Health Care Insurance

Del. Code tit. 29, ch. 52
in effect

Del. Code tit. 29, § 5201 Definitions.

For purposes of this chapter: (1) “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. (2) An “eligible child dependent” is one who is: a. The child of a regular officer, employee or eligible pensioner or spouse of a regular officer, employee or eligible pensioner, either by birth or adoption, who is under the age of 26 or is unmarried, regardless of age, and incapable of self support because of an intellectual, mental or physical disability which existed before age 21; or b. An unmarried child under the age of 19 years or the age of 24 if a full time student who depends for support upon and resides with a regular officer, employee or eligible pensioner in a regular parent-child relationship and qualifies as a dependent of the regular officer, employee or eligible pensioner under Internal Revenue Code § 105 (26 U.S.C. § 105). (3) a. “Eligible pensioner” means any of the following: 1. An individual who is receiving or is eligible to receive retirement benefits in accordance with the state employees’ pension plan under Chapters 53 and 55 of this title, the State Police pension plan under subchapter II and subchapter III of Chapter 83 of Title 11, the pension plan for state judiciary under Chapter 56 of this title, or is receiving retirement or disability benefits under the teachers’ retirement and disability plan under Chapter 39 of Title 14. 2. Individuals who were employed by the county prothonotary offices immediately prior to October 1, 1987, and who chose to remain in their respective county pension plans and who would otherwise be eligible to receive retirement benefits in accordance with the state employees’ pension plan under Chapters 53 and 55 of this title. 3. Employees who are receiving disability benefits under § 5253(c) of this title. b. For purposes of § 5202(a) & (b) of this title, “eligible pensioner” includes the eligible pensioner’s eligible spouse and child dependents. (4) “FDA” means the Food and Drug Administration. (5) “First employed” means the date when the eligible pensioner was first employed as a regular officer or employee. (6) “Mandatory retirement” means mandatory retirement under § 8361 of Title 11. (7) “Maximum state share” means the amount of the premium that the State pays for a plan on behalf of a regular officer or employee or an eligible pensioner before the proration ratio is applied under § 5202(b) of this title. (8) “Medicare” means the federal Medicare Program, 42 U.S.C. § 1395 et seq.; U.S. Public Law 89-87, as as amended. (9) “Plan” means a health-care insurance plan provided under this chapter. (10) “Premium” means the total premium or subscription charge for a plan. (11) “Primary care” means health care provided by a physician or an individual licensed under Title 24 to provide health care, with whom the patient has initial contact and by whom the patient may be referred to a specialist and includes family practice, pediatrics, internal medicine, and geriatrics. (12) a. “Regular officer or employee” means any of the following: 1. An individual who works the regularly scheduled full-time hours of the employing agency. 2. An individual who works at least 30 or more hours per week or 130 hours per month, with allowable interruptions, in a position of a continuing nature on a regular schedule expected to last at least 1 year from the date of initial appointment. The appointing authority shall determine at the time of appointment the qualifications of an appointee regarding the continuing nature and appointment duration criteria under this paragraph (12)a.2. 3. An employee who is receiving disability benefits under § 5253(b) of this title. 4. A member of a board or commission, if the member qualified for and was receiving coverage under the Delaware state group health insurance contract on January 1, 1993, as a member of that board or commission. b. A regular officer or employee called to active duty with Guard or Reserve for other than training purposes is deemed to be a “regular officer or employee” for the period of active duty until the period of active duty reaches 2 years. c. “Regular officer or employee” does not include any of the following: 1. An employee appointed to a temporary or seasonal position. 2. A member of a board or commission, except as provided under paragraph (12)a.4. of this section. (13) “Therapeutic equivalent” means a contraceptive drug, device, or product that is all of the following: a. Approved as safe and effective. b. Pharmaceutically equivalent to another contraceptive drug, device, or product in that it contains an identical amount of the same active drug ingredient in the same dosage form and route of administration and meets compendial or other applicable standards of strength, quality, purity, and identity. c. Assigned, by the FDA the same therapeutic equivalence code as another contraceptive drug, device or product.

Del. Code tit. 29, § 5202 Payment of premium; maximum state share; proration ratio.

