session (2023) (1) Provided in accordance with generally accepted standards of medical practice; (2) Clinically appropriate with regard to type, frequency, extent, location and duration; (3) Not provided primarily for the convenience of the patient or provider of health care; (4) Required to improve a specific health condition of a patient or to preserve the existing state of health of the patient; and (5) The most clinically appropriate level of health care that may be safely provided to the patient.  A provider of health care prescribing, ordering, recommending or approving a health care service or product does not, by itself, make that health care service or product medically necessary. (d) “Network plan” means a policy of health insurance offered by a hospital or medical services corporation under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the hospital or medical services corporation. The term does not include an arrangement for the financing of premiums. (e) “Provider of health care” has the meaning ascribed to it in NRS 629.031. Sec. 7.6. A hospital or medical services corporation that issues a policy of health insurance shall not discriminate against any person with respect to participation or coverage under the policy on the basis of actual or perceived gender identity or expression. Prohibited discrimination includes, without limitation: 1. Denying, cancelling, limiting or refusing to issue or renew a policy of health insurance on the basis of the actual or perceived gender identity or expression of a person or a family member of the person; 2. Imposing a payment or premium that is based on the actual or perceived gender identity or expression of an insured or a family member of the insured; 3. Designating the actual or perceived gender identity or expression of a person or a family member of the person as grounds to deny, cancel or limit participation or coverage; and 4. Denying, cancelling or limiting participation or coverage on the basis of actual or perceived gender identity or expression, including, without limitation, by limiting or denying coverage for health care services that are: – 21 – - 82nd Session (2023) (a) Related to gender transition, provided that there is coverage under the policy for the services when the services are not related to gender transition; or (b) Ordinarily or exclusively available to persons of any sex. Sec. 7.8. Chapter 695C of NRS is hereby amended by adding thereto the provisions set forth as sections 8 and 8.6 of this act. Sec. 8. 1. Except as otherwise provided in this section, a health maintenance organization that issues a health care plan shall include in the health care plan coverage for the medically necessary treatment of conditions relating to gender dysphoria and gender incongruence. Such coverage must include coverage of medically necessary psychosocial and surgical intervention and any other medically necessary treatment for such disorders provided by: (a) Endocrinologists; (b) Pediatric endocrinologists; (c) Social workers; (d) Psychiatrists; (e) Psychologists; (f) Gynecologists; (g) Speech-language pathologists; (h) Primary care physicians; (i) Advanced practice registered nurses; (j) Physician assistants; and (k) Any other providers of medically necessary services for the treatment of gender dysphoria or gender incongruence. 2. This section does not require a health care plan to include coverage for cosmetic surgery performed by a plastic surgeon or reconstructive surgeon that is not medically necessary. 3. A health maintenance organization that issues a health care plan shall not categorically refuse to cover medically necessary gender-affirming treatments or procedures or revisions to prior treatments if the plan provides coverage for any such services, procedures or revisions for purposes other than gender transition or affirmation. 4. A health maintenance organization that issues a health care plan may prescribe requirements that must be satisfied before the health maintenance organization covers surgical treatment of conditions relating to gender dysphoria or gender incongruence for an enrollee who is less than 18 years of age. Such requirements may include, without limitation, requirements that: (a) The treatment must be recommended by a psychologist, psychiatrist or other mental health professional; – 22 – - 82nd Session (2023) (b) The treatment must be recommended by a physician; (c) The enrollee must provide a written expression of the desire of the enrollee to undergo the treatment; (d) A written plan for treatment that covers at least 1 year must be developed and approved by at least two providers of health care; and (e) Parental consent is provided for the enrollee unless the enrollee is expressly authorized by law to consent on his or her own behalf. 5. When determining whether treatment is medically necessary for the purposes of this section, a health maintenance organization must consider the most recent Standards of Care prescribed by the World Professional Association for Transgender Health, or its successor organization. 