reglab/statecodes huggingface dataset:
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter III. Provisions Applicable to Group and Blanket Health Insurance › § 3566. Prescription medication.

§ 3566. Prescription medication.
(a) This section applies to every group or blanket policy or contract of health insurance, including each policy or contract issued by a health service corporation, which is delivered or issued for delivery in this State and which provides coverage for outpatient prescription drugs.
(b) Every group or blanket policy or contract of health insurance described in subsection (a) of this section shall provide coverage for any outpatient drug prescribed to treat a covered person for a covered chronic, disabling or life-threatening illness if the drug:
(1) Has been approved by the Food and Drug administration for at least 1 indication; and
(2) Is recognized for treatment of the indication for which the drug is prescribed in:
a. A prescription drug reference compendium approved by the Insurance Commissioner for purposes of this section; or
b. Substantially accepted peer reviewed medical literature.
(c) Coverage of a drug required by this section shall include coverage of medically necessary services associated with administration of the drug.
(d) This section does not require coverage for:
(1) Medication that may be obtained without a physician's prescription;
(2) Experimental drugs not otherwise approved for the proposed use or indication by the Food and Drug Administration; or
(3) Any disease, condition, service or treatment that is excluded from coverage under the policy.
(e) Nothing in this section shall prevent the operation of policy provisions involving deductibles, coinsurance, allowable charge limitations, maximum dollar policy limitations or coordination of benefits.
73 Del. Laws, c. 96, §  10;  73 Del. Laws, c. 315, §  5;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter III. Provisions Applicable to Group and Blanket Health Insurance › § 3567B. Experimental treatment coverage.

§ 3567B. Experimental treatment coverage.
(a) No group or blanket policy or contract of health insurance or certificate issued thereunder which is delivered, issued for deliver, or renewed in this State shall deny coverage, payment, or reimbursement for a National Coverage Determination Service on the basis that the service, item, test, or treatment is experimental or investigational.
(b) “National Coverage Determination Service” as used in this section shall mean a service, item, test, or treatment which has been determined to be covered nationally by the Secretary of the U.S. Department of Health and Human Services pursuant to the Social Security Act, § 1869 (f) [42 U.S.C. § 1395ff].
81 Del. Laws, c. 266, § 2;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter III. Provisions Applicable to Group and Blanket Health Insurance › § 3568. Newborn and infant hearing screening; coverage and reimbursement.

§ 3568. Newborn and infant hearing screening; coverage and reimbursement.
(a) Any group or blanket insurance health insurance policy which is delivered, issued for delivery, renewed, extended, or modified in this State by any health-care insurer and which provides coverage for a child shall be deemed to provide coverage for hearing loss screening tests of newborns and infants provided by a hospital before discharge.
(b) The amount of reimbursement for newborn or infant hearing screening provided under such a policy shall be consistent with reimbursement of other medical expenses under the policy, including the imposition of co-payment, coinsurance, deductible, or any dollar limit or other cost-sharing provisions otherwise applicable under the policy.
75 Del. Laws, c. 116, §  3;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter III. Provisions Applicable to Group and Blanket Health Insurance › § 3569. Use of Social Security numbers on insurance cards.

§ 3569. Use of Social Security numbers on insurance cards.
(a) As used in this section, “insurance card” means a card that a person or entity provides to an individual so that the individual may present the card to establish the eligibility of the individual or the individual's dependents to receive health, dental, optical, or accident insurance benefits, prescription drug benefits, or benefits under a managed care plan or a plan provided by a health maintenance organization, a health services plan corporation, or a similar entity.
(b) No person or entity which provides an insurance card shall use an individual's Social Security number as the identification number on that insurance card.
75 Del. Laws, c. 179, §  2;  70 Del. Laws, c. 186, §  1;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter III. Provisions Applicable to Group and Blanket Health Insurance › § 3571. Phenylketonuria (PKU) and other inherited metabolic diseases.