(a) (1) The maximum state share for a regular officer or employee and for an eligible spouse and child dependents who are not eligible for Medicare is as follows: a. Ninety-six percent of the premium for the basic individual, individual and spouse, individual and child, or family health care insurance plan. b. Ninety-five percent of the premium for a consumer-directed health plan for individual, individual and spouse, individual and child, or family. c. Ninety-three and one-half percent of the premium for an HMO plan for individual, individual and spouse, individual and child, or family. d. Eighty-six and three-quarter percent of the premium for a comprehensive PPO plan for individual, individual and spouse, individual and child, or family. e. Beginning January 1, 2006, employees identified under Title 14 who are receiving a short-term disability benefit for a period greater than 90 days under § 5253(b) of this title and have exhausted all of their paid leave, the maximum state share is an amount equivalent to that provided under paragraphs (a)(1)a. through (a)(1)d. of this section. (2) The maximum state share for an eligible pensioner who is not eligible for Medicare is the maximum state share under paragraph (a)(1) of this section. (3) The maximum state share for an eligible pensioner who is eligible for Medicare is 95% of the premium if paragraph (a)(4) of this section does not apply. (4) The maximum state share for an eligible pensioner who is eligible for Medicare is 100% of the premium for any of the following: a. An eligible pensioner receiving a disability pension. b. An eligible pensioner who is a primary survivor receiving a survivor’s pension under § 8372(b) of Title 11 due to the death in the line of duty of the employee. c. An eligible pensioner who was first employed before July 1, 1991. d. An eligible pensioner who retired on or before July 1, 2012. (b) (1) For purposes of this section: a. 1. “Prorated state share” means the dollar amount that the State pays for a plan on behalf of a regular officer or employee or an eligible pensioner. 2. The “prorated state share” is the product of multiplying the proration ratio with the maximum state share. b. 1. “Proration ratio” means the percentage applied to the maximum state share. 2. The “proration ratio” for eligible pensioners is based on when the eligible pensioner was first employed and the number of years the eligible pensioner had been employed as a regular officer or employee at the time of retirement. (2) The proration ratio is 100% for all of the following: a. A regular officer or employee and for an eligible spouse and child dependents. b. An eligible pensioner receiving a disability pension. c. An eligible pensioner who is a primary survivor receiving a survivor’s pension under § 8372(b) of Title 11 due to the death in the line of duty of the employee. d. An eligible pensioner who was first employed before July 1, 1991. (3) For eligible pensioners not included under paragraph (b)(2) of this section: a. For eligible pensioners who were first employed by the State on or after July 1, 1991, and before January 1, 2007, the proration ratio is as follows: 1. Less than 10 years, 0%. 2. At least 10 but less than 15 years, 50%. 3. At least 15 but less than 20 years, 75%. 4. Twenty or more years, 100%. b. For eligible pensioners who were first employed by the State on or after January 1, 2007, and before January 1, 2025, the proration ratio is as follows: 1. Less than 15 years, 0%. 2. At least 15 but less than 17.5 years, 50%. 3. At least 17.5 but less than 20 years, 75%. 4. Twenty or more years, 100%. c. For eligible pensioners who were first employed on or after January 1, 2025, and who are subject to mandatory retirement, the proration ratio is as follows: 1. Less than 15 years, 0%. 2. At least 15 but less than 17.5 years, 50%. 3. At least 17.5 but less than 20 years, 75%. 4. Twenty or more years, 100%. d. For eligible pensioners who were first employed on or after January 1, 2025, and who are not subject to mandatory retirement, the proration ratio is as follows: 1. Less than 15 years, 0%. 2. At least 15 but less than 20 years, 50%. 3. At least 20 but less than 25 years, 75%. 4. Twenty-five or more years, 100%. (c) If the employee or pensioner is covered in any way by a group insurance program issued by the same insurer, duplicate coverage shall not be procured by the State; however, it shall be at the employee’s or pensioner’s option as to whether to be covered by the state group insurance plan or by a program of the spouse. If covered by a program of the spouse, the employee or pensioner shall obtain no monetary credit or rebate from the State. (d) For the purposes of this chapter, eligible employees who were each first employed as a regular officer or employee by the State on or before December 31, 2011, and legally married on or before December 31, 2011, may each qualify as a regular officer, employee, or eligible pensioner of the State. In the case where 2 members of a family qualify, the options are as follows: (1) The 2 employees, or each eligible pensioner, and all eligible dependents may elect to enroll under 1 family contract. (2) Each employee, or each eligible pensioner, may elect to enroll under a separate contract. Eligible dependents may be enrolled under either contract, but no dependent shall be enrolled more than once under the state health insurance program. (3) The provisions of this paragraph shall continue to apply to a surviving spouse for employee only or employee and children contracts after the death of 1 of the spouses covered pursuant to this paragraph has occurred, as long as the surviving spouse is entitled to a survivor’s pension pursuant to § 5528 of this title. (4) Effective July 1, 2012, to December 31, 2017, if the 2 employees enroll under an employee and spouse or family contract, there shall be a $25 per month charge to the employee who enrolls for the coverage. If the employees choose to enroll in separate plans, employee only and employee and children contracts, either the employee cost share premium or a $25 per month charge shall apply to both contracts, whichever is less. If employee and spouse are eligible pensioners where 1 or both retire on or after July 1, 2012, and before July 1, 2017, only 1 $25 per month charge shall apply when separate contracts are required for a Medicare Supplement Plan. (5) Effective January 1, 2018, if the 2 employees or non-Medicare pensioners enroll under an employee and spouse or family contract, the employee or non-Medicare pensioner who enrolls for the coverage shall be charged 50% of the employee or non-Medicare pensioner cost share premium per month, or $25 per month, whichever is greater. If the employees or non-Medicare pensioners choose to enroll in separate plans, employee only and employee and children contracts, each employee or non-Medicare pensioner shall be charged 50% of the employee or non-Medicare cost share premium per month, or $25 per month, whichever is greater for the plans chosen. a. If both spouses are eligible pensioners and 1 is not yet Medicare eligible, the non-Medicare pensioner will enroll under a pensioner only or pensioner and children contract and the Medicare pensioner will enroll in the Medicare Supplement Plan. The non-Medicare pensioner shall be charged 50% of the cost share premium, or $25 per month, whichever is greater. b. If 1 spouse is a regular officer or employee and 1 spouse is a Medicare eligible pensioner, the regular officer or employee who enrolls for employee and spouse or family coverage shall be charged 50% of the employee cost share premium. If the employee and Medicare eligible spouse choose to enroll in separate plans, each employee and Medicare eligible pensioner shall be charged 50% of the employee and Medicare Supplement Plan cost share premium per month, or $25 per month, whichever is greater for the plans chosen. c. If both spouses are Medicare eligible and 1 or both retired on or after July 1, 2017, only one 50% cost share premium or $25 per month, whichever is greater, shall apply when separate contracts are required for a Medicare Supplement Plan. d. If both spouses are Medicare eligible and both retired after July 1, 2012, and before July 1, 2017, each Medicare eligible pensioner shall be charged $25 per month premium when separate contracts are required for a Medicare Supplement Plan. (6) In no case shall there be a monetary credit or return to the spouse for that spouse's basic credits. (e) If a regular officer or employee is required to pay any portion of the cost of the health-care insurance for regular officer's or employee’s own self, spouse or dependents, the regular officer or employee may enter into a written agreement with the State whereby that regular officer or employee agrees to reduce the regular officer's or employee's own salary in an amount equal to the portion of the health-care insurance that the regular officer or employee is required to pay. (f) Subsection (e) of this section shall not be effective until implementation has been approved by the State Treasurer, Secretary of Finance, Director of the Office of Management and Budget and Controller General. (g) Salary reductions voluntarily taken pursuant to subsection (e) of this section shall not affect the compensation used in the calculation of pension benefits under any state pension plan and shall be made on a pretax basis, provided that employees who had designated employee deductions on a posttax basis as of July 1, 2000, shall continue to have the right to make those deductions on a posttax basis as long as the employee remains in a benefit program or the employee makes a change to pretax employee benefit deductions. (h) A survivor who is receiving a deceased pensioner's retirement benefits in accordance with the State Employees’ Pension Plan under Chapters 53 and 55 of this title, the State Police Pension Plan under subchapter II and subchapter III of Chapter 83 of Title 11, the Pension Plan for State Judiciary under Chapter 56 of this title shall only be entitled to coverage for the survivor and any “eligible child dependent” as defined in § 5201 of this title.

Del. Code tit. 29, § 5203 Specifications of the coverage.

(a) The basic health care insurance plan for state employees shall be equivalent to the “minimum creditable coverage” as defined by applicable federal law and include coverage for contraceptive methods under § 5203A of this title. (b) (1) The plan shall be for all of the following: a. Regular employees and eligible pensioners under 65 years of age. b. Employees and eligible pensioners 65 years of age or over who are not entitled to services, rights, or benefits under the federal Medicare Program, 42 U.S.C. § 1395 et seq. c. For eligible pensioners entitled to services, rights, or benefits under the federal Medicare Program, a plan that is supplemental to Medicare parts A and B as follows: 1. For eligible pensioners first employed before January 1, 2025, a plan that is comparable to the Special Medicfill Medicare Supplement plan offered under this section on October 1, 2024. 2. For eligible pensioners first employed on or after January 1, 2025, 1 or more Medicare supplement plans that are not high deductible plans. (2) In addition to a plan under paragraph (b)(1)c. of this section, the coverage may include a plan under Medicare part C for eligible pensioners entitled to services, rights, or benefits under the federal Medicare Program if all of the following apply to the plan: a. The plan is only for eligible pensioners first employed on or after January 1, 2025. b. Each eligible pensioner can choose whether to enroll in a plan under paragraph (b)(1)c. of this section or the plan under this paragraph (b)(2). (c) (1) The basic plan must provide coverage for chronic care management and primary care and coverage at a reimbursement rate that is not less than the Medicare reimbursement for comparable physician services. (2) Coverage for chronic care management must not be subject to patient deductibles, copayments, or fees. (3) If a comparable Medicare reimbursement rate is not available, a plan shall reimburse for services at the rates generally available under Medicare for services such as office visits and prolonged preventive services, which may be further delineated by regulation. (d) The plan may not place any annual or lifetime numerical limitations on physical therapy or chiropractic care visits for the purpose of treating back pain.

