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Delaware General AssemblyDelaware RegulationsMonthly Register of RegulationsJune 2018

Regulatory Flexibility Act Form

Authenticated PDF Version

(18 Del.C. §311 & 24 Del.C. §716(c))
Third, the Department has determined that subsections 5.2 and 6.3 address the same issue, which is the statutory provision at 24 Del.C. §716(b) that allows carriers and TPAs to implement reasonable and nondiscriminatory cost containment and managed care provisions. Accordingly, the Department is combining these two paragraphs into a new section 7.0 entitled "Reasonable and Nondiscriminatory Provisions."
This regulation is adopted pursuant to 18 Del.C. §§102, 311 and 329 and 24 Del.C. §716 and promulgated in accordance with the Delaware Administrative Procedures Act, 29 Del.C. Ch. 101.
The following words and terms, when used in this regulation, should have the following meaning unless the context clearly indicates otherwise:
"Administrator" or "third party administrator" or "TPA" means "Administrator" or "third party administrator" or "TPA" as those terms are defined at 18 DE Admin. Code 1406-2.1.
"Carrier" means any entity that provides health insurance in this State. For the purposes of this regulation, carrier includes a health 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.
"Chiropractic" means "Chiropractic" as defined in 24 Del.C. §701 and in 24 DE Admin. Code 700.
"Chiropractic care or services" means those practices that a licensed doctor of chiropractic is licensed to provide pursuant to 24 Del.C. Ch. 7 and 24 DE Admin. Code 700.
"Commissioner" means the Commissioner of the Delaware Department of Insurance.
"Doctor of chiropractic" means a person who is licensed to administer chiropractic care or services pursuant to 24 Del.C. Ch. 7 and 24 DE Admin. Code 700.
"Medically necessary" means the providing of health care services or products that a prudent physician would provide to a patient for the purpose of diagnosing or treating an illness, injury, disease or its symptoms in a manner that is:
"Physician" means, for purposes of this regulation, anyone who is licensed as a physician pursuant to 24 Del.C. Ch. 17 or as a doctor of chiropractic pursuant to 24 Del.C. Ch. 7.
Nothing in this regulation shall prohibit a carrier or a TPA from implementing reasonable and nondiscriminatory cost containment or managed care provisions as permitted by 24 Del.C. §716(b).
The provisions of this regulation may not be waived, voided, or nullified by contract.
This regulation shall not create a private cause of action for any person or entity other than the Commissioner against a carrier or its representative based upon a violation of 24 Del.C. §716 or any provision of this regulation.
This regulation shall become effective on January 1, 2019.
Last Updated: December 31 1969 19:00:00.
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