§ 3571. Phenylketonuria (PKU) and other inherited metabolic diseases.
(a) Definitions. — In this section the following words shall have the meanings indicated:
(1) “Inherited metabolic diseases” shall mean diseases caused by an inherited abnormality of biochemistry. The words “inherited metabolic diseases” shall also include any diseases for which the State screens newborn babies.
(2) a. “Low protein modified formula or food product” means a formula or food product that is:
1. Specially formulated to have less than 1 gram of protein per serving; and
2. Intended to be used under the direction of a physician for the dietary treatment of an inherited metabolic disease.
b. “Low protein modified food product” does not include a natural food that is naturally low in protein.
(3) “Medical formula or food” means a formula or food that is:
a. Intended for the dietary treatment of an inherited metabolic disease for which nutritional requirements and restrictions have been established by medical research; and
b. Formulated to be consumed or administrated enterally under the direction of a physician.
(b) Application of this section. — The provisions of this section shall apply to any health insurance contract that:
(1) Provides coverage for a family member of the insured; and
(2) Is delivered or issued for delivery in the State.
(c) A health insurance contract shall, under the family member coverage, include coverage for medical formulas and foods and low protein modified formulas and modified food products for the treatment of inherited metabolic diseases, if such medical formulas and foods or low protein modified formulas and food products are:
(1) Prescribed as medically necessary for the therapeutic treatment of inherited metabolic diseases, and
(2) Administered under the direction of a physician.
76 Del. Laws, c. 176, §  2;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter III. Provisions Applicable to Group and Blanket Health Insurance › § 3571A. Hearing aid coverage.

§ 3571A. Hearing aid coverage.
(a) For purposes of this section, the term “hearing aid” means any nonexperimental, wearable instrument or device designed for the ear and offered for the purpose of aiding or compensating for impaired human hearing, but excluding batteries, cords, and other assistive listening devices such as FM systems.
(b) Every group and blanket health insurance contract, including each policy or contract issued by a health service corporation, which is delivered, issued for delivery, or renewed in this State on or after January 1, 2009, shall provide coverage of up to $1000 per individual hearing aid, per ear, every 3 years, for children less than 24 years of age, covered as a dependent by the policy holder.
(c) The insured may choose a hearing aid exceeding $1,000 and pay the difference in cost above the amount of coverage required by this section. Reimbursement shall be provided according to the respective principles and policies of the insurer. The insurer may require the policyholder to provide a prescription or show proof through other suitable documentation of the need for a hearing aid and nothing contained in this section shall preclude the insurer from conducting managed care, medical necessity, or utilization review or prevent the operation of such policy provisions as deductibles, coinsurance, allowable charge limitations, coordination of benefits or provisions restricting coverage to services by licensed, certified or carrier-approved providers or facilities.
(d) This section does not apply to insurance coverage providing benefits for:
(1) Hospital confinement indemnity;
(2) Disability income;
(3) Accident only;
(4) Long-term care;
(5) Medicare supplement;
(6) Limited benefit health;
(7) Specified diseased indemnity;
(8) Sickness or bodily injury or death by accident or both; and
(9) Other limited benefit policies.
76 Del. Laws, c. 244, §  2;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter III. Provisions Applicable to Group and Blanket Health Insurance › § 3571B. Required coverage for scalp hair prosthesis.

§ 3571B. Required coverage for scalp hair prosthesis.
(a) All group and blanket health insurance policies, contracts or certificates that are delivered or issued for delivery in this State by any health insurer, health service corporation or managed care organization which provide for medical or hospital expenses and also provide coverage for other prostheses, shall provide coverage for expenses for a scalp hair prosthesis worn for hair loss suffered as a result of alopecia areata, resulting from an autoimmune disease. Such coverage shall be subject to the same limitations and guidelines as other prostheses, provided that such coverage for alopecia areata shall not exceed $500 per year.
(b) For purposes of this section:
(1) “Prostheses” means artificial appliances used to replace lost natural structures. Prostheses include, but are not limited to, artificial arms, legs, breasts, or glass eyes.
(2) “Scalp hair prosthesis” means artificial substitutes for scalp hair that are made specifically for a specific individual.
(c) Such coverage may be subject to annual deductibles and co-insurance provisions as may be deemed appropriate and as are consistent with those established for other benefits under the plan of coverage. Written notice of the availability of such coverage shall be delivered to the insured, participant, policyholder, subscriber and beneficiary upon enrollment and annually thereafter.
(d) All group and blanket health benefit plans shall provide notice to each insured, participant, policyholder, subscriber and beneficiary under such plan regarding the coverage required by this section in accordance herewith. Such notice shall be in writing and prominently positioned in any literature or correspondence made available or distributed by the plan and shall be transmitted as part of any yearly informational packet sent to the insured, participant, policyholder, subscriber and beneficiary.
76 Del. Laws, c. 314, §  2;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter III. Provisions Applicable to Group and Blanket Health Insurance › § 3571C. Dental services for children with a severe disability.