Del. Code tit. 29, § 5203A Insurance coverage for contraceptive methods.

(a) The plan shall provide coverage for contraceptive methods that includes all of the following: (1) All FDA-approved contraceptive drugs, devices, and other products as follows: a. If the FDA has approved 1 or more therapeutic equivalents of a contraceptive drug, device, or product, the plan is not required to include all such therapeutically equivalent versions in its formulary as long as at least 1 is included and covered without cost-sharing and in accordance with this section. b. If there is a therapeutic equivalent of a drug, device, or other product for an FDA-approved contraceptive method, the plan may provide coverage for more than 1 drug, device, or other product and may impose cost-sharing requirements as long as at least 1 drug, device, or other product for that method is available without cost-sharing. If, however, an individual’s attending provider recommends a particular FDA-approved contraceptive based on a medical determination with respect to that individual, regardless of whether the contraceptive has a therapeutic equivalent, the plan shall provide coverage for the prescribed contraceptive drug, device, or product without cost-sharing. c. The plan is not required to provide coverage for male condoms. (2) FDA-approved emergency contraception available over-the-counter, whether with a prescription or dispensed consistent with the requirements of Chapter 25 of Title 24. (3) A prescription for contraceptives intended to last for no more than a 12-month period which may be dispensed all at once or over the course of the 12-month period, regardless of whether the covered individual was enrolled in the plan or policy under this chapter at the time the prescription contraceptive was first dispensed. (4) Voluntary female sterilization procedures. (5) Patient education and counseling on contraception. (6) Follow-up services related to the drugs, devices, products, and procedures covered under this subsection, including management of side effects, counseling for continued adherence, and device insertion and removal. (7) Immediate postpartum insertion of long-acting reversible contraception. (b) (1) Coverage provided under this section is not subject to any deductible, coinsurance, copayment, or any other cost-sharing requirement, except under paragraph (a)(1) of this section or as otherwise required under federal law. Coverage offered under this section may not impose unreasonable restrictions or delays in the coverage, except that reasonable medical management techniques may be applied to coverage within a method category, as defined by the FDA, but not across types of methods. (2) Coverage provided to a regular officer or employee or eligible pensioner under this section shall be the same for the covered individual’s covered spouse and covered dependents. (c) This section does not preclude coverage for contraceptive drugs, devices, products, and procedures as prescribed by a provider for reasons other than contraceptive purposes, including decreasing the risk of ovarian cancer, eliminating symptoms of menopause, or providing contraception that is necessary to preserve the life or health of the covered individual. (d) The plan is not required under this section to cover experimental or investigational treatments.

Del. Code tit. 29, § 5204 Selection of the group insurance carrier [Effective until Jan. 1, 2028].

(a) The health-care insurance coverage shall be provided through a carrier incorporated under the laws of this State or legally authorized to transact business within this State, having adequate servicing facilities to carry out the terms of the contract. (b) The health-care insurance coverage shall be provided by a carrier offering, at the employee’s or pensioner’s own expense, optional supplemental or extended benefits coverage to each regular employee or eligible pensioner and similar hospital, surgical/medical and supplemental or extended coverage for such employee’s or pensioner’s spouse and dependents. (c) (1) For plan year 2030 and thereafter, as set forth in paragraphs (c)(16) and (c)(17) of this section, health-care insurance shall be provided by a carrier whose cost per inpatient hospital service, outpatient service, and emergency department service may not exceed the applicable Medicare reference-based pricing target set forth in paragraph (c)(16) of this section, as of the date of service, for comparable services for the applicable plan year, and free-standing children's hospital outpatient Medicare rates may not exceed the applicable Medicare reference-based pricing target set forth in paragraph (c)(17) of this section, as of the date of service. For such services under the Group Health Insurance Plan, a covered individual is not liable for payment of any amount other than the copayments, coinsurance, and deductibles applicable under the terms of the covered individual’s health benefit plan, as determined by the network status of the provider. Any such cost sharing shall be calculated based on the carrier’s allowed payment amount. A covered individual shall not be billed or charged any amount in excess of the carrier’s allowed payment for such services. (2) “Emergency department service” means services generally performed in an emergency department, including trauma services, triage, and observation. (3) “Free-standing children's hospital” means a dedicated, independent pediatric facility, not integrated within a general adult hospital, identified by the Center for Medicaid and CHIP Services (CMCS) as a hospital that provides specialized care for infants, children, teens, and individuals predominately under 18 years of age. (4) “Free-standing children's hospital Medicare outpatient payment rate” means, for purposes of free-standing children's hospitals, payments for free-standing children's hospitals that include all payments made under the Medicare Outpatient Prospective Payment System (OPPS), as established August 1, 2000, and codified at 42 C.F.R. Part 419. (5) “Full Medicare rate” means the applicable wage-adjusted Medicare rate, inclusive of any applicable adjustments, as updated by the Centers for Medicare and Medicaid Services (CMS) on an annual basis. (6) “Inpatient hospital service” means services generally performed in an inpatient acute hospital care setting, including general inpatient hospital services covered under Medicare Part A, labor and delivery, and intensive care. (7) “Medicare” means the federal Medicare Program (U.S. Public Law 89-87, as amended; 42 U.S.C. § 1395 et seq.). (8) “Medicare-dependent rural hospital” means a hospital that meets at least 1 of the following requirements for the applicable plan year: a. The hospital meets the definition of a Medicare-dependent hospital as defined under 42 C.F.R. § 412.108 for at least 3 of the 5 years immediately preceding the applicable plan year. b. The hospital operates solely within a county that is classified by the federal Health Resources and Services Administration (HRSA) as a rural health area, a medically underserved area, and a health professional shortage area for primary care, and the hospital’s gross patient revenue attributed to Medicare patients accounts for more than 60% of its total gross patient revenue. (9) “Medicare reference-based (RBP) target” means a percentage of the full Medicare rate as set forth in paragraph (c)(5) of this section. With respect to free-standing children's hospitals, “Medicare reference-based (RBP) targets” has the meaning as defined in paragraph (c)(17) of this section. (10) “Nonprofessional services” means services categorized as inpatient hospital, outpatient hospital, and other medical services. “Nonprofessional services” does not include professional services. (11) “Outpatient service” means nonprofessional services not otherwise captured in the definition of Inpatient Hospital Service or emergency department service. (12) “Professional services” includes primary care, dental, specialist, therapy, the professional component of laboratory and radiology, and similar services, other than the facility fee component of hospital-based services. (13) “TEFRA rate” means the target amount under the federal Tax Equity and Fiscal Responsibility Act (TEFRA) Waiver Program applicable to free-standing children's hospitals set forth in 42 U.S.C. § 1395ww(b), including any updates and adjustments thereto. (14) “Urban Medicaid DSH hospital” means a hospital that met the criteria described in § 1923(b) of the federal Social Security Act (42 U.S.C. § 1369r-4(b)) and received Medicaid Disproportionate Share Hospital Program (DSH) payments from this State between July 1, 2021, and July 1, 2026. (15) If a comparable Medicare reimbursement rate is not available, reimbursement for services under the State Group Health Insurance Plan shall be determined using the Medicare rates generally applicable to similar services, as reasonably determined by the Statewide Benefits Office. (16) Applicable Medicare reference-based pricing targets for inpatient hospital services, outpatient services, and emergency department services. Unless otherwise specified in this section, services provided by non-free-standing children’s hospitals shall reflect Medicare reference-based pricing targets as follows: a. For plan years 2030 and 2031, all of the following apply: 1. 275% of the full Medicare rate for outpatient services. 2. 310% of the full Medicare rate for inpatient hospital services and emergency department services. b. For plan years 2032 and 2033, all of the following apply: 1. 250% of the full Medicare rate for outpatient services. 2. 275% of the full Medicare rate for inpatient hospital services and emergency department services. c. Beginning with plan year 2034, 250% of the full Medicare rate for inpatient hospital services, outpatient services, and emergency department services. (17) Applicable Medicare reference-based pricing targets for free-standing children’s hospitals. Unless otherwise specified in this section, services provided by free-standing children’s hospitals shall reflect Medicare reference-based pricing targets as follows: a. For plan years 2030 and 2031, all of the following apply: 1. 275% of the free-standing children’s hospital Medicare outpatient payment rate for outpatient services. 2. 310% of the TEFRA rate for inpatient hospital services. 3. 310% of the free-standing children’s hospital Medicare outpatient payment rate for emergency department services. b. For plan years 2032 and 2033, all of the following apply: 1. 250% of the free-standing children’s hospital Medicare outpatient payment rate for outpatient services. 2. 275% of the TEFRA rate for inpatient hospital services. 3. 275% of the free-standing children’s hospital Medicare outpatient payment rate for emergency department services. c. Beginning with plan year 2034, all of the following apply: 1. 250% of the free-standing children’s hospital Medicare outpatient payment rate for outpatient services. 2. 250% of the TEFRA rate for inpatient hospital services. 3. 250% of the free-standing children’s hospital Medicare outpatient payment rate for emergency department services. (18) Reference-based pricing target exemptions and modifications. — Paragraphs (c)(1) through (c)(17) of this section do not apply in any of the following circumstances: a. When a hospital meets the definition of a Medicare-dependent rural hospital pursuant to paragraph (c)(8)a. of this section. b. When a hospital meets the definition of a Medicare-dependent rural hospital pursuant to paragraph (c)(8)b. of this section and the Office of Value-Based Health Care Delivery has determined that the hospital has made demonstrative progress in adopting and implementing value-based payment models. c. When a hospital meets the definition of an urban Medicaid DSH hospital under this section. d. When the carrier and the hospital or applicable contracting provider entity are participants in a federal or state multi-payer global budget model approved by the Department under § 2503(a)(15)o.3. and (a)(15)p. of Title 18. The Department shall provide notice annually of global budget models that are approved pursuant to this paragraph (c)(18)d. (d) The health-care insurance coverage shall be provided by a carrier offering value-based care programs equivalent to those required by §§ 3342B and 3556A of Title 18.

