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Delaware General AssemblyDelaware RegulationsMonthly Register of RegulationsNovember 2018


Regulatory Flexibility Act Form

Authenticated PDF Version

Section 5 of the Act 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 Department is therefore proposing new 18 DE Admin. Code 1319, Arbitration of Disputes between Carriers and Primary Care and Chronic Care Management Providers, to implement the requirements of 18 Del.C. §§3342B and 3556A.
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 reimbursement 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, 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.
"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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