§ 3571C. Dental services for children with a severe disability.
(a) Definitions. — As used in this section:
(1) “Child with a severe disability” means a person under the age of 21 who, due to a significant mental or physical condition, illness, or disease, is likely to require specialized treatment or supports to secure effective access to dental care. The written certification of a child's treating physician, advance practice nurse, or licensed psychologist shall be sufficient to qualify a person as a “child with a severe disability.”
(2) “Dental services” means the full range of diagnostic and treatment services within the scope of benefits available under the health insurance contract or policy.
(b) Application of section. — This section applies to every group or blanket health insurance contract, including each policy or contract issued by a health service corporation, which is delivered, issued for delivery, or renewed in this State which provides coverage for dental services for a child.
(c) Payment authorization. — Every contract or policy described in subsection (b) of this section shall authorize payment to a licensed practitioner for dental services to a child with a severe disability irrespective of lack of contractual or network status. Unless otherwise negotiated with the practitioner in advance, such payment shall be in an amount at least equal to the insurer's reasonable and customary compensation for the same or similar services in the same geographical area. A nonnetwork practitioner accepting payment under this section may not balance bill the insured.
(d) Preservation of contract limits. — Nothing in this section shall prevent the application of contract or policy provisions involving deductibles, coinsurance, maximum dollar limitations or coordination of benefits, provided that such limits shall be applied using in-network standards.
(e) Waiver. — The Commissioner may establish, by regulation, standards authorizing the issuance of a waiver to an insurer from application of this section. At a minimum, such waiver standards shall only permit a time-limited, renewable waiver upon submission of clear and convincing documentation of the numerical and geographical availability of in-network practitioners willing and able to effectively treat a child with a severe disability.
77 Del. Laws, c. 54, §  2;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter III. Provisions Applicable to Group and Blanket Health Insurance › § 3571D. Screening of infants and toddlers for developmental delays.

§ 3571D. Screening of infants and toddlers for developmental delays.
(a) Definitions. — As used in this section:
(1) “Carrier” means any entity that provides health insurance in this State. For the purposes of this section, “carrier” includes an insurance company, health service corporation, health maintenance organization, and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation. “Carrier” also includes any third-party administrator or other entity that adjusts, administers, or settles claims in connection with health benefit plans.
(2) “Developmental screening” shall mean any developmental screening tool favorably mentioned by the American Academy of Pediatrics Committee on Children with Disabilities in its position paper on “Developmental Surveillance and Screening of Infants and Young Children,” or any program judged by the Department of Health and Social Services to be an equivalent program.
(b) This section shall apply to any health insurance contract that provides coverage for a family member of the insured and is delivered by a carrier or issued by a carrier for delivery in the State.
(c) This section shall not apply to policies that exclusively cover:
(1) Hospital confinement indemnity;
(2) Disability income;
(3) Accident only;
(4) Long-term care;
(5) Medicare supplement;
(6) Specified disease indemnity; or
(7) Sickness or bodily injury or death by accident, or both.
(d) Every health insurance policy covered by this section shall entitle children covered by the policy to receive developmental screenings at ages 9 months, 18 months, and 30 months.
77 Del. Laws, c. 207, §  2;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter III. Provisions Applicable to Group and Blanket Health Insurance › § 3571H. Payment for emergency medical services.

§ 3571H. Payment for emergency medical services.
(a) As used in this section:
(1) “Ambulance” shall have the same definition set forth in § 9702 of Title 16.
(2) “Basic life support” shall have the same definition set forth in § 9702 of Title 16.
(3) “Emergency medical services provider agency” shall have the same definition set forth in § 9802 of Title 16.
(4) “Volunteer fire company” shall mean the duly organized volunteer fire companies in the State.
(b) Notwithstanding any provision precluding an assignment of benefits in any group or blanket health insurance policy, contract, certificate or plan, delivered or issued for delivery in this State by any insurer, health service corporation, or health maintenance organization, when a volunteer fire company or other emergency medical services provider agency certified by the Delaware State Fire Prevention Commission renders covered emergency medical services or supplies, including but not limited to basic life support and ambulance service, any payment or reimbursement made by an insurer, health service corporation or health maintenance organization for such covered emergency medical services or supplies shall be paid directly to the volunteer fire company or other certified emergency medical services provider agency, or their designee, without regard to whether a contract exists between the volunteer fire company or certified emergency medical services provider agency and the insurer, health service corporation or health maintenance organization, and otherwise without regard to whether the volunteer fire company or emergency medical services provider agency is a part of any network maintained by the insurer, health service corporation or health maintenance organization.
(c) The limitations on balance billing provided in § 3348 of this title shall not apply to billing for emergency medical services within the scope of this section provided by volunteer fire companies or emergency medical services provider agencies certified by the Delaware State Fire Prevention Commission.
(d) This section shall apply to all policies, contracts, certificates or plans issued, renewed, modified, altered, amended or reissued on or after July 1, 2013.
(e) Nothing in this section should apply to supplemental health insurance policies that do not provide expense or reimbursement coverage for emergency medical services, basic life support or ambulance services.
79 Del. Laws, c. 76, §  2;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter III. Provisions Applicable to Group and Blanket Health Insurance › § 3571I. No lifetime or annual limits [For application of this section, see 79 Del. Laws, c. 9, § 19].