Del. Code tit. 29, § 5205 Duties of State Insurance Commissioner [Repealed].

Repealed by 69 Del. Laws, c. 64, § 68, effective July 1, 1993.

Del. Code tit. 29, § 5206 Duties of State Treasurer.

Upon written authorization the State Treasurer shall withhold from the employee’s salary or eligible pensioner’s benefits such sums as are necessary for the payment of premium or subscription charges for the optional supplemental or extended benefits coverage and for spouse or dependent coverage.

Del. Code tit. 29, § 5207 Temporary employees.

Any person not a “regular officer or employee” but employed by a state agency and who works the regularly scheduled full-time hours of the employing agency or at least 30 or more hours per week or 130 hours per month (with allowable interruptions) shall be eligible for the health care insurance established under this chapter provided such person authorize in writing a payroll deduction from such person’s salary of the amount of the premium for said insurance.

Del. Code tit. 29, § 5208 Employees of labor organizations.

Any labor organization representing the state employees may elect to participate in the health-care insurance plans provided by the provisions of this chapter for their regularly scheduled full-time regular employees who work in the State. The full cost of such coverages shall be remitted to the State by the labor organization no later than the first day of each calendar month for which coverage is being provided. The benefits provided to such employees and the cost of coverage shall be the same as provided to state employees covered by this chapter. Any labor organization wanting to participate in the state Group Health Insurance Program shall be governed by all provisions, rules and regulations of this chapter.

Del. Code tit. 29, § 5209 Employees of Delaware authorities or commissions.

