Primary Focus: Medical Management limitation
Title/Description: An Act Regarding the Process for Obtaining Prior Authorization for Health Insurance Purposes
Citation: 18 Del §3343, 3571V
Summary: This law amends section 3343, Title 18 and section 3571V, Title 18 of the Delaware Code by requiring health benefit plans that cover prescription drugs to place at least one formulation of each of the FDA-approved MAT drugs on the lowest tier of the carrier’s prescription drug formulary. Such drugs must be covered without prior authorization. Additionally, the law requires that at least one formulary of each medication within each tier be available without step-therapy requirements. Finally, plans must provide coverage for fees associated with the dispensing and administration of methadone at opioid treatment programs.
Effective Date: On and after January 1, 2020
Notes: Enacted by HB 220
Primary Focus: Compliance-Reporting Requirement
Title/Description: Serious Mental Illness Insurance Coverage
Citation: 149th General Assembly – Chapter 406
Summary: S.B. 230 amended Title 18 of the Delaware Code, §3343, by inserting a new provision, §3343(g), which requires insurers to submit annual reports to demonstrate compliance with the Federal Parity Law. S.B. 230 also amended Chapter 35, Title 18 of the Delaware Code by adding a new §3571T, which sets reporting requirements for private insurers. This bill also amends Title 31 of the Delaware Code, §525, to set the same requirements for public insurers.
Effective Date: 8/29/18
Primary Focus: Oversight and Coordination
Title/Description: Behavioral Health Consortium
Citation: 16 Del. C. §§ 5195, 5196, 5197
Summary: 16 Del. C. §§ 5195, 5196, 5197 establishes a Behavioral Health Consortium that will develop a statewide integrated plan for addressing the prevention and treatment of substance use and mental health, and provide oversight and coordination of the State’s private and public bodies to address behavioral health issues in Delaware. As a coordinate body, the Consortium will streamline processes to better address potential gaps and ensure quality delivery of care across the State. Emphasis will be placed on assuring that behavioral health related public commissions and committees do not operate in siloes, but instead have a resource for policy and practice recommendations.
The Consortium reports to the Governor or General Assembly and makes recommendations for legislative action to ensure quality delivery and expanded access to behavioral healthcare. There are 25 members in the Consortium, which includes diverse stakeholders to ensure geographical representation, subject matter experience and cultural competence. Representation includes members from government, hospitals, behavioral health providers, education, advocacy, insurance, and private citizens. Nine of the members are appointed by virtue of their respective positions, twelve are appointed by the Governor, two Senators are appointed by the President Pro Tempore of the Senate, and two members of the House of Representatives are appointed by the Speaker of the House.
Effective Date: April 5, 2018
Notes: Enacted by SB 111 on August 16, 2017, which created 16 Del. C. §§ 5195, 5196, 5197, further modified by SB 143 which was enacted on April 5, 2018.
There are 5 sections of the state insurance law relevant to parity. There are two identical sections for coverage of certain behavioral health conditions, and two identical sections for coverage of autism. There is also a section that requires large employer fully-insured plans to comply with the section of federal law in which the Federal Parity Law, used to reside. However, the location of the Federal Parity Law within federal law has changed and therefore this section of Delaware law no longer directly refers to the Federal Parity Law. However, this section does say that plans must comply with “any subsequent changes in federal law”, which could be interpreted as requiring plans to comply with the current Federal Parity Law.
It is not possible to provide a direct link to any of these sections. To find the sections that apply to individual plans, click here and scroll to “§ 3343 Insurance coverage for serious mental illness” for the behavioral health section and “§ 3366 Autism spectrum disorders coverage” for the autism section.
To find the sections that apply to employer plans, click here and scroll to “§ 3578 Insurance coverage for serious mental illness” for the behavioral health section and click here and scroll to “§ 3570A Autism spectrum disorders coverage” for the autism section.
To find the section that requires large employer fully-insured plans to comply with the section of federal law that used to contain the Federal Parity Law, click here and scroll to “§ 3576 Mental health parity”
Deductibles, copayments, coinsurance, annual maximums, lifetime maximums, inpatient day limits, outpatient visit limits, any other durational limits, and coverage for prescription medication for the listed behavioral health conditions must not “place a greater financial burden” than those in place for other medical services.
Plans are explicitly allowed to use non-quantitative treatment limitations (NQTLs) and other managed care techniques in ways that are “unique to mental health benefits.” It also states “This section shall not be interpreted to require a carrier to employ the same benefit management procedures for serious mental illnesses and drug and alcohol dependencies that are employed for the management of other illnesses”. This could be interpreted to mean that NQTLs can be used more frequently or more restrictively.
These sections require individual plans, small employer fully-insured plans, and large employer fully-insured plans to cover autism services through age 20. Plans must cover an annual maximum of $36,000 for applied behavior analysis, which can be adjusted for inflation each year.
Autism spectrum disorders are defined as “pervasive developmental disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), including Autistic Disorder, Asperger’s Disorder and Pervasive Developmental Disorder Not Otherwise Specified.”
Treatments for autism are listed as (and defined in this section):
Insurance plans may only review a child’s treatment plan once per year.
These sections also require the Secretary of the Department of Health and Social Services to review best practices and evidence-based research regarding medically necessary care for autism and inform the Commissioner of the Department of Insurance of these findings. The Commissioner is then required to issue a bulletin to plans informing them of the latest medically necessary treatments for autism they must cover.
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