Sections 1 and 2 of this Act identify DHIN as the State’s sanctioned provider of Health Data Utility (HDU) services. The HDU concept arises and builds off of services provided by Health Information Exchanges (HIEs) such as DHIN. Including this language will align with DHIN’s development and assist the State in responding to federal and other grant funding opportunities that require or prefer collaboration with a sanctioned HDU. Section 2 of this Act is a clarifying provision that states DHIN’s ability to contract with organizations in furtherance of its mission in business arrangements that facilitate DHIN’s underlying mission, notwithstanding that those organizations may provide services (such as direct provision of treatment to patients) that DHIN does not directly provide under this chapter. It also makes a technical change to align the list of stakeholders identified with lists that appear elsewhere in the statute. Section 3 of this Act aligns DHIN’s use cases more clearly with the requirements of federal law that relate to using health data for analytic and research purposes, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Federal Policy for Protection of Human Subjects (the Common Rule) and makes a technical correction to a description of DHIN processes. This change will also ensure consistency between permitted uses of claims data for research purposes and permitted uses of clinical data. Sections 4 and 5 clarify DHIN’s ability to incorporate clinically relevant information into a patient’s longitudinal record, excluding pricing information, for access as permitted by the laws and regulations governing DHIN’s HIE services. This clarification ensures patients will have access to the clinical information included in claims data for their own uses. Section 5 makes a technical correction to recognize that DHIN’s enabling legislation and applicable federal law do not permit DHIN to “report” data to the public that would be suitable for the public health improvement research and activities purposes designed to be encouraged by that section, and clarifies that the identified agencies will have access to the standardized claims data sets curated by DHIN from the Delaware Health Care Claims Database as otherwise permitted under this statute at no cost.
This Act is a substitute for Senate Bill No. 319 and makes all of the following changes: 1. Changes the definition of “hormone replacement therapy” to clarify that hormone replacement therapy must be approved by the United States Food and Drug and Administration. 2. Removes pellet medication from the definition of “hormone replacement therapy” because it is not currently approved by the United States Food and Drug and Administration for treating menopause or perimenopause. 3. Makes technical corrections. Like Senate Bill No. 319, this substitute requires individual health insurance plans, group and blanket health insurance plans, the state employee health plan, and state Medicaid insurance to cover medically necessary diagnostic services and treatment for menopause, perimenopause, and symptoms of menopause or perimenopause, including all of the following: 1. Consultation and diagnostic testing. 2. Hormonal therapies, including hormone replacement therapy and bioidentical hormone treatments, that are approved by the United States Food and Drug Administration. 3. Non-hormonal treatments, including selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, neurokinin B antagonists, and other medications to manage menopause symptoms. 4. All drugs, devices, and combination products approved by the United States Food and Drug Administration for the treatment of menopause and perimenopause symptoms. 5. Therapy to treat menopause induced by a hysterectomy. 6. Behavioral health care services. 7. Pelvic floor physical therapy. 8. Bone health treatments due to hormonal changes related to menopause and perimenopause, including screenings and medications. 9. Preventative services for early detection and treatment of health conditions related to menopause and perimenopause, including osteoporosis and cancer. 10. Counseling and education regarding menopause management. Additionally, an insurer or carrier must provide clear and accessible information about covered diagnostic services and treatment for menopause, perimenopause, and menopause and perimenopause symptoms to each covered individual or Medicaid recipient. Menopause and perimenopause diagnostic and treatment benefits or assistance must be provided to the same extent as benefits or assistance for other medical conditions, but coverage for medically necessary hormone replacement therapy provided under this Act may not be any of the following, except as otherwise provided by federal Medicaid law: 1. Denied or limited, if the use of the hormone replacement therapy is supported by national clinical guidelines, national standards of care, or peer-reviewed medical literature for the treatment of menopause, perimenopause, or menopause and perimenopause symptoms. 2. Subject to prior authorization or step therapy requirements. The Act provides a religious exemption for group and blanket health policies. If the coverage requirement conflicts with a religious employer’s bona fide religious beliefs or practices, the religious employer may request a coverage exclusion for the coverage required under Section 2 of this Act and an insurer shall grant the exclusion. A religious employer who is granted an exclusion must give its employees reasonable and timely notice of the exclusion. This Act applies to all policies, contracts, or certificates that are issued, renewed, modified, altered, amended, or reissued after December 31, 2027.
