Section 695C.16934 - Required provision concerning coverage for medically necessary treatment of conditions relating to gender dysphoria and gender incongruence; restriction on refusal to cover certain treatments; authority of health maintenance organization to prescribe requirements for covering surgical treatments for minors; determination of medical necessity1. 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:(b) Pediatric endocrinologists;(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;(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: (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(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.Added to NRS by 2023, 2041Added by 2023, Ch. 376,§8, eff. 7/1/2023.