§ 3571I. No lifetime or annual limits [For application of this section, see 79 Del. Laws, c. 9, § 19].
(a) (1) Except as provided in subsection (b) of this section, a group health plan, or a health insurance issuer offering group or individual health insurance coverage, may not establish any lifetime limit on the dollar amount of benefits for any individual.
(2) a. Except as provided in paragraph (a)(2)b., subsections (b) and (d) of this section, a group health plan, or a health insurance issuer offering group or individual health insurance coverage, may not establish any annual limit on the dollar amount of benefits for any individual.
b. A health flexible spending arrangement (as defined in § 106(c)(2) of the Internal Revenue Code) [26 U.S.C. § 106(c)(2)] is not subject to the requirement in paragraph (a)(2)a. of this section.
(b) (1) The rules of this section do not prevent a group health plan, or a health insurance issuer offering group or individual health insurance coverage, from placing annual or lifetime dollar limits with respect to any individual on specific covered benefits that are not essential health benefits to the extent that such limits are otherwise permitted under applicable federal or state law.
(2) The rules of this section do not prevent a group health plan, or a health insurance issuer offering group or individual health insurance coverage, from excluding all benefits for a condition. However, if any benefits are provided for a condition, then the requirements of this section apply. Other requirements of federal or state law may require coverage of certain benefits.
(c) The term “essential health benefits” as used in this section means essential health benefits under § 1302(b) of the Patient Protection and Affordable Care Act [42 U.S.C. § 18022(b)], as the law and its implementing regulations were in effect on January 1, 2018; Delaware law; and applicable state regulations.
(d) (1) With respect to plan years beginning prior to January 1, 2014, a group health plan, or a health insurance issuer offering group or individual health insurance coverage, may establish, for any individual, an annual limit on the dollar amount of benefits that are essential health benefits, provided the limit is no less than the following amounts:
a. For a plan year beginning on or after September 23, 2010, but before September 23, 2011, $750,000.
b. For a plan year beginning on or after September 23, 2011, but before September 23, 2012, $1,250,000.
c. For plan years beginning on or after September 23, 2012, but before January 1, 2014, $2,000,000.
(2) In determining whether an individual has received benefits that meet or exceed the applicable amount described in paragraph (d)(1) of this section, a plan or issuer must take into account only essential health benefits.
79 Del. Laws, c. 99, §  8;  82 Del. Laws, c. 186, § 4;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter III. Provisions Applicable to Group and Blanket Health Insurance › § 3571K. Prohibition on excessive waiting periods [For application of this section, see 79 Del. Laws, c. 99, § 19].

§ 3571K. Prohibition on excessive waiting periods [For application of this section, see 79 Del. Laws, c. 99, § 19].
A group health plan and a health insurer offering group health insurance coverage shall not apply any waiting period that exceeds 90 days. As used in this section, “waiting period” means the period that must pass before coverage for an employee or dependent who is otherwise eligible to enroll under the terms of a group health plan can become effective.
79 Del. Laws, c. 99, §  8;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter III. Provisions Applicable to Group and Blanket Health Insurance › § 3571L. Nondiscrimination in health care [For application of this section, see 79 Del. Laws, c. 99, § 19].

§ 3571L. Nondiscrimination in health care [For application of this section, see 79 Del. Laws, c. 99, § 19].
(a) Providers. — A group health plan and a health insurer offering group health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health-care provider who is acting within the scope of that provider's license or certification under applicable state law. This section shall not require that a group health plan or health insurer contract with any health-care provider willing to abide by the terms and conditions for participation established by the plan or insurer. Nothing in this section shall be construed as preventing a group health plan, a health insurer or the Commissioner from establishing varying reimbursement rates based on quality or performance measures.
(b) Individuals. — The provisions of § 1557 of the Patient Protection and Affordable Care Act (relating to nondiscrimination) [42 U.S.C. § 18116], as the law and its implementing regulations were in effect on January 1, 2018, apply with respect to a group health plan or health insurer offering group health insurance coverage.
79 Del. Laws, c. 99, §  8;  82 Del. Laws, c. 186, § 6;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter III. Provisions Applicable to Group and Blanket Health Insurance › § 3571M. Comprehensive health insurance coverage [For application of this section, see 79 Del. Laws, c. 99, § 19].