The Health Care Professional Access Act requires carriers to participate in uniform processes with specific timetables to create speed-to-market for health care professionals. Currently, health care professionals may be employed for 6 months or more with no ability to collect insurer reimbursement due to lengthy carrier credentialing process. Ensuring uniformity across carriers, as well as relevant procedural standards, will help attract and retain health care professionals in our state, enable movement between practices and the creation of new ones, and ensure nondiscrimination in credentialing decisions. Under this Act, credentialing processes are limited to 45 days. This Act additionally provides for provisional credentialing, whereby reimbursement ability is provided even more quickly for certain health care professionals, including FQHCs, and in designated shortage areas which currently include mental health professionals statewide and primary and dental care in Kent and Sussex Counties, or is offered if timelines are not met. Oversight of compliance with this Act falls to the applicable regulatory agency. The Act also ensures specific processes and health care professional rights during a carrier’s intent to terminate a credential. More than 30 states have credentialing standards in law, with additional jurisdictions considering relevant legislation. Components of this legislation are derived from the National Association of Insurance Commissioners’ Health Care Professional Credentialing Verification Model Act. This substitute differs from the original in that it does the following: - Clarifies that it applies to those carriers that require credentialing and does not require carriers to create a credentialing process if they do not already do so; - Clarifies the process for credentialing of health care professionals whose primary or home state is not Delaware and prefer to use the credentialing process in their primary or home state; - Allows a carrier to require earlier recredentialing to address activity that could disqualify a health care professional from credentialing; - Allows for certain electronic delivery of recredentialing notices; - Simplifies the language for the basis to deny, suspend, nonrenew, or terminate a health care professional’s to align with NCQA standards; - Clarifies that the penalties and remedies in this Act are in addition to those already otherwise available; and - Makes technical changes to information about CAQH.
Approximately one in five adults report experiencing a mental health condition. At the same time, many individuals continue to face delays or barriers when trying to access care, even when they have insurance coverage. Delays, denials, or truncation of treatment leave families and their doctors battling for coverage instead of focusing on treatment and recovery. Families must pay out of pocket for care, on top of premiums for coverage they are not receiving. Further, Delawareans are five times more likely to go out-of-network for mental health care than for primary care, resulting in higher costs. This Act, known as the Fair Standards in Mental Health Care Act, builds on previous work to advance mental health parity and aims to ensure patients with private insurance can access timely, evidence-based mental health and substance use disorder care in Delaware. This Act supports improved access to mental health disorder and substance use disorder treatment by: 1. Adding and refining key terms, including definitions of mental health disorders and substance use disorders, level of care criteria, medically necessary treatment, utilization review and utilization review criteria to ensure consistency with widely accepted clinical standards of treatment and service intensity determination. This bill forges gold-standard clinical guidelines through requiring insurers to use transparent, evidence-based standards from independent experts, including the American Academy of Child and Adolescent Psychiatry. 2. Requiring coverage for all medically necessary treatment, including emergency services and all clinically appropriate levels of care. This bill ends prior authorization delays for mental health and guarantees emergency mental health coverage, just as Delaware already does for addiction treatment. 3. Requiring at least one formulation of certain FDA-approved medications to treat substance use disorders to be placed on the lowest-cost tier of drug formularies. 4. Prohibiting discrimination against individuals with current or predicted mental health disorders or substance use disorders. 5. Requiring carriers to arrange coverage of medically necessary out-of-network services without additional cost to the enrollee if in-network options are unavailable within applicable network access standards, thus ensuring real network access. 6. Removing language currently in the code barring a private right of action for violations of 18 Del. Code § 3343. In addition, the Act clarifies that carriers must provide nonquantitative treatment limitation parity analysis (NQTL parity analysis) that they are required to have completed under federal law to health care providers and current and prospective covered persons, free of charge, upon request. This Act applies to individual health insurance policies under Chapter 33 of Title 18 and group and blanket health insurance policies under Chapter 35 of Title 18. This Act applies to all policies, contracts, or certificates issued, renewed, modified, altered, amended, or reissued after December 31, 2027. This Act also makes technical corrections to conform existing law to the standards of the Delaware Legislative Drafting Manual.