(a) Any Delaware authority or commission may elect to participate in the health-care insurance plans provided by the provisions of this chapter for regularly scheduled full-time employees. The full cost of such coverage shall be remitted to the State by the authority or commission no later than the first day of each calendar month for which coverage is being provided. the benefits provided to such employees and the cost of coverage shall be the same as provided to state employees covered by this chapter. Any Delaware authority or commission participating in the State Group Health Insurance program shall be governed by all provisions, rules and regulations of this chapter and the State Employee Benefits Committee. (b) Any regularly scheduled full-time employee of the Delaware Stadium Corporation, the Delaware Riverfront Corporation, a Public/Private Partnership as defined in § 8702A of this title, or the Fort DuPont Redevelopment and Preservation Corporation may elect to participate in the health insurance plans provided by the State Group Health Insurance Program. The full cost of such coverage shall be remitted to the State no later than the first day of each calendar month for which coverage is being provided. The benefits provided to such employees and the cost of coverage shall be the same as provided to state employees covered by this chapter. Any Delaware Stadium Corporation, Public/Private Partnership as defined in § 8702A of this title, or Fort DuPont Redevelopment and Preservation Corporation employee participating in the State Group Health Insurance Program shall be governed by all provisions, rules and regulations of this chapter and the State Employee Benefits Committee. (c) All per diem and contractual employees of the Delaware General Assembly who have been continuously employed for 5 or more years may elect to participate in the health-insurance plans provided by the State Group Health Insurance Program. The full cost of such coverage shall be remitted to the State by such employees no later than the first of each calendar month for which coverage is being provided. The benefits provided to such employees and the cost of coverage shall be the same as provided to state employees covered by this chapter. Any such employees participating in the State Group Health Insurance Program shall be governed by all provisions, rules and regulations of this chapter and the State Employee Benefits Committee. (d) Any volunteer fire or volunteer ambulance company in Delaware may elect to participate in the health-care insurance plans provided by the provisions of this chapter for paid employees. The full cost of such coverage shall be remitted to the State by the volunteer fire or volunteer ambulance company participating no later than the first day of each calendar month for which coverage is being provided. The benefits provided to such paid employees and the cost of coverage shall be the same as provided to state employees covered by this chapter. Any volunteer fire or volunteer ambulance company in Delaware participating in the State Group Health Insurance Program shall be governed by all provisions, rules and regulations of this chapter and the State Employee Benefits Committee. (e) Any county, soil and water conservation districts or municipality and the Municipal Services Commission for the City of New Castle may elect to participate in the health-care insurance plans provided by this chapter for any of the following: (1) Regularly scheduled full-time employees; (2) Anyone receiving or who is eligible to receive retirement benefits in accordance with the Delaware County and Municipal Police/Firefighter Pension Plan with Chapter 88 of Title 11 or the county and municipal pension plan under Chapter 55A of this title. The full cost of such coverage shall be remitted to the State by the county, soil and water conservation districts or municipality and the Municipal Services Commission for the City of New Castle no later than the first day of each calendar month for which coverage is being provided. The benefits provided to such employees and the cost of coverage shall be the same as provided to the state employees covered by this chapter. Any employee participating in the State Group Health Insurance Program through this subsection shall be governed by all provisions, rules and regulations of this chapter and the State Employee Benefits Committee. For the purposes of this subsection, a “full-time employee” is an employee who works at least 30 hours or more per week or 130 hours per month (with allowable interruptions). Retirees receiving benefits may authorize the State Pension Office to deduct their share of cost from their monthly pension. Participation by any county, soil and water conservation districts or municipality and the Municipal Services Commission for the City of New Castle shall be subject to approval of the State Employee Benefits Committee. (f) Anyone receiving retirement benefits in accordance with the Delaware and Municipal Police/Firefighter Pension Plan under Chapter 88 of Title 11 or the county and municipal pension plan under Chapter 55A of this title, may elect to participate in the health insurance plans provided by the State Group Health Insurance Program. The retiree shall authorize the State Pension Office to deduct the full cost of coverage from the retiree’s monthly pension. (g) The State Employee Benefits Committee shall be authorized to recover costs from any Delaware authority or commission, the Delaware Stadium Corporation, the Delaware Riverfront Corporation, the Fort DuPont Redevelopment and Preservation Corporation, any volunteer fire company, any county soil and water conservation district, and any municipality which elects for its employees to participate in the health-care insurance plans provided by this chapter, based on the number of participating employees. Further, the State Employee Benefits Committee shall be authorized to recover costs from any nonstate organization which is permitted to and elects to participate in the health-care insurance plans provided by this chapter, based on the number of participating employees. The revenue derived from such cost recovery shall be used exclusively to support the administration of the State Group Health Insurance Program.

Del. Code tit. 29, § 5210 Authority and duties of the State Employee Benefits Committee [For application of this section, see 85 Del. Laws, c. 176, § 4].

The State Employee Benefits Committee established by § 9602 of this title shall have the following powers, duties and functions under this chapter: (1) Control and management of the State employees group health insurance program provided for in this chapter. (2) Authority to establish the State employees group health insurance program on an insured or self-insured basis. (3) Selection of the carriers or third-party administrators deemed to offer the best plan to satisfy the interests of the State and its employees and pensioners in carrying out the intent of this chapter. (4) Authority to adopt rules and regulations for the general administration of the Delaware state employees group health insurance program (program), which must include all of the following for program participants: a. Beginning January 1, 1993, a spousal coordination of benefits policy that applies to the spouse of a program participant when the spouse is eligible for health-care coverage through the spouse’s own employer. b. Beginning July 1, 2011, the spousal coordination of benefits policy under paragraph (4)a. of this section also applies to a retired spouse of a program participant when the spouse is collecting a retirement benefit through the spouse’s own employment and is eligible for retiree health-care coverage through that retirement benefit. c. Beginning July 1, 2027, a pensioner coordination of benefits policy for eligible pensioners who were first employed on or after January 1, 2015, that applies to an eligible pensioner if the eligible pensioner is eligible for health-care coverage through their employer and that health-care coverage is not through a plan under this chapter. The policy under this paragraph (4)c. must be comparable to the spousal coordination of benefits policy under paragraph (4)a. of this section. (5) Authority to make and enter into any and all contracts with any agency of the State, or any outside agency, for the purpose of assisting in the general administration of this chapter. (6) Whenever the balance of the fund equity of the Employees’ Health Insurance Fund exceeds the amount determined by the State Employee Benefits Committee to be sufficient to meet anticipated claims plus a reasonable reserve, the State Employee Benefits Committee, in its sole discretion, may transfer the excess balance or any part of it to the OPEB Fund, established pursuant to Chapter 52B of this title, to provide a source for the future payment of retiree health benefits or the Disability Insurance Program, pursuant to Chapter 52A of this title. (7) Ensure that carriers administering plans for group health insurance under this chapter comply with all requirements and provisions concerning pre-authorization set forth in Chapter 33, subchapter II, and Chapter 35, subchapter V of Title 18.

Del. Code tit. 29, § 5211 Coverage for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome.

The plan shall provide coverage for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome, including the use of intravenous immunoglobulin therapy.

Del. Code tit. 29, § 5212 Cost sharing in prescription insulin drugs.

(a) For purposes of this section, “prescription insulin drug” means a drug containing insulin that is dispensed under Chapter 47 of Title 16 for the treatment of diabetes. (b) The plan must provide coverage for prescription insulin drugs that does all of the following: (1) Caps the total amount that a covered individual is required to pay for covered prescription insulin drugs at no more than $100 per month for each enrolled individual, regardless of the amount or types of insulin needed to fill the covered individual’s prescriptions. The $100 per month cap includes deductible payments and cost-sharing amounts charged once a deductible is met. (2) Includes at least 1 formulation of each of the following types of prescription insulin drugs on the lowest tier of the drug formulary developed and maintained by the carrier: a. Rapid-acting. b. Short-acting. c. Intermediate-acting. d. Long-acting. (3) For purposes of paragraph (b)(2) of this section, the “lowest tier of the drug formulary” means either of the following: a. If the prescription insulin drug is a generic drug, the lowest tier for generic drugs. b. If the prescription insulin drug is a brand-name drug, the lowest tier for brand-name drugs. (c) The cap on the amount a covered individual is required to pay under paragraph (b)(1) of this section applies to an enrolled individual who is in compliance with all coordination of benefits policies of the plan, including spousal coordination of benefits.

Del. Code tit. 29, § 5213 Coverage for epinephrine autoinjectors.

(a) For purposes of this section, “epinephrine autoinjector” means a single-use device used for the automatic injection of a premeasured dose of epinephrine into the human body. (b) The plan shall provide coverage for medically-necessary epinephrine autoinjectors by including at least 1 formulation of epinephrine autoinjectors on the lowest tier of the drug formulary developed and maintained by the carrier.

Del. Code tit. 29, § 5214 Coverage for insulin pumps.

