Title 18 Insurance
1300 Health Insurance General Provisions
1306 Certificate and Standards for Health Plans or Policies [Formerly Regulation 60]
1.0 Authority
This regulation is adopted in accordance with 18 Del.C. §2312 and 18 Del.C. §3603 and promulgated in accordance with 29 Del.C. Ch. 101.
2.0 Purpose
The purpose of this regulation is to promote wellness by establishing criteria and procedures for the Delaware Insurance Commissioner's designation of insurance policies and subscriber contracts meeting or exceeding said criteria as certified health plans or policies (CHPs).
3.0 Applicability and Scope
This regulation shall apply to individual and group health insurance policies, including subscriber contracts of health service corporations, fraternal benefit societies and health maintenance organizations delivered or issued for delivery in this state on or after the effective date hereof.
4.0 Definitions
4.1 For purposes of this regulation:
"Carrier" means an insurer providing medical, hospital or surgical expense incurred health insurance policies, a non-profit health service corporation, a fraternal benefits society, and a health maintenance organization.
"Certified Health Plan or Policy" or "CHP" means a carrier's plan or policy which meets or exceeds the criteria specified in Section 5 of this regulation and has been so certified by the Delaware Insurance Commissioner.
"Insured" means the individual persons whose medical expenses are paid by a carrier's policy or contract.
5.0 Certified Health Plan Criteria
5.1 On and after the effective date hereof, no individual or group health insurance policy or subscriber contract of any carrier delivered or issued for delivery in this state shall indicate that it is a certified health plan or policy or CHP unless the Delaware Insurance Commissioner has so certified, pursuant to this regulation, that it:
5.1.1 Provides significant economic incentives to insureds designed to encourage their participation in the practice of healthy lifestyle behaviors. Such incentives may, for example, be in the form of health care insurance premium reductions, benefit enhancements, or in the case of employer-paid plans, direct financial compensation;
5.1.2 Provides significant economic disincentives and penalties to insureds who incorrectly certify participation in the practice of health lifestyle behaviors. Such disincentives and penalties may, for example, be in the form of increased deductibles and copayments, or surcharges.
5.1.3 Sets forth economic incentives and disincentives substantial enough to encourage behavior modification.
5.1.4 Provides benefits for appropriate screening examinations and designated adult immunizations.
5.2 The Delaware Insurance Commissioner shall certify a health plan or policy (CHP) that meets the following criteria or an equivalent. A plan or policy such as the one described in the following paragraphs is to be used as an example only and is not meant to limit the types of plans or policies which will be approved as Certified Health Plans under section 5.1 above by the Insurance Commissioner.
5.2.1 Includes the following healthy lifestyle behaviors and respective minimum premium credits for those insureds certifying that they adhere to the prescribed behaviors. An insured must be a nonsmoker to qualify for any credit.
5.2.1.1 No tobacco — (no use of tobacco products at least six months prior to the issuance of the CHP and while the CHP is in force) - 20% credit.
5.2.1.2 Regular exercise — (participating, three or more times per week, in an aerobic activity such as brisk walking, running, swimming, and bicycling, maintaining sixty percent of the maximum heart rate: 140—170 beats per minute for persons under 30 years of age; 130—150 beats per minute for persons between 30 and 49 years of age; and 120—140 beats per minute for persons 50 years of age and older; for twenty minutes) — 5% credit.
5.2.1.3 Moderate alcohol consumption — (no more than two drinks in any 24-hour period nor more than seven drinks in any week. A drink means twelve (12) ounces of beer, or four (4) ounces of wine, or 1.4 ounces of spirits per day) — 5% credit.
5.2.1.4 Blood pressure maintenance — (maintaining blood pressure equal to or less than 140/90 mm Hg, with or without physician-prescribed medication) — 5% credit.
5.2.1.5 Weight control — (maintaining desirable weight as determined by: 1. the 1983 Metropolitan Life Insurance Company tables; 2. lean body mass calculations; or 3. skin fold measurements) — 5% credit.