This Act clarifies that individual, group, and blanket health insurance carriers must provide for and pay for services (including immunizations) that were recommended by the Advisory Committee on Immunization Practices of the Center for Disease Control (CDC) and the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA) that were in effect as of January 1, 2025. They must also cover immunizations that were supported by national clinical guidelines or national standards of care in effect on January 1, 2025. To that end, this Act removes provisions that permit carriers to deny coverage for these items or services simply because they are not currently recommended by the Advisory Committee on Immunization Practices of the CDC and the comprehensive guidelines supported by the HRSA. This Act also removes obsolete United States Preventative Task Force provisions related to breast cancer screening from 2009.
This Act amends Titles 16, 18, 29, and 31 of the Delaware Code and Chapter 237, Volume 83 of the Laws of Delaware relating to primary care insurance. Among other things, the Act does the following: Section 1 of the Act amends § 9903 of Title 16 of the Delaware Code to provide that the Health Care Commission, in coordination with the Primary Care Reform Collaborative, will monitor compliance of primary care providers with value-based care delivery models established under the Office of Value-Based Health Care Delivery (OVBHCD). Section 2 of the Act amends § 9904A of Title 16 to remove a time frame limitation for the period during which the Health Care Commission is authorized to request written reports by health insurers regarding progress in adopting and implementing value-based payment models. Under the Act, the PCRC may continue to request such reporting going forward. Section 3 of the Act amends § 329 of Title 18 to provide that administrative penalties for violations of §2503(a)(12), §2503(a)(15), § 3342B, and § 3556A of Title 18 may be equivalent to the amount of the violation, and that penalties imposed for such violations are to be deposited into a Primary Care Fund, which will be used by the Statewide Benefits Office and the Division of Medicaid and Medical Assistance. Section 4 of the Act amends § 334 of Title 18 to clarify that the OVBHCD has the ability to promulgate regulations necessary to accomplish the stated goals of reducing health-care costs by increasing the availability of high quality, cost-efficient health insurance products that have stable, predictable, and affordable rates. Section 5 of the Act amends § 2503 of Title 18 to extend current cost containment calculations to rate filing year 2027. Given their relative size and patient populations within Delaware's health care market, Delaware's two smallest hospitals and lone free-standing children's hospital are exempt from that extension. In rate filing year 2028 and thereafter, the Act specifies that costs per service for health benefit plans may not exceed certain Medicare Reference-Based Pricing Targets, which are based on the “Full Medicare rate,” meaning the applicable wage-adjusted base Medicare rate for different services, the Free-Standing Children’s Hospital Medicare outpatient payment rate, or the TEFRA Rate, meaning the target amount under the federal Tax Equity and Fiscal Responsibility Act (TEFRA) Waiver Program applicable to Free-Standing Children's Hospitals, unless certain exemptions apply. Those exemptions are for Delaware's two smallest hospitals and, if making progress with value-based care, for a Delaware hospital in a high-growth, high-Medicare population region. Carriers issuing plans in the commercial market for 2 consecutive years and that cover more than 5,000 members must meet minimum percentages of alternative payment model contracting, as specified. Section 6 of the Act amends § 3342B of Title 18 concerning primary care coverage offered by individual insurance plans. Under the Act, starting in 2026, carriers must spend at least 11.5% of their total cost of medical care on primary care, at least 5% of which must be via prospective primary care management payments. Carriers must offer value-based care programs and may not deny contracted