6. A health maintenance organization shall make a reasonable effort to ensure that the benefits required by subsection 1 are made available to an enrollee through a provider of health care who participates in the network plan of the health maintenance organization. If, after a reasonable effort, the health maintenance organization is unable to make such benefits available through such a provider of health care, the health maintenance organization may treat the treatment that the health maintenance organization is unable to make available through such a provider of health care in the same manner as other services provided by a provider of health care who does not participate in the network plan of the health maintenance organization. 7. If an enrollee appeals the denial of a claim or coverage under this section on the grounds that the treatment requested by the enrollee is not medically necessary, the health maintenance organization must consult with a provider of health care who has experience in prescribing or delivering gender-affirming treatment concerning the medical necessity of the treatment requested by the enrollee when considering the appeal. 8. A health care plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2023, has the legal effect of including the coverage required by subsection 1, and any provision of the plan or renewal which is in conflict with the provisions of this section is void. 9. As used in this section: (a) “Cosmetic surgery”: (1) Means a surgical procedure that: – 23 – - 82nd Session (2023) (I) Does not meaningfully promote the proper function of the body; (II) Does not prevent or treat illness or disease; and (III) Is primarily directed at improving the appearance of a person. (2) Includes, without limitation, cosmetic surgery directed at preserving beauty. (b) “Gender dysphoria” means distress or impairment in social, occupational or other areas of functioning caused by a marked difference between the gender identity or expression of a person and the sex assigned to the person at birth which lasts at least 6 months and is shown by at least two of the following: (1) A marked difference between gender identity or expression and primary or secondary sex characteristics or anticipated secondary sex characteristics in young adolescents. (2) A strong desire to be rid of primary or secondary sex characteristics because of a marked difference between such sex characteristics and gender identity or expression or a desire to prevent the development of anticipated secondary sex characteristics in young adolescents. (3) A strong desire for the primary or secondary sex characteristics of the gender opposite from the sex assigned at birth. (4) A strong desire to be of the opposite gender or a gender different from the sex assigned at birth. (5) A strong desire to be treated as the opposite gender or a gender different from the sex assigned at birth. (6) A strong conviction of experiencing typical feelings and reactions of the opposite gender or a gender different from the sex assigned at birth. (c) “Medically necessary” means health care services or products that a prudent provider of health care would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that are necessary and: (1) Provided in accordance with generally accepted standards of medical practice; (2) Clinically appropriate with regard to type, frequency, extent, location and duration; (3) Not provided primarily for the convenience of the patient or provider of health care; (4) Required to improve a specific health condition of a patient or to preserve the existing state of health of the patient; and – 24 – - 82nd Session (2023) (5) The most clinically appropriate level of health care that may be safely provided to the patient.  A provider of health care prescribing, ordering, recommending or approving a health care service or product does not, by itself, make that health care service or product medically necessary. (d) “Network plan” means a health care plan offered by a health maintenance organization under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the health maintenance organization. The term does not include an arrangement for the financing of premiums. (e) “Provider of health care” has the meaning ascribed to it in NRS 629.031. Sec. 8.6. A health maintenance organization that issues a health care plan shall not discriminate against any person with respect to participation or coverage under the plan on the basis of actual or perceived gender identity or expression. Prohibited discrimination includes, without limitation: 1. Denying, cancelling, limiting or refusing to issue or renew a health care plan on the basis of the actual or perceived gender identity or expression of a person or a family member of the person; 2. Imposing a payment or premium that is based on the actual or perceived gender identity or expression of an enrollee or a family member of the enrollee; 3. Designating the actual or perceived gender identity or expression of a person or a family member of the person as grounds to deny, cancel or limit participation or coverage; and 4. Denying, cancelling or limiting participation or coverage on the basis of actual or perceived gender identity or expression, including, without limitation, by limiting or denying coverage for health care services that are: (a) Related to gender transition, provided that there is coverage under the plan for the services when the services are not related to gender transition; or (b) Ordinarily or exclusively available to persons of any sex. Sec. 9. NRS 695C.050 is hereby amended to read as follows: 695C.050 1. Except as otherwise provided in this chapter or in specific provisions of this title, the provisions of this title are not applicable to any health maintenance organization granted a certificate of authority under this chapter. This provision does not apply to an insurer licensed and regulated pursuant to this title – 25 – - 82nd Session (2023) except with respect to its activities as a health maintenance organization authorized and regulated pursuant to this chapter. 