Health plans and Medicaid answer care approval requests faster

Private health carriers, the Department, and Medicaid managed care entities must answer prior authorization requests within set time limits. Private health carriers answer requests for their insureds. For Medicaid and CHIP, the Department and Medicaid managed care entities answer requests submitted by or for recipients. A shorter deadline in another statute still applies. For private health carriers and Medicaid or CHIP, operating rules may allow more than two business days, but the response cannot take more than seven calendar days. For private health carriers, if the Insurance Commissioner finds an operating-rule revision unsuitable for Nevada and gives notice, later requests must be answered within two business days. For Medicaid and CHIP, the same two-day deadline applies after the Department gives notice of an unsuitable revision. Medicaid and CHIP deadlines apply to requests for recipients. They do not require coverage of care or people outside program coverage rules. The deadlines apply for other purposes beginning January 1, 2026. Requests submitted before then are excluded under private contracts or policies issued before that date, and under Medicaid or a Medicaid managed care entity; requests under renewed private coverage are included.

Health carriers and Medicaid or CHIP decision makers may not require prior authorization for specified care. The private-plan rules apply to health carriers. The separate Medicaid and CHIP rules apply to the Department and Medicaid managed care entities. For private health carriers, the list includes outpatient substance use treatment, specified preventive care, pediatric hospice, certain care for neonatal abstinence syndrome, and blood glucose test strips for people with diabetes. For Medicaid and CHIP, the list includes specified preventive care, pediatric hospice, and certain care for neonatal abstinence syndrome; it does not include outpatient substance use treatment or test strips. These rules do not require Medicaid or CHIP to cover care or people outside program coverage rules. These rules apply for other purposes beginning January 1, 2026. Requests submitted before then under the specified private coverage or to Medicaid or a Medicaid managed care entity are excluded.

A health carrier must treat a particular request as approved if it violates the response rules or the ban on prior authorization for listed care. The rule applies to requests handled by a health carrier under the response rules or the listed-care prohibitions. The approval applies to the particular request involved in the violation. This rule applies for other purposes beginning January 1, 2026.

A health carrier must develop a compliant prior authorization process and obtain the Insurance Commissioner's approval to keep requiring prior authorization. This applies to health carriers that want to keep requiring prior authorization under health insurance contracts or policies. The process must comply with the specified prior authorization rules. This requirement applies to contracts or policies issued or renewed after January 1, 2026.