Jan. 1, 2027].
(a) For purposes of this section:
(1) a. "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.
b. "Carrier" does not mean 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 1397aa. et seq.), known
as Medicare, Medicaid, or any other similar coverage under state or federal governmental plans.
(2) "Chronic care management" means the services in the Chronic Care Management Services Program, as administered by the
Centers for Medicare and Medicaid Services, and includes Current Procedural Terminology ("CPT") codes 99487, 99489, and 99490.
(3) "Medicare" means the federal Medicare Program (U.S. Public Law 89-87, as amended) (42 U.S.C. § 1395 et seq.).
(4) "Primary care" means health care provided by a physician or an individual licensed under Title 24 to provide health care, with
whom the patient has initial contact and by whom the patient may be referred to a specialist and includes family practice, pediatrics,
internal medicine, and geriatrics.
(b) (1) A carrier shall provide coverage for chronic care management and primary care at a reimbursement rate that is not less than
the Medicare reimbursement for comparable services.
(2) This subsection applies to a group health insurance policy, plan, or contract that is delivered, issued for delivery, or renewed
by a carrier on or after January 1, 2019.
(3) A carrier shall do the following:
a. By 2022, spend at least 7% of its total cost of medical care on primary care.
b. By 2023, spend at least 8.5% of its total cost of medical care on primary care.
c. By 2024, spend at least 10% of its total cost of medical care on primary care.
d. By 2025, spend at least 11.5% of its total cost of medical care on primary care.
(c) If a comparable Medicare reimbursement rate is not available, a carrier shall reimburse for services at the rates generally available
under Medicare for services such as office visits and prolonged preventive services, which may be further delineated by regulation.
(d) (1) The Department shall arbitrate disagreements regarding rates under this section. The parties must pay the cost of the arbitration.
(2) The Department shall adopt regulations to implement the requirements of this subsection no later than March 31, 2019.
(e) The provisions of this section may not be waived by contract. Any contractual arrangement in conflict with the provisions of this
section or that purports to waive any requirements of this section is void.
(f) Coverage for chronic care management must not be subject to patient deductibles, copayments, or fees.‹ Prev All Delaware sections Next ›
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