§ 3571M. Comprehensive health insurance coverage [For application of this section, see 79 Del. Laws, c. 99, § 19].
(a) Coverage for essential health benefits package. —
A health insurer that offers health insurance coverage in the small group market shall ensure that such coverage includes the essential health benefits package in conformity with § 1302 of the Patient Protection and Affordable Care Act [42 U.S.C. § 18022], as the law and its implementing regulations were in effect on January 1, 2018, and state law. The Commissioner shall issue a regulation setting forth what constitutes “essential health benefits” for purposes of this section.
(b) Cost-sharing under group health plans. —
A group health plan shall ensure that any annual cost-sharing imposed under the plan does not exceed the limitations provided for under § 1302(c)(1) and (2) of the Patient Protection and Affordable Care Act [42 U.S.C. § 18022(c)(1) and (2)], as the law and its implementing regulations were in effect on January 1, 2018, and state law.
(c) Child-only plans. —
If a health insurer offers health insurance coverage in any level of coverage specified under § 1302(d) of the Patient Protection and Affordable Care Act [42 U.S.C. § 18022(d)], as the law and its implementing regulations were in effect on January 1, 2018, or state law, the health insurer shall also offer such coverage in that level as a plan in which the only enrollees are individuals who, as of the beginning of the plan year, are under the age of 21.
(d) Dental only. —
This section shall not apply to a plan described in § 1311(d)(2)(B)(ii) of the Patient Protection and Affordable Care Act [42 U.S.C. § 18031(d)(2)(B)(ii)], as the law and its implementing regulations were in effect on January 1, 2018.
79 Del. Laws, c. 99, §  8;  81 Del. Laws, c. 79, § 30;  82 Del. Laws, c. 186, § 7;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter III. Provisions Applicable to Group and Blanket Health Insurance › § 3571O. Insurance offered through the state health insurance exchange [For application of this section, see 79 Del. Laws, c. 99, § 19].

§ 3571O. Insurance offered through the state health insurance exchange [For application of this section, see 79 Del. Laws, c. 99, § 19].
(a) A health insurer that offers health insurance coverage in the small group market through the state health insurance exchange program established pursuant to the Patient Protection and Affordable Care Act [P.L. 111-148] shall first satisfy all certification standards required by federal and state law, and the health insurer shall offer only those plans that are “qualified health plans” as required by federal and state law.
(b) The Commissioner shall adopt regulations, in accordance with the Administrative Procedures Act [Chapter 101 of Title 29], that set forth the certification and compliance standards and requirements for health insurers operating within the state health exchange.
79 Del. Laws, c. 99, §  8;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter III. Provisions Applicable to Group and Blanket Health Insurance › § 3571Q. Notification and reasons for cancellation or nonrenewal [For application of this section, see 79 Del. Laws, c. 390, § 8].

§ 3571Q. Notification and reasons for cancellation or nonrenewal [For application of this section, see 79 Del. Laws, c. 390, § 8].
A notice of cancellation or nonrenewal of group health insurance coverage by an insurer due to nonpayment of premiums shall be in writing, shall be delivered to the policyholder or mailed to the policyholder at the last known address of the policyholder, shall state the effective date of the cancellation or nonrenewal and shall be accompanied by a written explanation of the specific reasons for the cancellation or nonrenewal. Proof of mailing of such cancellation or nonrenewal notice shall be retained by the insurer for a period of not less than 1 year. This section shall not apply to any long-term care policy where notice provisions regarding cancellations or nonrenewals are specifically addressed elsewhere in this title or in regulations promulgated thereunder.
79 Del. Laws, c. 390, §  4;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter III. Provisions Applicable to Group and Blanket Health Insurance › § 3571T. Coverage for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome.

§ 3571T. Coverage for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome.
(a) All group and blanket health insurance policies, contracts, or certificates that are delivered, issued for delivery, renewed, extended, or modified in this State by any health insurer, health service corporation, or health maintenance organization shall provide coverage for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome, including the use of intravenous immunoglobulin therapy.
(b) At any time that the State determines it is required under federal law to defray the cost of any coverage for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome required under subsection (a) of this section, the requirements under subsection (a) of this section are inoperative and the State may not assume any obligation for the cost of coverage for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome.
81 Del. Laws, c. 400, § 2;  84 Del. Laws, c. 233, § 39;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter III. Provisions Applicable to Group and Blanket Health Insurance › § 3571V. Time of submitting claim for reimbursement.