2. Solicitation of enrollees by a health maintenance organization granted a certificate of authority, or its representatives, must not be construed to violate any provision of law relating to solicitation or advertising by practitioners of a healing art. 3. Any health maintenance organization authorized under this chapter shall not be deemed to be practicing medicine and is exempt from the provisions of chapter 630 of NRS. 4. The provisions of NRS 695C.110, 695C.125, 695C.1691, 695C.1693, 695C.170, 695C.1703, 695C.1705, 695C.1709 to 695C.173, inclusive, 695C.1733, 695C.17335, 695C.1734, 695C.1751, 695C.1755, 695C.1759, 695C.176 to 695C.200, inclusive, and 695C.265 do not apply to a health maintenance organization that provides 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 of Health and Human Services. This subsection does not exempt a health maintenance organization from any provision of this chapter for services provided pursuant to any other contract. 5. The provisions of NRS 695C.1694 to 695C.1698, inclusive, 695C.1701, 695C.1708, 695C.1728, 695C.1731, 695C.17333, 695C.17345, 695C.17347, 695C.1735, 695C.1737, 695C.1743, 695C.1745 and 695C.1757 and sections 8 and 8.6 of this act apply to a health maintenance organization that provides health care services through managed care to recipients of Medicaid under the State Plan for Medicaid. Sec. 10. NRS 695C.330 is hereby amended to read as follows: 695C.330 1. The Commissioner may suspend or revoke any certificate of authority issued to a health maintenance organization pursuant to the provisions of this chapter if the Commissioner finds that any of the following conditions exist: (a) The health maintenance organization is operating significantly in contravention of its basic organizational document, its health care plan or in a manner contrary to that described in and reasonably inferred from any other information submitted pursuant to NRS 695C.060, 695C.070 and 695C.140, unless any amendments to those submissions have been filed with and approved by the Commissioner; (b) The health maintenance organization issues evidence of coverage or uses a schedule of charges for health care services – 26 – - 82nd Session (2023) which do not comply with the requirements of NRS 695C.1691 to 695C.200, inclusive, or 695C.207 [;] or sections 8 and 8.6 of this act; (c) The health care plan does not furnish comprehensive health care services as provided for in NRS 695C.060; (d) The Commissioner certifies that the health maintenance organization: (1) Does not meet the requirements of subsection 1 of NRS 695C.080; or (2) Is unable to fulfill its obligations to furnish health care services as required under its health care plan; (e) The health maintenance organization is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees; (f) The health maintenance organization has failed to put into effect a mechanism affording the enrollees an opportunity to participate in matters relating to the content of programs pursuant to NRS 695C.110; (g) The health maintenance organization has failed to put into effect the system required by NRS 695C.260 for: (1) Resolving complaints in a manner reasonably to dispose of valid complaints; and (2) Conducting external reviews of adverse determinations that comply with the provisions of NRS 695G.241 to 695G.310, inclusive; (h) The health maintenance organization or any person on its behalf has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive or unfair manner; (i) The continued operation of the health maintenance organization would be hazardous to its enrollees or creditors or to the general public; (j) The health maintenance organization fails to provide the coverage required by NRS 695C.1691; or (k) The health maintenance organization has otherwise failed to comply substantially with the provisions of this chapter. 2. A certificate of authority must be suspended or revoked only after compliance with the requirements of NRS 695C.340. 3. If the certificate of authority of a health maintenance organization is suspended, the health maintenance organization shall not, during the period of that suspension, enroll any additional groups or new individual contracts, unless those groups or persons were contracted for before the date of suspension. – 27 – - 82nd Session (2023) 4. If the certificate of authority of a health maintenance organization is revoked, the organization shall proceed, immediately following the effective date of the order of revocation, to wind up its affairs and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of the organization. It shall engage in no further advertising or solicitation of any kind. The Commissioner may, by written order, permit such further operation of the organization as the Commissioner may find to be in the best interest of enrollees to the end that enrollees are afforded the greatest practical opportunity to obtain continuing coverage for health care. Sec. 10.8. Chapter 695G of NRS is hereby amended by adding thereto the provisions set forth as sections 11 and 11.6 of this act. Sec. 11. 