providers the opportunity to participate in an offered value-based care program. In addition, the Commissioner is required to issue regulations regarding the calculation of total cost of care. Section 7 of the Act applies the same changes as Section 6 of the Act to § 3556A of Title 18, concerning primary care coverage offered by group insurance plans. Section 8 of the Act deletes a sunsetting clause contained in Section 14, Chapter 237, Volume 83 of the Laws of Delaware, which would have repealed § 2503(a)(12)a., § 3442B(b)(3), and § 3556A(b)(3) of title 18, effective January 1, 2027. Section 9 of the Act amends § 5204 of Title 29 to provide that health-insurance coverage for public officers and employees shall be provided by a carrier whose cost per service may not exceed certain Medicare Reference-Based Pricing Targets, which are based on the Full Medicare rate, the Free-Standing Children's Hospital Medicare outpatient payment rate, or the TEFRA Rate, unless certain exemptions apply. Those exemptions are for Delaware's two smallest hospitals and, if making progress with value-based care, for a Delaware hospital in a high-growth, high-Medicare population region. In addition, Section 9 of the Act specifies that coverage shall be provided by a carrier offering value-based care programs equivalent to the commercial market requirements. Section 10 of the Act amends §5224 of Title 29 concerning primary care coverage of insurance coverage for public officers and employees, to require plans to report data to the OVBHCD on the percentage of primary care spending as a percentage of total medical costs for plan years 2027 and 2028 and to increase spending on primary care by 1% per year thereafter until primary care spending reaches 11.5% of total medical costs. Section 11 of the Act creates §539 of Title 31, concerning state public assistance, to require entities providing health insurance under § 505(3) to report data on the percentage of primary care spending as a percentage of total medical costs for 2 plan years and, in subsequent years, increase primary care spending by 1% until primary care spending reaches 11.5% of total medical costs. Section 12 of the Act provides that the Department of Insurance shall promulgate regulations pursuant to the Act within 18 months of enactment, but shall promulgate regulations on or before January 1, 2027 establishing a methodology to determine any appropriate annual inflationary or other applicable adjustments to a hospital's Full Medicare Rate. Like Senate Substitute No. 1 for Senate Bill No. 1, this Act differs from Senate Bill No. 1 in that it bases the limits for costs per service for health benefit plans on Medicare Reference-Based Pricing Targets, which may differ based on whether the services are outpatient services, inpatient hospital services, or emergency department services, and on whether the services are being provided by a Free-Standing Children's Hospital; under Senate Bill No. 1, the limits for cost-per-service were based on a percentage of Medicare reimbursement for comparable services. In addition, this Act provides more guidance regarding the application of exemptions from those limits. In addition, Senate Substitute No. 2 for Senate Bill No. 1 differs from Senate Bill No. 1 in that it makes technical edits to definitions and it provides that the Department of Insurance and the State Employee Benefits Office shall lead a process, in consultation with Delaware hospitals, to recommend an appropriate methodology to determine and apply any inflationary or other applicable adjustments to a hospital's Full Medicare Rate not otherwise captured in a hospital's annual Medicare rate update by January 1, 2027. Senate Substitute No. 2 for Senate Bill No. 1 also adds an exemption from the aggregate unit price growth limits in § 2503(a)(12)a.3. of Title 18 for a hospital that is a Free-Standing Children's Hospital, a hospital that qualifies as a Medicare-Dependent Rural Hospital on the grounds that it meets the definition of a Medicare-dependent hospital under 42 C.F.R. § 412.108 for at least 3 of the 5 years immediately preceding the applicable rate filing year, or an Urban Medicaid DSH Hospital.