§ 3571V. Time of submitting claim for reimbursement.
(a) For purposes of this section:
(1) “Carrier” means any entity that provides health insurance in this State. “Carrier” includes an insurance company, health service corporation, health maintenance organization, and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation. “Carrier” also includes any third-party administrator or other entity that adjusts, administers, or settles claims in connection with health benefit plans.
(2) “Carrier” does not mean an entity that provides a plan of health insurance or health benefits designed for issuance to persons eligible for coverage under Titles XVIII, XIX, and XXI of the Social Security Act (42 U.S.C. §§ 1395 et seq., 1396 et seq. and 1397 et seq.), known as Medicare, Medicaid, or any other similar coverage under state or federal governmental plans.
(b) Regardless of network status, a carrier shall permit a provider a minimum of 180 days from the date a covered service is rendered to submit a claim for reimbursement. Any contract between a carrier and provider that prohibits a provider from submitting a claim beyond the minimum time limit required under this section shall not be deemed a violation of this section.
82 Del. Laws, c. 111, § 4;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter III. Provisions Applicable to Group and Blanket Health Insurance › § 3571W. Electronic medical claims.

§ 3571W. Electronic medical claims.
(a) This section shall apply to all claims for healthcare services that are submitted as part of group or blanket health insurance contracts.
(b) For purposes of this section:
(1) “Carrier” means any entity that provides health insurance in this State. “Carrier” includes an insurance company, health service corporation, health maintenance organization, and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation. “Carrier” also includes any third-party administrator or other entity that adjusts, administers, or settles claims in connection with health benefit plans.
(2) “Carrier” does not mean an entity that provides a plan of health insurance or health benefits designed for issuance to persons eligible for coverage under Titles XVIII, XIX, and XXI of the Social Security Act (42 U.S.C. §§ 1395 et seq., 1396 et seq. and 1397 et seq.), known as Medicare, Medicaid, or any other similar coverage under state or federal governmental plans.
(c) A carrier shall accept primary and secondary claims electronically from providers regardless of network status.
(d) A carrier shall permit a provider to receive electronic remittance advice (ERA/835) files for claims payments upon the completion of the necessary agreements required by the carrier.
(e) Any electronic claim shall be acknowledged by the carrier electronically no later than 2 business days following receipt of the claim to the entity submitting the claim.
82 Del. Laws, c. 111, § 4;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter III. Provisions Applicable to Group and Blanket Health Insurance › § 3571X. Medication assisted treatment for drug and alcohol dependencies.

§ 3571X. Medication assisted treatment for drug and alcohol dependencies.
(a) For purposes of this section, “medication-assisted treatment” means the use of U.S. Food and Drug Administration-approved medications, in combination with counseling and behavioral therapies, to provide a whole patient approach to the treatment of drug and alcohol dependencies.
(b) If group health insurance coverage provides prescription medication benefits for the treatment of mental illness and drug and alcohol dependencies, a health insurer must place at least 1 formulation of a medication-assisted treatment on the lowest tier of the drug formulary developed and maintained by the carrier, including each of the following:
(1) Buprenorphine.
(2) Naltrexone.
(3) Naloxone.
(4) A product containing both buprenorphine and naloxone.
(c) A health insurer that provides coverage for prescription drugs must cover the fees associated with the administration or dispensing of methadone dispensed at an opioid treatment program as defined under 42 C.F.R. § 8.2.
(d) A health insurer shall provide benefits under this section as follows:
(1) Not impose a prior authorization requirement.
(2) Must authorize coverage of prescription medicine without imposing a step therapy requirement for at least 1 formulation of each prescription medication for medication-assisted treatment that is on each tier of the drug formulary developed and maintained by the health insurer.
82 Del. Laws, c. 199, § 2;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter III. Provisions Applicable to Group and Blanket Health Insurance › § 3571Y. Coverage for epinephrine autoinjectors.

§ 3571Y. Coverage for epinephrine autoinjectors.
(a) For purposes of this section, “epinephrine autoinjector” means a single-use device used for the automatic injection of a premeasured dose of epinephrine into the human body.
(b) All group and blanket health insurance policies, contracts, or certificates that are delivered, issued for delivery, renewed, extended, or modified in this State shall provide coverage for medically-necessary epinephrine autoinjectors by including at least 1 formulation of epinephrine autoinjectors on the lowest tier of the drug formulary developed and maintained by the carrier.
(c) Nothing in this section prevents the operation of a policy provision required by this section as a deductible, coinsurance, allowable charge limitation, coordination of benefits, or a provision restricting coverage to services by a licensed, certified, or carrier-approved provider or facility.
(d) (1) For individuals who are 18 years of age or under, this section applies to all policies, contracts, or certificates issued, renewed, modified, altered, amended, or reissued after December 31, 2021.
(2) For individuals who are more than 18 years of age, this section applies to all policies, contracts, or certificates issued, renewed, modified, altered, amended, or reissued after December 31, 2024.
(e) This section does not apply to accident-only, specified disease, hospital indemnity, Medicare supplement, long-term care, disability income, or other limited benefit health insurance policies.
83 Del. Laws, c. 42, § 2;  84 Del. Laws, c. 36, § 2;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter IV. Large Employer Health Insurance Standards › § 3573. Limitations on preexisting condition limitations [For application of this section, see 79 Del. Laws, c. 99, § 19].