1. Except as otherwise provided in this section, a managed care organization that issues a health care plan shall include in the health care plan coverage for the medically necessary treatment of conditions relating to gender dysphoria and gender incongruence. Such coverage must include coverage of medically necessary psychosocial and surgical intervention and any other medically necessary treatment for such disorders provided by: (a) Endocrinologists; (b) Pediatric endocrinologists; (c) Social workers; (d) Psychiatrists; (e) Psychologists; (f) Gynecologists; (g) Speech-language pathologists; (h) Primary care physicians; (i) Advanced practice registered nurses; (j) Physician assistants; and (k) Any other providers of medically necessary services for the treatment of gender dysphoria or gender incongruence. 2. This section does not require a health care plan to include coverage for cosmetic surgery performed by a plastic surgeon or reconstructive surgeon that is not medically necessary. 3. A managed care organization that issues a health care plan shall not categorically refuse to cover medically necessary gender-affirming treatments or procedures or revisions to prior treatments if the plan provides coverage for any such services, procedures or revisions for purposes other than gender transition or affirmation. – 28 – - 82nd Session (2023) 4. A managed care organization that issues a health care plan may prescribe requirements that must be satisfied before the managed care organization covers surgical treatment of conditions relating to gender dysphoria or gender incongruence for an insured who is less than 18 years of age. Such requirements may include, without limitation, requirements that: (a) The treatment must be recommended by a psychologist, psychiatrist or other mental health professional; (b) The treatment must be recommended by a physician; (c) The insured must provide a written expression of the desire of the insured to undergo the treatment; (d) A written plan for treatment that covers at least 1 year must be developed and approved by at least two providers of health care; and (e) Parental consent is provided for the insured unless the insured is expressly authorized by law to consent on his or her own behalf. 5. When determining whether treatment is medically necessary for the purposes of this section, a managed care organization must consider the most recent Standards of Care prescribed by the World Professional Association for Transgender Health, or its successor organization. 6. A managed care organization shall make a reasonable effort to ensure that the benefits required by subsection 1 are made available to an insured through a provider of health care who participates in the network plan of the managed care organization. If, after a reasonable effort, the managed care organization is unable to make such benefits available through such a provider of health care, the managed care organization may treat the treatment that the managed care organization is unable to make available through such a provider of health care in the same manner as other services provided by a provider of health care who does not participate in the network plan of the managed care organization. 7. If an insured appeals the denial of a claim or coverage under this section on the grounds that the treatment requested by the insured is not medically necessary, the managed care organization must consult with a provider of health care who has experience in prescribing or delivering gender-affirming treatment concerning the medical necessity of the treatment requested by the insured when considering the appeal. 8. Evidence of coverage subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after – 29 – - 82nd Session (2023) July 1, 2023, has the legal effect of including the coverage required by subsection 1, and any provision of the plan or renewal which is in conflict with the provisions of this section is void. 9. As used in this section: (a) “Cosmetic surgery”: (1) Means a surgical procedure that: (I) Does not meaningfully promote the proper function of the body; (II) Does not prevent or treat illness or disease; and (III) Is primarily directed at improving the appearance of a person. (2) Includes, without limitation, cosmetic surgery directed at preserving beauty. (b) “Gender dysphoria” means distress or impairment in social, occupational or other areas of functioning caused by a marked difference between the gender identity or expression of a person and the sex assigned to the person at birth which lasts at least 6 months and is shown by at least two of the following: (1) A marked difference between gender identity or expression and primary or secondary sex characteristics or anticipated secondary sex characteristics