5.2.1.6 Non-abuse of drugs — (complete avoidance of substances illegal under state or federal law, and ingestion or use of legend drugs only as prescribed by a physician) — 5% credit.
5.2.1.7 Seat belt usage — (using seat belts in the manner prescribed by the manufacturer whenever riding in or driving a private passenger vehicle) — 5% credit.
5.2.1.8 Section 5.2.1.1 through 5.2.1.7 above is not intended to represent a static or fixed set of criteria. As actuarial data develops on the effects of healthy lifestyle behaviors, carriers are encouraged to creatively modify their CHPs. Some carriers may prefer to "phase in" credit levels to encourage consistent behavior.
5.2.2 Provides benefits for periodic preventive screening examinations as appropriate to the insured's age, sex, and health condition, as determined by protocol established by the Delaware Division of 40%.
5.2.5 Nothing in sections 5.2.1 through 5.2.4 above should in and of itself be viewed as a requirement of a plan or policy which will be certified by the Insurance Commissioner. Insurers are encouraged to develop and submit plans of their own design that will meet the criteria outlined in section 5.1 above. Public Health and approved by the Delaware Insurance Commissioner.
5.2.3 Provides benefits for specific adult immunizations as determined by protocol established by the Delaware Division of Public Health and approved by the Delaware Insurance Commissioner.
5.2.4 Provides that, upon determination by a carrier that an insured has incorrectly certified in a material way his or her compliance with sections 5.2.1.1 through 5.2.1.7 above, the carrier shall surcharge or increase applicable deductibles or co-payments. The surcharge per insured shall not exceed an amount equal to three (3) times the credit received as a result of the materially incorrect certification and no increases in co-payment or deductible may exceed the co-payment or deductible by more than
6.0 Implementation
6.1 Carriers may implement a CHP in such a manner that there is no effect on present or anticipated total insurance premiums collected from a group.
6.2 Carriers shall provide a certification form to all insureds under a CHP. The form, whereby the insured may certify participation in the practice of healthy lifestyle behaviors as required by the CHP, shall be filed with and approved by the Delaware Insurance Commissioner prior to use. Said form shall include notification of the applicable penalties set forth in section 5.2.4 of this regulation.
6.3 CHPs shall include a provision which contains the following form of notice:
6.3.1 "If at any time during the policy period an insured who has previously certified participation in the practice of healthy lifestyle behaviors as required by the CHP ceases to practice any or all of such behaviors, he or she shall notify the carrier in writing within thirty (30) days. Upon notice to the carrier, the insured shall repay any premium credit earned from the date the insured ceased such practice."
6.4 Carriers issuing CHPs may investigate, at any time, to verify an insured's compliance with the requirements of the CHP. Insureds shall cooperate with reasonable efforts by carriers to verify the certification under section 5.2.1 above.
7.0 Procedures for Certification
7.1 Carriers desiring to apply for the Delaware Insurance Commissioner's certification of a Health Plan or Policy as a CHP, shall file with the Delaware Insurance Department, a copy of the plan or policy together with documentation sufficient to demonstrate that it meets or exceeds the criteria specified in section 5.1 of this regulation. The Delaware Insurance Department may request additional information to support the application.
7.2 If, after thirty (30) days from the date of the application, or after fifteen (15) days from the date of submission of additional information requested by the Delaware Insurance Commissioner, whichever is later, the Delaware Insurance Department has not acted, the carrier may notify the Delaware Insurance Department by letter that the plan or policy will be deemed certified as a CHP on the tenth day following receipt of the letter.
8.0 Uncertified Plans
Nothing in this regulation shall preclude insurers, health service plans, fraternal benefit societies and health maintenance organizations from offering health plans and policies not certified by the Commissioner but otherwise meeting the requirements of law.
9.0 Separability
If any provision of this regulation shall be held invalid, the remainder of the regulation shall not be affected thereby.
10.0 Effective Date
10.1 This regulation shall become effective thirty (30) days after the issuance of the order promulgating this regulation.
10.2 This order, and the regulation herein, shall become effective thirty (30) days after the issuance of the order.