§ 3573. Limitations on preexisting condition limitations [For application of this section, see 79 Del. Laws, c. 99, § 19].
A health benefit plan that covers a large group in this State:
(1) Shall not deny, exclude or limit benefits for a covered individual because of a preexisting condition;
(2) May impose an affiliation period. An affiliation period shall run concurrently with any waiting period. A health maintenance organization may, in lieu of an affiliation period, use an alternative method to address adverse selection with the prior approval of the Commissioner;
(3) Shall waive an affiliation period for the period of time an individual was previously covered by creditable coverage if such creditable coverage was continuous to a date not more than 63 days prior to the effective date of the new coverage. For purposes of calculating continuous coverage, a waiting period shall not be considered a gap in coverage. This paragraph shall not preclude application of any waiting period applicable to all new enrollees under the plan. The method of crediting and certifying coverage shall be determined by the Commissioner by regulation; and
(4) May not exclude coverage for late enrollees for a preexisting condition.
A health benefit plan shall not establish rules for eligibility for any individual to enroll under the plan based on any health status-related factors in relation to the individual or a dependent of the individual.
71 Del. Laws, c. 143, §  14;  73 Del. Laws, c. 89, §  1;  76 Del. Laws, c. 176, §  3;  79 Del. Laws, c. 99, §  9;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter IV. Large Employer Health Insurance Standards › § 3575. Rate regulation.

§ 3575. Rate regulation.
A carrier offering a large group health benefit plan may not require any individual (as a condition of enrollment or continued enrollment under the plan) to pay a premium or contribution that is greater than such premium or contribution for a similarly situated individual enrolled in the plan on the basis of any health status-related factor in relation to the individual or to an individual enrolled under the plan as a dependent of the individual. This prohibition shall not be construed to restrict the amount that an employer may be charged for coverage under a large group health benefit plan or to prevent a carrier from establishing premium discounts or rebates or modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention, if not otherwise prohibited by law.
71 Del. Laws, c. 143, §  14;  73 Del. Laws, c. 89, §  1;  76 Del. Laws, c. 176, §  3;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter IV. Large Employer Health Insurance Standards › § 3576. Mental health parity.

§ 3576. Mental health parity.
A carrier offering a large group health plan shall comply with the provisions of 42 U.S.C. § 300gg-5, Public Law 104-204 and any subsequent changes in federal law.
71 Del. Laws, c. 143, §  14;  73 Del. Laws, c. 89, §  1;  76 Del. Laws, c. 176, §  3;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter IV. Large Employer Health Insurance Standards › § 3577. Newborns and mothers health protection.

§ 3577. Newborns and mothers health protection.
A carrier offering a health benefit plan shall comply with the provisions of 42 U.S.C. § 300gg-4 and any subsequent changes in federal law.
71 Del. Laws, c. 143, §  14;  73 Del. Laws, c. 89, §  1;  76 Del. Laws, c. 176, §  3;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter IV. Large Employer Health Insurance Standards › § 3579. Health insurance; pharmacies; electronic reimbursement.

§ 3579. Health insurance; pharmacies; electronic reimbursement.
(a) This section shall apply to:
(1) Insurers and nonprofit health service plans that provide, directly or through a pharmacy benefit manager, coverage for prescription drugs under health insurance policies or contracts that are issued or delivered in this State; and
(2) Health maintenance organizations that provide, directly or through a pharmacy benefit manager, coverage for prescription drugs under contracts that are issued or delivered in this State.
(b) If an entity subject to this section requires a pharmacy to submit a request for payment electronically, then the pharmacy or its designated agent may choose to be reimbursed electronically, and in that event the entity shall electronically reimburse such pharmacy and shall provide the appropriate payment data electronically.
(c) An entity subject to this section may not impose on a pharmacy a processing fee for the electronic reimbursement or for providing payment data electronically, provided that the electing pharmacy agrees to, and can accept claims details for the payments electronically and provide accurate electronic funds transfer information to the entity making payments.
(d) Subsequent to January 6, 2010, any pharmacy that requires electronic reimbursement under this section shall allow an entity 45 days to become compliant herewith from the date of the pharmacy's initial request to commence electronic reimbursement between the parties.
77 Del. Laws, c. 116, §  2;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter V. Pre-Authorization Transparency › § 3582 . Disclosure and review of pre-authorization requirements.