in young adolescents. (2) A strong desire to be rid of primary or secondary sex characteristics because of a marked difference between such sex characteristics and gender identity or expression or a desire to prevent the development of anticipated secondary sex characteristics in young adolescents. (3) A strong desire for the primary or secondary sex characteristics of the gender opposite from the sex assigned at birth. (4) A strong desire to be of the opposite gender or a gender different from the sex assigned at birth. (5) A strong desire to be treated as the opposite gender or a gender different from the sex assigned at birth. (6) A strong conviction of experiencing typical feelings and reactions of the opposite gender or a gender different from the sex assigned at birth. (c) “Medically necessary” means health care services or products that a prudent provider of health care would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that are necessary and: (1) Provided in accordance with generally accepted standards of medical practice; – 30 – - 82nd Session (2023) (2) Clinically appropriate with regard to type, frequency, extent, location and duration; (3) Not provided primarily for the convenience of the patient or provider of health care; (4) Required to improve a specific health condition of a patient or to preserve the existing state of health of the patient; and (5) The most clinically appropriate level of health care that may be safely provided to the patient.  A provider of health care prescribing, ordering, recommending or approving a health care service or product does not, by itself, make that health care service or product medically necessary. (d) “Network plan” means a health care plan offered by a managed care organization under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the managed care organization. The term does not include an arrangement for the financing of premiums. (e) “Provider of health care” has the meaning ascribed to it in NRS 629.031. Sec. 11.6. A managed care organization that issues a health care plan shall not discriminate against any person with respect to participation or coverage under the plan on the basis of actual or perceived gender identity or expression. Prohibited discrimination includes, without limitation: 1. Denying, cancelling, limiting or refusing to issue or renew a health care plan on the basis of the actual or perceived gender identity or expression of a person or a family member of the person; 2. Imposing a payment or premium that is based on the actual or perceived gender identity or expression of an insured or a family member of the insured; 3. Designating the actual or perceived gender identity or expression of a person or a family member of the person as grounds to deny, cancel or limit participation or coverage; and 4. Denying, cancelling or limiting participation or coverage on the basis of actual or perceived gender identity or expression, including, without limitation, by limiting or denying coverage for health care services that are: (a) Related to gender transition, provided that there is coverage under the plan for the services when the services are not related to gender transition; or – 31 – - 82nd Session (2023) (b) Ordinarily or exclusively available to persons of any sex. Sec. 12. NRS 232.320 is hereby amended to read as follows: 232.320 1. The Director: (a) Shall appoint, with the consent of the Governor, administrators of the divisions of the Department, who are respectively designated as follows: (1) The Administrator of the Aging and Disability Services Division; (2) The Administrator of the Division of Welfare and Supportive Services; (3) The Administrator of the Division of Child and Family Services; (4) The Administrator of the Division of Health Care Financing and Policy; and (5) The Administrator of the Division of Public and Behavioral Health. (b) Shall administer, through the divisions of the Department, the provisions of chapters 63, 424, 425, 427A, 432A to 442, inclusive, 446 to 450, inclusive, 458A and 656A of NRS, NRS 127.220 to 127.310, inclusive, 422.001 to 422.410, inclusive, and sections 15 and 15.6 of this act, 422.580, 432.010 to 432.133, inclusive, 432B.6201 to 432B.626, inclusive, 444.002 to 444.430, inclusive, and 445A.010 to 445A.055, inclusive, and all other provisions of law relating to the functions of the divisions of the Department, but is not responsible for the clinical activities of the Division of Public and Behavioral Health or the professional line activities of the other divisions. (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. §§ 15001 et seq. (d) Shall, after considering advice from agencies of local governments and nonprofit organizations which provide social services, adopt a master plan for the provision of human services in this State. The Director shall revise the plan biennially and deliver a copy of the plan to the Governor and the Legislature at the beginning of each regular session. The plan must: (1) Identify and assess the plans and programs of the Department for the provision of human services, and any duplication of those services by federal, state and local agencies; (2) Set forth priorities for the provision of those services; – 32 – - 