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Delaware General AssemblyDelaware RegulationsMonthly Register of RegulationsJanuary 2019

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In the November 1, 2018 edition of the Register of Regulations at 22 DE Reg. 366, the Commissioner of the Delaware Department of Insurance (Commissioner) published a notice of intent to codify proposed new Regulation 1319, and solicited written comments from the public for thirty (30) days as mandated by the Administrative Procedures Act at 29 Del.C. §10118(a). The Delaware Code authority for the new regulation is 18 Del.C. §§311, 3342B, and 3556A and 29 Del.C. Ch. 101.
As discussed in the introductory paragraphs of the proposal, Senate Bill 227 (as amended by Senate Amendment No. 1 and House Amendment No. 1 as amended by House Amendment No. 1 to House Amendment No. 1 (collectively SB 227)) was signed into law on August 29, 2018. Section 5 of SB 227 adds new 18 Del.C. §3342B to the Uniform Health Policy Provisions Law codified at 18 Del.C. Chapter 33, Subchapter 1. Section 6 of the Act adds new 18 Del.C. §3556A to Chapter 35 of the Delaware Insurance Code, which concerns group and blanket health insurance.
Both new provisions require, inter alia, that insurance carriers "provide coverage for chronic care management and primary care at a reimbursement rate that is not less than the Medicare reimbursement for comparable physician services." The Act also requires the Delaware Department of Insurance (the Department) to "arbitrate disagreements regarding rates under this section" for which the parties involved in the dispute must pay, and to "adopt regulations to implement the requirements of this section no later than 90 days after the effective date of this Act."
In addition to publishing the proposal in the Register of Regulations, the Department also published the proposal on its website. The Department did not hold a public hearing on the proposed new regulation.
1. Proposed new 18 DE Admin. Code 1319, Arbitration of Disputes between Carriers and Primary Care and Chronic Care Management Providers, implements the requirements of 18 Del.C. §§3342B and 3556A.
3. The Commissioner finds that it is appropriate to adopt 18 DE Admin. Code 1319 as proposed in the November 1, 2018 Register of Regulations, for the reasons set forth above and in the proposal, with the following commenter-suggested amendments that the Commissioner has determined do not require further public notice or comment under the APA because the amendments are non-substantive pursuant to 29 Del.C. §10118(c):
b. Add the phrase "pursuant to 18 Del.C. §§3342 and 3556 to the definition of "primary care provider" to avoid any confusion as to the mechanism by which an obstetrician/gynecologist may serve as a primary care provider; and
c. Substitute the phrase "in accordance with 18 Del.C. §§3342B and 3556A” for "in its entirety" at subsection 3.1 to ensure that the denial of payment that triggers arbitration was in accordance with the underlying statutory provisions.
For the foregoing reasons, the Commissioner concludes that it is appropriate to adopt 18 DE Admin. Code 1319, as discussed in the above Findings of Fact for the reasons set forth above and in the proposal.
The actions hereinabove referred to were taken by the Commissioner pursuant to 18 Del.C. §§311, 3342B, and 3556A on the date indicated below. The effective date of this Order shall be ten (10) days from the date this Order is published in the Delaware Register of Regulations. The effective date of the Regulation shall be as stated in the text of the Regulation.
IT IS SO ORDERED.
The 10th day of December, 2018.
1.1 The purpose of this regulation is to implement 18 Del.C. §§3342B and 3556A, which require health insurance carriers to submit to arbitration any dispute with a provider regarding [claims for a carrier’s final] reimbursement [decision] for primary care and chronic care management services.
1.2 This Regulation is promulgated pursuant to 18 Del.C. §§311, 3342B, and 3556A and 29 Del.C. Ch. 101. This Regulation should not be construed to create any cause of action not otherwise existing at law.
"Carrier" or "insurance 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.
"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.
"Department" means the Delaware Department of Insurance.
"Medicare" means the federal Medicare Program (U.S. Public Law 89-87, as amended) [42 U.S.C. § 64 1395 et seq.].
"Primary care" means health care provided by a primary care provider.
"Primary care provider" means any physician or individual licensed under Title 24 of the Delaware Code to provide health care, with whom the patient has initial contact and by whom the patient may be referred to a specialist. Examples of a primary care provider include primary care physicians (including an obstetrician - gynecologist [pursuant to 18 Del.C. §§3342 and 3556], to the extent that provider is serving in the role as a primary care provider), certified nurse practitioners, physician assistants, and other front-line practitioners for chronic care management and primary care who provide primary care in a family, pediatrics, internal medicine, or a geriatrics practice.
"Provider" means a provider of chronic care management or a primary care provider.
3.1 A carrier shall notify a provider, in writing, of a carrier's final decision regarding reimbursement for an individual claim, procedure or service, if the decision does not authorize reimbursement of the provider's charge in [its entirety accordance with 18 Del.C. §§3342B and 3556A]. Such notice may be separate from or a part of the written notice of the carrier's decision.
"You have the right to seek review of our decision regarding the amount of your reimbursement. The Delaware Insurance Department provides claim arbitration services which are in addition to, but do not replace, any other legal or equitable right you may have to a review of this decision or any right of review based on your contract with us. You can contact the Delaware Insurance Department for information about arbitration by calling the Arbitration Secretary at 302-674-7322 or by sending an email to: DOI-arbitration@state.de.us. All requests for arbitration must be filed within 60 days from the date you receive this notice; otherwise, this decision will be final."
Last Updated: December 31 1969 19:00:00.
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