§ 3582 . Disclosure and review of pre-authorization requirements.
(a) A utilization review entity shall make any current pre-authorization requirements and restrictions readily accessible on its website and in written or electronic form upon request for covered persons, health-care providers, and others with access to the website. Information from a utilization review entity that is not an insurer, health-benefit plan, or health-service corporation shall make this information available at an electronic pre-authorization portal that is accessible in real time. Requirements shall be described in detail but also in clear, easily-understandable language. Clinical criteria shall be described in language easily understandable by a health-care provider practicing in the same clinical area.
(b) If an insurer, health-benefit plan, or health-service corporation intends either to implement a new pre-authorization requirement or restriction, or amend an existing requirement or restriction, they shall ensure that the new or amended requirement is not implemented unless their website has been updated to reflect the new or amended requirement or restriction. This shall not extend to expansion of coverage for new health-care services.
(c) If an insurer, health-benefit plan, or health-service corporation intends either to implement a new pre-authorization requirement or restriction, or amend an existing requirement or restriction, they shall provide covered persons who are currently authorized by the utilization review entity for coverage of the affected health-care service and all contracted health-care providers who provide affected health-care service or services of written notice of the new or amended requirement or amendment no less than 60 days before the requirement or restriction is implemented. Such notice may be delivered electronically or by other means.
(d) Insurers, health-benefit plans, and health-service corporations utilizing pre-authorization shall report de-identified statistics regarding pre-authorization approvals, denials, and appeals to the Delaware Health Information Network in a format and frequency, no less than twice annually, of the Delaware Health Information Network's request. The Department may also request this data at any time. The statistics shall include, but may be expanded upon or further delineated by regulation, categories for all of the following:
(1) For denials, the aggregated reasons for denials such as, but not limited to, medical necessity or incomplete pre-authorization submission.
(2) For appeals:
a. Practitioner specialty;
b. Medication, diagnostic test, or diagnostic procedure;
c. Indication offered;
d. Reason for underlying denial; and
e. Number of denials overturned upon appeal.
80 Del. Laws, c. 310, § 2;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter V. Pre-Authorization Transparency › § 3583 . Utilization review entity's obligations with respect to pre-authorizations in nonemergency circumstances.

§ 3583 . Utilization review entity's obligations with respect to pre-authorizations in nonemergency circumstances.
(a) If a utilization review entity requires pre-authorization of a pharmaceutical, the utilization review entity must complete its process or render an adverse determination and notify the covered person's health-care provider within 2 business days of obtaining a clean pre-authorization or of using services described in § 3377 of this title.
(b) If a utilization review entity requires pre-authorization of a health-care service, the utilization review entity must grant a pre-authorization or issue an adverse determination and notify the covered person's health-care provider of the determination within 8 business days of receipt of a clean pre-authorization not submitted through electronic pre-authorization. For purposes of this subsection, a clean pre-authorization includes the results of any face-to-face clinical evaluation or second opinion that may be required.
(c) If a utilization review entity requires pre-authorization of a health-care service, the utilization review entity must grant a pre-authorization or issue an adverse determination and notify the covered person's health-care provider of the determination within 5 business days of receipt of a clean pre-authorization through electronic pre-authorization. For purposes of this subsection, a clean pre-authorization includes the results of any face-to-face clinical evaluation or second opinion that may be required.
80 Del. Laws, c. 310, § 2;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter V. Pre-Authorization Transparency › § 3584. Utilization review entity's obligations with respect to pre-authorization concerning emergency health-care services.

§ 3584. Utilization review entity's obligations with respect to pre-authorization concerning emergency health-care services.
A utilization review entity must follow all emergency procedures and mandates as delineated in §§ 3349 and 3565 of this title.
80 Del. Laws, c. 310, § 2;
2023 Delaware Code › Title 18 - Insurance Code › Chapter 35. GROUP AND BLANKET HEALTH INSURANCE › Subchapter V. Pre-Authorization Transparency › § 3585. Retrospective denial.

§ 3585. Retrospective denial.
The utilization review entity may not revoke, limit, condition or restrict a pre-authorization on ground of medical necessity after the date the health-care provider received the pre-authorization. Any language attempting to disclaim payment for services on the basis of changes to medical necessity that have been pre-authorized and delivered while under coverage shall be null and void. A proper notification of policy changes validly delivered as per § 3372 of this title may void a pre-authorization if received after pre-authorization but before delivery of the service.
80 Del. Laws, c. 310, § 2;