82nd Session (2023) (3) Provide for communication and the coordination of those services among nonprofit organizations, agencies of local government, the State and the Federal Government; (4) Identify the sources of funding for services provided by the Department and the allocation of that funding; (5) Set forth sufficient information to assist the Department in providing those services and in the planning and budgeting for the future provision of those services; and (6) Contain any other information necessary for the Department to communicate effectively with the Federal Government concerning demographic trends, formulas for the distribution of federal money and any need for the modification of programs administered by the Department. (e) May, by regulation, require nonprofit organizations and state and local governmental agencies to provide information regarding the programs of those organizations and agencies, excluding detailed information relating to their budgets and payrolls, which the Director deems necessary for the performance of the duties imposed upon him or her pursuant to this section. (f) Has such other powers and duties as are provided by law. 2. Notwithstanding any other provision of law, the Director, or the Director’s designee, is responsible for appointing and removing subordinate officers and employees of the Department. Sec. 13. NRS 287.010 is hereby amended to read as follows: 287.010 1. The governing body of any county, school district, municipal corporation, political subdivision, public corporation or other local governmental agency of the State of Nevada may: (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 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. (b) Purchase group policies of life, accident or health insurance, or any combination thereof, for the benefit of such officers and employees, and the dependents of such officers and employees, as have authorized the purchase, from insurance companies authorized to transact the business of such insurance in the State of Nevada, and, where necessary, deduct from the compensation of officers and employees the premiums upon insurance and pay the deductions upon the premiums. – 33 – - 82nd Session (2023) (c) Provide group life, accident or health coverage through a self-insurance reserve fund and, where necessary, deduct contributions to the maintenance of the fund from the compensation of officers and employees and pay the deductions into the fund. The money accumulated for this purpose through deductions from the compensation of officers and employees and contributions of the governing body must be maintained as an internal service fund as defined by NRS 354.543. The money must be deposited in a state or national bank or credit union authorized to transact business in the State of Nevada. Any independent administrator of a fund created under this section is subject to the licensing requirements of chapter 683A of NRS, and must be a resident of this State. Any contract with an independent administrator must be approved by the Commissioner of Insurance as to the reasonableness of administrative charges in relation to contributions collected and benefits provided. The provisions of NRS 686A.135, 687B.352, 687B.408, 687B.723, 687B.725, 689B.030 to 689B.050, inclusive, and sections 3 and 3.6 of this act, 689B.265, 689B.287 and 689B.500 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. (d) Defray part or all of the cost of maintenance of a self- insurance fund or of the premiums upon insurance. The money for contributions must be budgeted for in accordance with the laws governing the county, school district, municipal corporation, political subdivision, public corporation or other local governmental agency of the State of Nevada. 2. If a school district offers group insurance to its officers and employees pursuant to this section, members of the board of trustees of the school district must not be excluded from participating in the group insurance. If the amount of the deductions from compensation required to pay for the group insurance exceeds the compensation to which a trustee is entitled, the difference must be paid by the trustee. 3. In any county in which a legal services organization exists, the governing body of the county, or of any school district, municipal corporation, political subdivision, public corporation or other local governmental agency of the State of Nevada in the county, may enter into a contract with the legal services organization pursuant to which the officers and employees of the legal services organization, and the dependents of those officers and employees, are eligible for any life, accident or health insurance – 34 – - 82nd Session (2023) provided pursuant to this section to the officers and employees, and the dependents of the officers and employees, of the county, school district, municipal corporation, political subdivision, public corporation or other local governmental agency. 4. If a contract is entered into pursuant to subsection 3, the officers and employees of the legal services organization: (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 governmental agency with which the legal services organization has contracted; and (b) Must be required by the contract to pay the premiums or contributions for all insurance which they elect to accept or of which they authorize the purchase. 