AN ACT TO AMEND TITLE 18 OF THE DELAWARE CODE RELATING TO INSURANCE COVERAGE.

Coverage scope expanded from 'serious mental illnesses and drug and alcohol dependencies' to all 'mental health disorders and substance use disorders,' meaning insurers must now cover a much wider range of conditions including anxiety, PTSD, personality disorders, and other previously excluded diagnoses.

Bill moved from House Amendment No. 1 (House of Representatives) to Senate Bill No. 22 (Delaware State Senate), with new primary sponsors Sen. Townsend and Sen. Pinkney added alongside Rep. Minor-Brown, and extensive bipartisan co-sponsorship from both chambers.

New clinical assessment tools defined as mandatory standards: ASAM criteria (substance use), LOCUS (adult mental health), CALOCUS-CASII (children/adolescents 6-18 mental health), and ECSII (early childhood). These determine levels of care, placement, continued stay, and discharge decisions.

Insurers must cover all levels of care described in ASAM, LOCUS, CALOCUS-CASII, and ECSII criteria, including residential settings, intensive outpatient programs, inpatient settings with withdrawal management, and emergency services including mobile crisis response teams.

Emergency medication access: plans must provide immediate access without prior authorization to a 5-day emergency supply of prescribed medications for mental health or substance use disorders when an emergency medical condition exists, including opioid withdrawal/stabilization medications.

Medication formulary requirements expanded: all FDA-approved medications to treat one or more substance use disorders (not just medication-assisted treatment drugs) must be placed on the lowest formulary tier. Step therapy may only require therapeutically equivalent AB-rated generics with same active ingredient, dosage form, and strength.

Network adequacy standards: carriers must ensure timely access to non-urgent services within 10 business days and urgent services within 24 hours. If in-network providers are unavailable, carriers must execute single-case agreements with out-of-network providers at no greater cost-sharing than in-network.

New 'meaningful benefits' requirement: if a carrier provides any mental health or substance use disorder benefits in one classification, it must provide meaningful benefits (including core treatments) in every classification where medical/surgical benefits are provided.

Utilization review restrictions strengthened: no concurrent utilization review during first 14 days of inpatient admission, 30 days of IOP, or 5 days of withdrawal management. Carriers may only deny coverage for initial 14-day inpatient treatment if it was contrary to ASAM/LOCUS/CALOCUS-CASII/ECSII criteria.

Transparency requirement: carriers must provide NQTL parity compliance analyses free of charge within 30 days of request by any health care provider, current covered person, or prospective covered person. Plans and provider contracts must disclose this right.

Anti-discrimination provision: carriers may not rely on discriminatory factors or evidentiary standards when designing NQTLs for mental health/substance use benefits. A factor is discriminatory if based on biased or non-objective information that disadvantages mental health benefits compared to medical/surgical benefits.

NQTL stringency test: NQTLs for mental health/substance use benefits may not be more restrictive than the predominant NQTL applied to substantially all medical/surgical benefits. Carriers must collect and evaluate outcomes data, cannot disregard data suggesting material access differences, and must take reasonable action to address noncompliance.

Federal provisions published at 89 Federal Register 77586 (September 23, 2024) are incorporated into the section in their entirety as state law, and this incorporation remains in effect regardless of any subsequent federal amendment, repeal, or nonenforcement.