(a) For purposes of this section, “insulin pump” means a small, portable medical device that is approved by the U.S. Food and Drug Administration to provide continuous subcutaneous insulin infusion. (b) The plan shall provide coverage for a medically-necessary insulin pump at no cost to a covered individual, including deductible payments and cost-sharing amounts charged once a deductible is met.

Del. Code tit. 29, § 5215 Annual behavioral health well check.

(a) As used in this section “Behavioral health well check” means a predeductible annual visit with a licensed mental health clinician with at minimum a masters level degree. The well check must include but is not limited to a review of medical history, evaluation of adverse childhood experiences, use of a group of developmentally-appropriate mental health screening tools, and may include anticipatory behavioral health guidance congruent with stage of life using the diagnosis of “annual behavioral health well check.” (b) The plan shall provide coverage of an annual behavioral health well check, which, except as provided in subsection (d) of this section, shall be reimbursed through the following common procedural terminology (CPT) codes at the same rate that such CPT codes are reimbursed for the provision of other medical care, provided that reimbursement may be adjusted for payment of claims that are billed by a nonphysician clinician so long as the methodology to determine such adjustments is comparable to and applied no more stringently than the methodology for adjustments made for reimbursement of claims billed by nonphysician clinicians for other medical care, in accordance with 45 CFR § 146.136(c)(4): (1) 99381. (2) 99382. (3) 99383. (4) 99384. (5) 99385. (6) 99386. (7) 99387. (8) 99391. (9) 99392. (10) 99393. (11) 99394. (12) 99395. (13) 99396. (14) 99397. (c) (1) The State Employee Benefits Committee shall administratively update this list of codes if the CPT codes listed in subsection (b) of this section are altered, amended, changed, deleted, or supplemented. (2) Reimbursement of any of the CPT codes listed in subsection (b) of this section or updated under paragraph (c)(1) of this section for the purpose of covering an annual behavioral health well check may not be denied because such CPT code was already reimbursed for the purpose of covering a service other than an annual behavioral health well check. (3) Reimbursement of any of the CPT codes listed in subsection (b) of this section or updated under paragraph (c)(1) of this section for the purpose of covering a service other than an annual behavioral health well check may not be denied because such CPT code was already reimbursed for the purpose of covering an annual behavioral health well check. (d) An annual behavioral health well check may be reimbursed through a value-based arrangement, a capitated arrangement, a bundled payment arrangement, or any other alternative payment arrangement that is not a traditional fee-for-service arrangement, provided that a carrier must have documentation demonstrating that within such payment arrangement the annual behavioral health well check is valued commensurate to the value established under subsection (b) of this section. (e) An annual behavioral health well check may be incorporated into and reimbursed within any type of integrated primary care service delivery method including, but not limited to, the psychiatric collaborative care model, the primary care behavioral health model or behavioral health consultant model, any model that involves co-location of mental health professionals within general medical settings, or any other integrated care model that focuses on the delivery of primary care. (f) Nothing in this section prevents the operation of policy provisions such as copayments, coinsurance, allowable charge limitations, coordination of benefits, or provisions restricting coverage to services rendered by licensed, certified, or carrier-approved providers or facilities.

Del. Code tit. 29, § 5216 Cost sharing in diabetes equipment and supplies.

(a) For purposes of this section, “diabetes equipment and supplies” means blood glucose meters and strips, urine testing strips, syringes, continuous glucose monitors and supplies, and insulin pump supplies. (b) The plan for regular employees and eligible pensioners who are not entitled to services, rights, or benefits under the federal Medicare program shall provide coverage for diabetes equipment or supplies as follows: (1) A covered individual shall pay under the health plan no more than $35 per month for each enrolled individual, regardless of the amount or types of diabetes equipment or supplies needed. The $35 per month cap includes deductible payments and cost-sharing amounts charged once a deductible is met. (2) Cost-sharing shall not be imposed under the covered individual’s drug coverage. (c) The cap on the amount a covered individual is required to pay under subsection (b) of this section applies to an enrolled individual who is in compliance with all coordination of benefits policies of the plan, including spousal coordination of benefits.

Del. Code tit. 29, § 5217 Supplemental and diagnostic breast examinations [For application of this section, see 84 Del. Laws, c. 121, § 5].

(a) As used in this section: (1) “Breast magnetic resonance imaging” or “breast MRI” means a diagnostic tool, including standard and abbreviated breast MRI, that uses radio waves and magnets to produce detailed images of structures within the breast. A breast MRI may be used as a screening tool when clinically indicated, including after indeterminant results from a mammogram that requires additional evaluation and for those at high risk for breast cancer. (2) “Breast ultrasound” means a noninvasive diagnostic tool that uses high-frequency sound waves and their echoes to produce detailed images of structures within the breast. A breast ultrasound may be used as a screening tool when clinically indicated, including after indeterminant results from a mammogram that requires additional evaluation and for those at high risk for breast cancer. (3) “Cost-sharing requirement” means a deductible, coinsurance, or copayment and any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense. (4) “Diagnostic breast examination” means a medically-necessary and clinically-appropriate examination of the breast, including such examination using breast MRI, breast ultrasound, or mammogram, that is used for either of the following: a. To evaluate an abnormality seen or suspected from a screening examination for breast cancer. b. To evaluate an abnormality detected by another means of examination. (5) “Mammogram” means a diagnostic or screening mammography exam using a low-dose X-ray to produce an image of the breast. (6) “Supplemental breast screening examination” means a medically-necessary and clinically-appropriate examination of the breast, including such examination using breast MRI, breast ultrasound, or mammogram, that is used for either of the following: a. To screen for breast cancer when there is no abnormality seen or suspected in the breast. b. Based on personal or family medical history or additional factors that may increase the individual’s risk of breast cancer. (b) The plan shall provide coverage for diagnostic breast examinations and supplemental breast screening examinations. The terms of such coverage, including cost-sharing requirements, shall be no less favorable than the cost-sharing requirements applicable to screening mammography for breast cancer.

Del. Code tit. 29, § 5218 Coverage for allergenic protein dietary supplements [For application of this section, see 84 Del. Laws, c. 376, § 5].

(a) For purposes of this section: (1) “Dietary supplement” means as defined in the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. § 321. (2) “Early egg allergen introduction dietary supplement” means a dietary supplement that is prescribed to an infant by a health-care practitioner and contains sufficient infant-safe, well-cooked egg protein to reduce the risk of food allergies. (3) “Early peanut allergen introduction dietary supplement” means a dietary supplement that is prescribed to an infant by a health-care practitioner and contains sufficient infant-safe peanut protein to reduce the risk of food allergies. (4) “Health-care practitioner” means an individual licensed and authorized to write medical orders for an individual under Title 24. (5) “Infant” means a child who has not attained the age of 1 year. (b) (1) The plan shall provide coverage for at least 1 of each of the following: a. An early egg allergen introduction dietary supplement. b. An early peanut allergen introduction dietary supplement. (2) The coverage required under paragraph (b)(1) of this section shall be provided at no cost to a covered individual, including deductible payments and cost-sharing amounts charged once a deductible is met.