5. A contract that is entered into pursuant to subsection 3: (a) Must be submitted to the Commissioner of Insurance for approval not less than 30 days before the date on which the contract is to become effective. (b) Does not become effective unless approved by the Commissioner. (c) Shall be deemed to be approved if not disapproved by the Commissioner within 30 days after its submission. 6. As used in this section, “legal services organization” means an organization that operates a program for legal aid and receives money pursuant to NRS 19.031. Sec. 14. NRS 287.04335 is hereby amended to read as follows: 287.04335 If the Board provides health insurance through a plan of self-insurance, it shall comply with the provisions of NRS 686A.135, 687B.352, 687B.409, 687B.723, 687B.725, 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.174, inclusive, and sections 11 and 11.6 of this act, 695G.176, 695G.177, 695G.200 to 695G.230, inclusive, 695G.241 to 695G.310, inclusive, and 695G.405, in the same manner as an insurer that is licensed pursuant to title 57 of NRS is required to comply with those provisions. Sec. 14.8. Chapter 422 of NRS is hereby amended by adding thereto the provisions set forth as sections 15 and 15.6 of this act. Sec. 15. 1. Except as otherwise provided in this section, the Director shall include in the State Plan for Medicaid a requirement that the State, to the extent authorized by federal law, must pay the nonfederal share of expenditures incurred for the – 35 – - 82nd Session (2023) medically necessary treatment of conditions relating to gender dysphoria and gender incongruence. Such treatment includes medically necessary psychosocial and surgical intervention and any other medically necessary treatment for such disorders provided by: (a) Endocrinologists; (b) Pediatric endocrinologists; (c) Social workers; (d) Psychiatrists; (e) Psychologists; (f) Gynecologists; (g) Speech-language pathologists; (h) Primary care physicians; (i) Advanced practice registered nurses; (j) Physician assistants; and (k) Any other providers of medically necessary services for the treatment of gender dysphoria or gender incongruence. 2. This section does not require the Director to include in the State Plan for Medicaid coverage for cosmetic surgery performed by a plastic surgeon or reconstructive surgeon that is not medically necessary. 3. The Department shall not categorically refuse to cover any medically necessary gender-affirming treatments or procedures or revisions to prior treatments if the State Plan for Medicaid provides coverage for any such services, procedures or revisions for purposes other than gender transition or affirmation. 4. When determining whether treatment is medically necessary for the purposes of this section, the Department must consider the most recent Standards of Care published by the World Professional Association for Transgender Health, or its successor organization. 5. If a person appeals the denial of a payment or coverage under this section on the grounds that the treatment requested by the person is not medically necessary, the Division must consult with a provider of health care who has experience in prescribing or delivering gender-affirming treatment concerning the medical necessity of the treatment requested by the person when considering the appeal. 6. As used in this section: (a) “Cosmetic surgery”: (1) Means a surgical procedure that: (I) Does not meaningfully promote the proper function of the body; – 36 – - 82nd Session (2023) (II) Does not prevent or treat illness or disease; and (III) Is primarily directed at improving the appearance of a person. (2) Includes, without limitation, cosmetic surgery directed at preserving beauty. (b) “Gender dysphoria” means distress or impairment in social, occupational or other areas of functioning caused by a marked difference between the gender identity or expression of a person and the sex assigned to the person at birth which lasts at least 6 months and is shown by at least two of the following: (1) A marked difference between gender identity or expression and primary or secondary sex characteristics or anticipated secondary sex characteristics in young adolescents. (2) A strong desire to be rid of primary or secondary sex characteristics because of a marked difference between such sex characteristics and gender identity or expression or a desire to prevent the development of anticipated secondary sex characteristics in young adolescents. (3) A strong desire for the primary or secondary sex characteristics of the gender opposite from the sex assigned at birth. (4) A strong desire to be of the opposite gender or a gender different from the sex assigned at birth. (5) A strong desire to be treated as the opposite gender or a gender different from the sex assigned at birth. (6) A strong conviction of experiencing typical feelings and reactions of the opposite gender or a gender different from the sex assigned at birth. (c) “Medically necessary” means health care services or products that a prudent provider of health care would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that