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Delaware General AssemblyDelaware RegulationsMonthly Register of RegulationsDecember 2016


Regulatory Flexibility Act Form

Authenticated PDF Version

INSURANCE COMMISSIONER KAREN WELDIN STEWART hereby gives notice of proposed Department of Insurance Regulation 1317 relating to Network Disclosure and Transparency. The docket number for this proposed regulation is 3252.
Proposed Regulation 1317 was initially published in the Delaware Register of Regulations on September 1, 2016. Following the initial publication, the Department has changed the Delaware Code references for §3371 to §3370A; modified Section 1.0 and subsections 3.1, 3.4, 4.1, 4.3, and 6.3; inserted a new Section 5.0; renumbered original Sections 5.0, 6.0, 7.0, and 8.0; modified Appendix 1, paragraph 6; and added a new Appendix 2, in response to certain comments received, and is re-publishing the proposed Regulation 1317 on December 1, 2016, as modified.
Email: rhonda.west@state.de.us
1.1 The purpose of this Regulation is to implement 18 Del.C. §§3370A and 3571S, which require (1) health insurers to maintain accurate and complete provider directories, to update provider directories frequently, to audit the accuracy and completeness of such directories and make the directories easily accessible to covered persons in a variety of formats, and (2) facility-based providers and non-network providers to provide timely written out-of-network disclosures to patients that fully inform such patients of the potential that out-of-network providers may be rendering care and the associated costs thereof. This Regulation is promulgated pursuant to 18 Del.C. §§3370A and 3571S; and 29 Del.C. Ch. 101. This Regulation should not be construed to create any cause of action not otherwise existing at law.
1.2 Consistent with 18 Del.C. §§3370A and 3571S, this regulation applies to every policy or contract of health insurance which is delivered or issued for delivery in this State, including each policy or contract issued by a health-service corporation, which provides medical, major medical, or similar comprehensive-type coverage, and which designates network physicians or providers (hereinafter referred to collectively as “network providers”). However, this regulation applies only to items, services or conditions for which coverage is provided by those policies or contracts (hereinafter referred to as “covered services”).
Facility-based provider” means a provider who provides health care services to covered persons who are in an in-patient or ambulatory facility, including services such as pathology, anesthesiology, or radiology.
Health care provider” means any provider who provides health care services to covered person who are not in a facility-based setting, and includes a provider who provides health care services to a covered person based upon a referral from another provider without the knowledge of or input from the covered person.
3.1 When a facility-based provider schedules a procedure, seeks prior authorization from a health insurer for the provision of non-emergency covered services to a covered person, or prior to the provision of any non-emergency covered services, the facility shall ensure that the covered person has received a timely, written out-of-network disclosure required by 18 Del.C. §§3370A or 3571S, as applicable, in the form attached hereto as Appendix 1 (the “facility-based provider disclosure”). The provision of the facility-based provider disclosure shall be considered timely if it is provided to the covered person within (3) business days after such procedure is scheduled if the medical necessity of a procedure allows such time, and if not, in as timely a manner as possible.
4.1 Prior to the provision of any non-emergency covered services, the health care provider shall ensure that the covered person has received a timely, written out-of-network disclosure required by 18 Del.C. §§3370A or 3571S, as applicable, in the form attached hereto as Appendix 2 (the “health care provider disclosure”). The provision of the health care provider disclosure shall be considered timely if it is provided to the covered person within three (3) business days after the services are scheduled if the medical necessity of a procedure allows such time, and if not, in as timely a manner as possible.
When a facility-based provider or a health care provider requests a laboratory service for a covered person that does not require an in-person visit, that provider must provide disclosure to the covered person if the facility being utilized is an out-of-network facility. If the requesting provider does not provide the required disclosure to the covered person, the covered person shall not be subject to any balance billing of the out-of-network service(s). If the laboratory service being requested requires an in-person visit, the laboratory must provide the covered person written disclosure of the out-of-network service(s) and a consent form prior to rendering any service(s). If the laboratory does not provide the required disclosure to the covered person, the covered person shall not be subject to any balance billing.
PLEASE RETURN THIS FORM TO [INSERT FACILITY NAME] ON OR PRIOR TO YOUR DATE OF SERVICE
4. Services that are provided by an out-of-network provider will be provided on an out-of-network basis, which may result in additional charges for which you may be responsible. These charges are in addition to any coinsurance, deductibles and copayments applicable under your health insurance policy.
2. Services provided on an out-of-network basis may result in additional charges for which you may be responsible. These charges are in addition to any coinsurance, deductibles and copayments applicable under your health insurance policy.
Last Updated: December 31 1969 19:00:00.
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