Del. Code tit. 29, § 5219 Services related to the termination of pregnancy.

The plan shall provide coverage for services related to the termination of pregnancy. Such coverage may not be subject to any deductible, coinsurance, copayment, or any other cost-sharing requirement and must cover the full scope of services permissible under the law.

Del. Code tit. 29, § 5220 Pharmacist services reimbursement [For application of this section, see 85 Del. Laws, c. 253, § 23].

(a) The plan must provide reimbursement to a pharmacist for a service or procedure at a rate not less than that provided to other nonphysician practitioners if the service or procedure is all of the following: (1) Within the scope of practice of a pharmacist. (2) Would otherwise be covered under the policy, plan, or contract if the service or procedure is provided by any health-care service provider or practitioner, including a physician, advance practice registered nurse, or physician associate. (b) Whenever a service is performed by a licensed pharmacist and reimbursed by the plan, the licensed pharmacist must be granted such rights of participation, plan admission, and registration as may be granted by the plan to any health-care service provider or practitioner, including a physician, advance practice registered nurse, or physician associate performing such a service.

Del. Code tit. 29, § 5221 Mammogram coverage.

The plan shall provide coverage for annual mammograms for the purpose of early detection for a woman 40 years of age or older, with or without referral from the woman’s health-care provider.

Del. Code tit. 29, § 5222 Ovarian cancer screening and monitoring tests [For application of this section, see 84 Del. Laws, c. 488, § 3].

(a) For purposes of this section: (1) “At risk for ovarian cancer” means any of the following: a. Having a family history of any of the following: 1. One or more first- or second-degree relatives with ovarian cancer. 2. Clusters of women relatives with breast cancer. 3. Nonpolyposis colorectal cancer. 4. Breast cancer in a male relative. b. Testing positive for any of the following genetic mutations: 1. Brca1 or brca2. 2. Lynch Syndrome. c. Having a personal history of any of the following: 1. Ovarian cancer. 2. Endometriosis. 3. Unexplained infertility. 4. Uterine fibroids. 5. Polycystic ovarian syndrome. (2) “Monitoring tests” and “screening tests” mean tests and examinations for ovarian cancer using any of the following methods that are recommended by a patient’s physician: a. Tumor marker tests supported by national clinical guidelines, national standards of care, or peer reviewed medical literature. b. Transvaginal ultrasound. c. Pelvic examination. d. Other screening tests supported by national clinical guidelines, national standards of care, or peer reviewed medical literature. (b) The plan shall provide coverage for all of the following: (1) Monitoring tests for ovarian cancer after a woman is treated for ovarian cancer. (2) Annual screening tests for women at risk for ovarian cancer. (c) Coverage required by subsection (b) of this section must be at no cost to a covered individual, including deductible payments and cost-sharing amounts charged once a deductible is met.

Del. Code tit. 29, § 5223 Coverage for removal of excess skin and subcutaneous tissue [For application of this section, see 85 Del. Laws, c. 88, § 5].

(a) For purposes of this section: (1) “Medically necessary” means as defined in § 3581 of Title 18. (2) “Panniculectomy” means an operative procedure used to contour the abdominal wall by removing significant excess skin and subcutaneous adipose tissue. (b) The plan must provide coverage for medically necessary removal of excess skin and subcutaneous tissue, including a panniculectomy.

Del. Code tit. 29, § 5224 Primary care coverage.

The plan shall do all of the following: (1) Provide coverage in compliance with § 5204(c) of this title. (2) Exclude certain high-cost claims in calculating the total cost of medical care for purposes of this section, as authorized by the State Employee Benefits Committee. (3) Report data to the Office of Value-Based Health Care Delivery on high-cost claims and on the percentage of primary care spending as a percentage of total medical costs for plan year 2027 by July 1, 2029, and for plan year 2028 by July 1, 2030. (4) In plan year 2029, increase primary care spending by 1% from the higher of the 2 prior plan years. (5) In plan years 2030, 2031, and additional plan years as necessary, increase primary care spending by 1% until primary care spending reaches 11.5% of total medical costs. (6) Spend at least 11.5% of total cost of medical care on primary care each plan year thereafter.

Del. Code tit. 29, § 5225 Coverage for pre-exposure prophylaxis treatment and post-exposure prophylaxis treatment [For application of this section, see 85 Del. Laws, c. 452, § 5].

(a) As used in this section: (1) “Cost-sharing requirement” includes a deductible, coinsurance, copayment, and out-of-pocket expense. (2) “Essential support services” include all of the following: a. HIV testing. b. Hepatitis B and C testing. c. Kidney function assessment through creatinine testing and calculated estimated creatinine clearance or glomerular filtration rate. d. Pregnancy testing. e. Sexually transmitted infection screening and counseling. f. Adherence counseling. (3) “FDA” means the United States Food and Drug Administration. (4) “HIV” means the human immunodeficiency virus. (5) “Medically necessary” means as defined in § 3581 of Title 18. (6) “PEP” means post-exposure prophylaxis medication for preventing HIV infection after possible HIV exposure. (7) “PrEP” means pre-exposure prophylaxis medication for preventing HIV infection before possible HIV exposure. (8) “Therapeutic equivalent” means a PrEP or a PEP that is all of the following: a. Approved as safe and effective. b. Pharmaceutically equivalent to another PrEP or another PEP because it contains an identical amount of the same active drug ingredient in the same dosage form and route of administration and meets compendial or other applicable standards of strength, quality, purity, and identity. c. Assigned, by the FDA, the same therapeutic equivalence code as another PrEP or another PEP. (b) (1) The plan must provide coverage for all of the following: a. Medically necessary PrEP. b. Medically necessary PEP. c. Medically necessary essential support services. (2) Except as otherwise provided in paragraph (b)(3) of this section, the coverage required under paragraph (b)(1) of this section must be provided without any of the following: a. Cost-sharing requirements. b. Prior authorization or step therapy requirements. c. Unreasonable delay in coverage determination. (3) a. If the FDA has approved 1 or more therapeutic equivalents of a PrEP or a PEP, the plan is not required to cover all of the therapeutic equivalent versions of that PrEP or that PEP, so long as at least 1 therapeutic equivalent version of that PrEP and at least 1 therapeutic equivalent version of that PEP are covered without cost-sharing, prior authorization, or step therapy requirements. For purposes of this section, a long-acting version of a PrEP or a PEP is not therapeutically equivalent to another long-acting version of a PrEP or a PEP with a different duration. b. If there is a therapeutic equivalent of a PrEP or a PEP, the plan may provide coverage for more than 1 version of that PrEP or that PEP and may impose cost-sharing, prior authorization, or step therapy requirements, so long as at least 1 version of that PrEP and at least 1 version of that PEP in the same method of administration is covered without cost-sharing, prior authorization, or step therapy requirements. But the plan must provide coverage for a particular PrEP or a particular PEP without cost-sharing, prior authorization, or step therapy requirements, regardless of whether the PrEP or the PEP has a therapeutic equivalent, if a covered individual’s treating health-care provider recommends that particular PrEP or that particular PEP based on a medical determination regarding that covered individual.