are necessary and: (1) Provided in accordance with generally accepted standards of medical practice; (2) Clinically appropriate with regard to type, frequency, extent, location and duration; (3) Not provided primarily for the convenience of the patient or provider of health care; (4) Required to improve a specific health condition of a patient or to preserve the existing state of health of the patient; and (5) The most clinically appropriate level of health care that may be safely provided to the patient. – 37 – - 82nd Session (2023)  A provider of health care prescribing, ordering, recommending or approving a health care service or product does not, by itself, make that health care service or product medically necessary. (d) “Provider of health care” has the meaning ascribed to it in NRS 629.031. Sec. 15.6. The Department shall not discriminate against any person with respect to participation or coverage under Medicaid on the basis of actual or perceived gender identity or expression. Prohibited discrimination includes, without limitation: 1. Denying, cancelling, limiting or refusing to issue a payment or coverage on the basis of the actual or perceived gender identity or expression of a person or a family member of the person; 2. Imposing a payment that is based on the actual or perceived gender identity or expression of a recipient of Medicaid or a family member of the recipient; 3. Designating the actual or perceived gender identity or expression of a person or a family member of the person as grounds to deny, cancel or limit participation or coverage; and 4. Denying, cancelling or limiting participation or coverage on the basis of actual or perceived gender identity or expression, including, without limitation, by limiting or denying payment or coverage for health care services that are: (a) Related to gender transition, provided that there is coverage under Medicaid for the services when the services are not related to gender transition; or (b) Ordinarily or exclusively available to persons of any sex. Sec. 16. 1. There is hereby appropriated from the State General Fund to the Division of Health Care Financing and Policy of the Department of Health and Human Services for the costs of providing coverage under Medicaid for the treatment of conditions relating to gender dysphoria and gender incongruence required by section 15 of this act the following sums: For the Fiscal Year 2023-2024 .................................. $162,926 For the Fiscal Year 2024-2025 .................................. $182,654 2. Any balance of the sums appropriated by subsection 1 remaining at the end of the respective fiscal years must not be committed for expenditure after June 30 of the respective fiscal years by the entity to which the appropriation is made or any entity to which money from the appropriation is granted or otherwise transferred in any manner, and any portion of the appropriated money remaining must not be spent for any purpose after September 20, 2024, and September 19, 2025, respectively, by – 38 – - 82nd Session (2023) either the entity to which the money was appropriated or the entity to which the money was subsequently granted or transferred, and must be reverted to the State General Fund on or before September 20, 2024, and September 19, 2025, respectively. 3. Expenditure of $1,239,172 not appropriated from the State General Fund or the State Highway Fund is hereby authorized during Fiscal Year 2023-2024 by the Division of Health Care Financing and Policy of the Department of Health and Human Services for the same purposes as set forth in subsection 1. 4. Expenditure of $1,076,246 not appropriated from the State General Fund or the State Highway Fund is hereby authorized during Fiscal Year 2024-2025 by the Division of Health Care Financing and Policy of the Department of Health and Human Services for the same purposes as set forth in subsection 1. Sec. 17. 1. There is hereby appropriated from the State General Fund to the Division of Health Care Financing and Policy of the Department of Health and Human Services the sum of $19,500 for the costs of information system upgrades and actuarial rate setting associated with carrying out the provisions of this act. 2. Any remaining balance of the appropriation made by subsection 1 must not be committed for expenditure after June 30, 2024, by the entity to which the appropriation is made or any entity to which money from the appropriation is granted or otherwise transferred in any manner, and any portion of the appropriated money remaining must not be spent for any purpose after September 20, 2024, by either the entity to which the money was appropriated or the entity to which the money was subsequently granted or transferred, and must be reverted to the State General Fund on or before September 20, 2024. 3. Expenditure of $48,000 not appropriated from the State General Fund or the State Highway Fund is hereby authorized during Fiscal Year 2023-2024 by the Division of Health Care Financing and Policy of the Department of Health and Human Services for the same purposes as set forth in subsection 1. Sec. 18. 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. 19. This act becomes effective on July 1, 2023. 20 ~~~~~ 23