Early access to language is essential to child development. Children identified as Deaf or hard of hearing rely on hearing aids for language development. Language development leads to success in school. Medicaid coverage of hearing aids for children younger than 21 years old applies only to children who qualify for Medicaid. Delaware currently requires private insurers to provide minimum coverage of $1,000 for each hearing aid for individuals younger than 24 years old, covered as a dependent by the policyholder. The cost of hearing aids can vary widely but can cost from $3,000 to $5,000 out-of-pocket. This can be too expensive for families, even with the current $1,000 coverage requirement. The cost of a cochlear implant can range from $30,000 to $100,000, depending on the necessary device, surgery, and rehabilitation. Delaware does not currently require insurers to cover the costs of cochlear implants. This Act is a second substitute for Senate Bill No. 269 and differs from the first substitute Senate Bill No. 269 by changing the cost-sharing limitation to require insurers to cover at least 95%, instead 100%, of the cost of benefits for hearing aid and earmold benefits provided under § 3357(b)(1)a., § 3571A(b)(1)a., and § 5224(b)(1)a. of this Act. Like the first substitute to Senate Bill No. 269, this Act differs from Senate Bill No. 269 in all of the following ways: 1) Includes external sound processors in the definition of a cochlear implant. 2) Clarifies that, for group and blanket health policies and the state employee health plan, the required coverage of hearing-aid related parts and services is limited to individuals younger than 26 years old and covered as a dependent by the policyholder. 3) Names this Act in honor of T. Hollis Jennings who is a testament to the success of state-mandated hearing aid coverage and early intervention. Hollis got hearing aids when she was an infant. Her language developed typically, with no need for speech therapy. She now exceeds grade-level benchmarks in math and ELA. She’s also a phenomenal singer. 4) Makes technical changes to strike through and underline format to make it easier to see changes and to correct grammar. Like Senate Bill No. 269 and the first substitute for Senate Bill No. 269, this Act requires individual health insurance policies under Chapter 33 of Title 18, group and blanket health insurance policies under Chapter 35 of Title 18, and the state employee health plan under Chapter 52 of Title 29 to cover all of the following: 1) At least 1 hearing aid for each ear at least every 3 years, or before the expiration of the 3-year period if a health care professional determines that a new hearing aid is medically necessary. For hearing aids with earmolds, insurers are required to cover at least 1 earmold for each ear at least annually, or sooner if new earmolds are medically necessary. The cost-sharing limitation applies only to coverage of hearing aids. The types of hearing aid covered includes a hearing aid with an earmold, a hearing aid with slim tubing, a receiver-in-ear hearing aid, a bone-anchored hearing aid, and a cochlear implant. 2) Medically necessary hearing aid-related parts, attachments, or accessories. 3) Medically necessary related services related to prescribing, fitting, implanting, or dispensing hearing aids. Coverage must include medically necessary related services provided by a hearing care professional who specializes in providing care to pediatric patients. For individual health insurance policies, the coverage required under this Act applies to all covered individuals, regardless of age, because federal law prohibits states from limiting coverage for an essential health benefit based on an individual’s age unless there is a clinical reason. For group and blanket health insurance policies and the state employee health plan, the required coverage applies only to individuals younger than 26 years old and covered as a dependent by the policyholder. This Act also makes technical corrections to conform existing law to the standards of the Delaware Legislative Drafting Manual and reorganizes paragraphs for clarity. This Act applies to all policies, contracts, or certificates issued, renewed, modified, altered, amended, or reissued after December 31, 2027.
In Delaware, all individual health insurance policies, all group and blanket health insurance policies, the State employee health insurance plan, and Medicaid are required to cover chiropractic and physical therapy treatment for chronic back pain without annual or lifetime numerical limits on physical therapy or chiropractic care visits. To evaluate the effectiveness of this coverage requirement, the Patient Centered Care Subcommittee of the Addiction Action Committee, under the Delaware Department of Health and Social Services, sent a survey to chiropractic therapy and physical therapy providers in Delaware. Although the survey showed that the coverage requirement has improved treatment of chronic pain patients, the survey also showed that the coverage requirement provides supportive chronic pain treatment for only the thoracic region of the spine, which is the middle of the spine from the base of the neck to the bottom of the ribs, and the lumbar region of the spine, which is the lower back. The treatment of chronic pain through chiropractic supportive care, physical therapy, or both, can prevent a patient from requiring opioid pain medications or more expensive treatments, but excluding vital areas of the spine and body from coverage may limit the effectiveness of chiropractic therapy and physical therapy treatment and limits a chronic pain patient’s potential for improvement. This Act encourages treatment of chronic pain patients without opioids by updating the required health insurance coverage to prohibit annual or lifetime numerical visits on physical therapy or chiropractic care visits that are for the purpose of treating the spine and other neuromusculoskeletal structures, including extremities. The updated coverage required under this Act applies to all policies, contracts, or certificates issued, renewed, modified, altered, amended, or reissued after December 31, 2026. This Act also makes technical corrections to conform existing law to the standards of the Delaware Legislative Drafting Manual.