Del. Code tit. 29, § 5226 Certified registered nurse anesthetists [For application of this section, see 85 Del. Laws, c. 455, § 4].

(a) If the plan provides coverage for a health service that a certified registered nurse anesthetist is licensed to perform under Title 24, the reimbursement rate for the service provided by the certified registered nurse anesthetist may not be less than the reimbursement rate paid to licensed physicians providing the same service. (b) Nothing in this section shall be construed to prohibit the plan from establishing variable reimbursement rates based on quality or performance measures.

Del. Code tit. 29, § 5227 Coverage for diagnostic services and treatment for menopause and perimenopause [For application of this section, see 85 Del. Laws, c. 482, § 5].

(a) As used in this section: (1) “Hormone replacement therapy” means medical treatment, approved by the United States Food and Drug Administration, that replaces a hormone that an individual’s body is no longer making or no longer making enough of, as determined by a licensed health-care professional. “Hormone replacement therapy” includes prescribing any of the following: a. A cream. b. An oral medication. c. A vaginal device. d. Another method approved by the United States Food and Drug Administration. (2) “Medically necessary” means providing of health-care services or products that a prudent licensed health-care professional would provide to a patient for the purpose of diagnosing or treating an illness, injury, disease or its symptoms in a manner that is all of the following: a. In accordance with generally accepted standards of medical practice. b. Consistent with the symptoms or treatment of the condition. c. Not solely for anyone’s convenience. d. Not including investigational or experimental health-care services. (3) “Menopause” means the permanent end of menstruation due to loss of ovarian follicular function, characterized by the end of ovulation and a decline in estrogen and progesterone production. (4) “Menopause and perimenopause symptoms” include any of the following: a. Irregular menstrual periods. b. Hot flashes. c. Vaginal or bladder changes, including genitourinary syndrome of menopause. d. Decreased fertility. e. Loss of bone density, including osteoporosis. f. Elevated low-density lipoprotein cholesterol levels. g. Sleep disturbances, including night sweats. (5) “Perimenopause” means the transitional period leading to menopause, marked by fluctuating hormone levels and changes in the menstrual cycle. (b) (1) The plan must provide coverage for medically necessary diagnostic services and treatment for menopause, perimenopause, and menopause and perimenopause symptoms, including all of the following: a. Consultation and diagnostic testing. b. Hormonal therapies, including hormone replacement therapy and bioidentical hormone treatments, that are approved by the United States Food and Drug Administration. c. Nonhormonal treatments, including selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, neurokinin B antagonists, and other medications to manage menopause and perimenopause symptoms. d. All drugs, devices, and combination products approved by the United States Food and Drug Administration for the treatment of menopause and perimenopause symptoms. e. Therapy to treat menopause induced by a hysterectomy. f. Behavioral health care services. g. Pelvic floor physical therapy. h. Bone health treatments due to hormonal changes related to menopause and perimenopause, including screenings and medications. i. Preventative services for early detection and treatment of health conditions related to menopause and perimenopause, including osteoporosis and cancer. j. Counseling and education regarding menopause management. (2) A carrier shall provide clear and accessible information to each covered individual regarding covered diagnostic services and treatment for menopause, perimenopause, and menopause and perimenopause symptoms. (3) Coverage for medically necessary hormone replacement therapy provided under this section may not be any of the following: a. Denied or limited, if the use of the hormone replacement therapy is supported by national clinical guidelines, national standards of care, or peer-reviewed medical literature for the treatment of menopause, perimenopause, or menopause and perimenopause symptoms. b. Subject to prior authorization or step therapy requirements. (4) Except as otherwise provided in paragraph (b)(3) of this section, benefits provided under this section must be provided to covered individuals to the same extent as other benefits for any other medical condition covered under the plan. (c) Nothing in this section prevents the operation of a policy provision required by this section as a deductible, coinsurance, allowable charge limitation, coordination of benefits, or a provision restricting coverage to services by a licensed, certified, or carrier-approved provider or facility.

Del. Code tit. 29, § 5228 Biomarker testing [For application of this section, see 85 Del. Laws, c. 484 § 5].

(a) For purposes of this section: (1) “Biomarker” means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention, including known gene-drug interactions for medications being considered for use or already being administered. Biomarkers include gene mutations, characteristics of genes, and protein expression. A biomarker is not an assessment of how a covered person or enrollee feels, functions or survives. (2) “Biomarker testing” means the analysis of an individual’s tissue, blood, or other biospecimen for the presence of a biomarker. Biomarker testing includes single-analyte tests, multi-plex panel tests, protein expression, and whole exome, whole genome, and whole transcriptome sequencing. (3) “Investigatory and experimental biomarker tests” means biomarker tests that are subject to the United States food and drug administration’s investigational device exemption (C.F.R. Part 812). (4) “Medically necessary” means as defined in § 3581 of this title. (5) “Nationally recognized clinical practice guideline” means an evidence-based clinical practice guideline developed by independent organizations or medical professional societies using a transparent methodology and reporting structure and with a conflict-of-interest policy. A clinical practice guideline establishes a standard of care informed by a systematic review of evidence and an assessment of the benefits and risks of alternative care options and includes recommendations intended to optimize patient care. (6) “Screening” means a medical procedure or test for a covered person who has yet to display symptoms of a particular disease or condition for the purpose of determining the person’s likelihood of having the disease or condition. (b) All individual health insurance policies, contracts, or certificates that are delivered, issued for delivery, renewed, extended, or modified in this State shall provide coverage for biomarker testing to guide or inform treatment decisions for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of a covered person’s disease or condition when the test is medically necessary as demonstrated by medical and scientific evidence, including any of the following: (1) Labeled indications for an FDA-approved or FDA-cleared test. (2) Indicated tests for an FDA-approved drug. (3) Warnings and precautions on FDA-approved drug labels. (4) Centers for Medicare and Medicaid Services (CMS) national coverage determinations or Medicare administrative contractor (MAC) local coverage determinations. (5) Nationally recognized clinical practice guidelines. (c) A biomarker test that meets 1 of the medical and scientific evidence outlined in paragraphs (b)(1) through (b)(5) of this section shall not be considered an investigational or experimental health-care service. (d) Carriers must ensure that coverage for biomarker testing, as required by subsection (b) of this section, is provided in a manner that limits disruptions in care, including the need for multiple biopsies or biospecimen samples. (e) Nothing in this section prevents the operation of a policy provision required by this section as a deductible, coinsurance, allowable charge limitation, coordination of benefits, or a provision restricting coverage to services by a licensed, certified, or carrier-approved provider or facility. (f) Nothing in this section restricts the use of utilization management. (g) Nothing in this section shall be construed to require coverage of biomarker testing for screening purposes or coverage of investigatory and experimental biomarker tests.
Source: DE Code (Official Site)URL: https://delcode.delaware.gov/title29/c052/index.htmlFetched: 10/4/2026

Starting a business in Delaware? Delaware LLC guide: costs and requirements