This Legislation is the Delaware Pre-Authorization Reform Act of 2025. Section 1 of the Act applies to health Insurance Contracts regulated under Chapter 33 of Title 18. Section 1 provides that changes in utilization review terms for a health-care service, such as the clinical criteria used to conduct utilization reviews for a health-care service, will apply only upon re-authorization of the health-care service. Covered persons must be notified at least 6 months before any changes to utilization review terms, except in certain circumstances such as changes in clinical guideline status In addition, Section 1 sets qualifications for who may make determinations with regard to requests for pre- authorization of health-care services and appeals of adverse determinations; a timeline and required contents for the notification of an outcome of appeal of an adverse determination or a notification that additional information is necessary to make the determination of appeal; and requirements for any utilization review entity used to perform utilization review by an insurer, health-benefit plan, or health-service corporation. Section 1 also shortens the timelines for the determination of pre-authorization requests and notification to the health-care provider of the determination. For requests for pre-authorization of non-urgent health-care services not submitted electronically, the utilization review entity must notify the health-care provider within 5 business days of receipt of the request; for requests submitted electronically, notification must be given within 3 business days of receipt. For requests for pre-authorization for urgent health-care services submitted electronically, notification must be given within 24 hours of receipt. By January 1, 2027, insurers, health-benefit plans, health-service corporations, and utilization review entities must accept and respond to electronic pre-authorization requests through the same platform as the electronic request was submitted. In addition, Section 1 extends the time period that a pre-authorization is valid for from 60 days to 90 days. Finally, Section 1 provides that no more than 1 pre-authorization may be required for a single episode of care, and that if pre-authorization is granted as to a health-care service that is part of a group of services for which a bundled payment is charged, pre-authorization for the other health-care services included in the group is deemed to be approved as well. Section 2 of the Act applies to Group and Blanket Health Insurance under Chapter 35 of Title 18 and makes the same changes to pre-authorization standards and procedures that Section 1 of the Act makes to Health Insurance Contracts regulated under Chapter 33 of Title 18. Section 3 of the Act provides that the State Employee Benefits Committee established under § 9602 of the Title 29 of the Delaware Code must ensure that carriers administering plans for group health insurance comply with the requirements and provisions for pre-authorization set forth in Chapter 33, Subchapter II and Chapter 35, Subchapter V of Title 18. Section 4 of the Act provides that the Act will apply to health insurance policies, contracts, or certificates issued, modified, or renewed after December 31, 2026. Section 5 of the Act provides that the Department of Health and Social Services must, to the extent feasible, assure that contracts awarded to carriers providing health insurance relating to Medicaid assistance comply with the requirements and provisions for pre-authorization set forth in Chapter 33, Subchapter II and Chapter 35, Subchapter V of Title 18. Section 6 provides that this Act is known as the "Delaware Pre-Authorization Reform Act of 2025."
This Act is a substitute for HB 200 and differs from HB 200 by requiring health insurance coverage only for pre-exposure prophylaxis (“PrEP”) medication and post-exposure prophylaxis (“PEP”) medication. This Act also makes technical corrections including updating section numbers and updating the applicability date so insurance companies can file rates that include the cost of the coverage required under this Act. This Act requires individual health insurance plans, group and blanket health insurance plans, the state employee health plan, and state Medicaid insurance to cover medically necessary PrEP medication for the prevention of human immunodeficiency virus (“HIV”) infection before possible HIV exposure and medically necessary PEP medication for the prevention of HIV infection after possible HIV exposure. The coverage must include must be provided without any of the following: 1. Cost-sharing requirements, including deductibles, coinsurance, copayments, and out-of-pocket expenses. 2. Prior authorization or step therapy requirements. 3. Unreasonable delay in coverage determination. This Act applies to all policies, contracts, or certificates that are renewed, modified, altered, amended, or reissued after December 31, 2027.
