Healthcare (Insurance)

This Act is a substitute for HB 200 and differs from HB 200 by requiring health insurance coverage only for pre-exposure prophylaxis (“PrEP”) medication and post-exposure prophylaxis (“PEP”) medication. This Act also makes technical corrections including updating section numbers and updating the applicability date so insurance companies can file rates that include the cost of the coverage required under this Act. This Act requires individual health insurance plans, group and blanket health insurance plans, the state employee health plan, and state Medicaid insurance to cover medically necessary PrEP medication for the prevention of human immunodeficiency virus (“HIV”) infection before possible HIV exposure and medically necessary PEP medication for the prevention of HIV infection after possible HIV exposure. The coverage must include must be provided without any of the following: 1. Cost-sharing requirements, including deductibles, coinsurance, copayments, and out-of-pocket expenses. 2. Prior authorization or step therapy requirements. 3. Unreasonable delay in coverage determination. This Act applies to all policies, contracts, or certificates that are renewed, modified, altered, amended, or reissued after December 31, 2027.

Excess skin and subcutaneous tissue can create a risk of rashes or infections, make walking and movement difficult, and make everyday chores difficult. An example of treatment that removes excess skin and subcutaneous tissue is a panniculectomy. A panniculectomy is an operative procedure that contours, or changes the shape and form, of the abdomen by removing significant excess skin and subcutaneous tissue. Removal of excess skin and subcutaneous tissue can improve a patient’s health and quality of life. This Act requires individual health insurance plans delivered under Chapter 33 of Title 18 and group and blanket health insurance plans delivered under Chapter 35 of Title 18 to cover medically necessary removal of excess skin and subcutaneous tissue, including panniculectomies. This Act also requires the State employee health insurance plan and State Medicaid plans to cover medically necessary removal of excess skin and subcutaneous tissue, including panniculectomies. Medically necessary means as defined in § 3371(8) for individual health insurance plans and as defined in § 3581(8) for group and blanket health insurance plans, State employee health insurance plans, and State Medicaid plans. This Act applies to all policies, contracts, or certicates issued, renewed, modified, alterered, amended, or resissued after December 31, 2026.

This Legislation is the Delaware Pre-Authorization Reform Act of 2025. Section 1 of the Act applies to health Insurance Contracts regulated under Chapter 33 of Title 18. Section 1 provides that changes in utilization review terms for a health-care service, such as the clinical criteria used to conduct utilization reviews for a health-care service, will apply only upon re-authorization of the health-care service. Covered persons must be notified at least 6 months before any changes to utilization review terms, except in certain circumstances such as changes in clinical guideline status In addition, Section 1 sets qualifications for who may make determinations with regard to requests for pre- authorization of health-care services and appeals of adverse determinations; a timeline and required contents for the notification of an outcome of appeal of an adverse determination or a notification that additional information is necessary to make the determination of appeal; and requirements for any utilization review entity used to perform utilization review by an insurer, health-benefit plan, or health-service corporation. Section 1 also shortens the timelines for the determination of pre-authorization requests and notification to the health-care provider of the determination. For requests for pre-authorization of non-urgent health-care services not submitted electronically, the utilization review entity must notify the health-care provider within 5 business days of receipt of the request; for requests submitted electronically, notification must be given within 3 business days of receipt. For requests for pre-authorization for urgent health-care services submitted electronically, notification must be given within 24 hours of receipt. By January 1, 2027, insurers, health-benefit plans, health-service corporations, and utilization review entities must accept and respond to electronic pre-authorization requests through the same platform as the electronic request was submitted. In addition, Section 1 extends the time period that a pre-authorization is valid for from 60 days to 90 days. Finally, Section 1 provides that no more than 1 pre-authorization may be required for a single episode of care, and that if pre-authorization is granted as to a health-care service that is part of a group of services for which a bundled payment is charged, pre-authorization for the other health-care services included in the group is deemed to be approved as well. Section 2 of the Act applies to Group and Blanket Health Insurance under Chapter 35 of Title 18 and makes the same changes to pre-authorization standards and procedures that Section 1 of the Act makes to Health Insurance Contracts regulated under Chapter 33 of Title 18. Section 3 of the Act provides that the State Employee Benefits Committee established under § 9602 of the Title 29 of the Delaware Code must ensure that carriers administering plans for group health insurance comply with the requirements and provisions for pre-authorization set forth in Chapter 33, Subchapter II and Chapter 35, Subchapter V of Title 18. Section 4 of the Act provides that the Act will apply to health insurance policies, contracts, or certificates issued, modified, or renewed after December 31, 2026. Section 5 of the Act provides that the Department of Health and Social Services must, to the extent feasible, assure that contracts awarded to carriers providing health insurance relating to Medicaid assistance comply with the requirements and provisions for pre-authorization set forth in Chapter 33, Subchapter II and Chapter 35, Subchapter V of Title 18. Section 6 provides that this Act is known as the "Delaware Pre-Authorization Reform Act of 2025."

This resolution requires the Division of Medicaid and Medical Assistance to present a report to the Delaware General Assembly, by January 1, 2026, for the provision of insurance coverage for Community Health Worker services by Medicaid providers, which must include a draft State plan amendment or waiver, as appropriate, to the Governor and all members of the General Assembly, with copies to the Director and the Librarian of the Division of Research of Legislative Council, and the Delaware Public Archives.

This Act requires that individual, group, State employee, and public assistance insurance plans provide coverage for biomarker testing, when the test is supported by medical and scientific evidence. The Act applies to all such policies, contracts, or certificates issued, renewed, modified, altered, amended, or reissued after December 31, 2027. This Act is a substitute for and differs from Senate Bill No. 120 in that this Act clarifies that it does not prevent a provision restricting coverage to services by a licensed, certified, or carrier-approved provider or facility, restrict the use of utilization management, or require coverage of biomarker testing for screening purposes or coverage of investigatory and experimental biomarker tests. In addition, the Act differs from Senate Bill No. 120 in that it applies to policies, contracts, or certificates issued, renewed, modified, altered, amended, or reissued after December 31, 2027, rather than December 31, 2026.

The purpose of this Act is to protect medical providers in the State from out-of-state lawsuits and investigations that threaten the practice of medicine in the State. To that end this Act does the following: 1) Clarifies that physicians, physician assistants, and nurses that provide lawful healthcare services in the State do not engage in unprofessional conduct and cannot be disciplined for such services even if such services are illegal or considered to be unprofessional conduct or the unauthorized practice of medicine or nursing in another state. 2) In a civil action or proceeding, prohibits any healthcare provider from disclosing communications and records concerning healthcare services unless the patient authorizes such disclosure, with some exceptions. 3) Provides protections from civil and criminal actions that arise in another state that are based on the provision of health care services that are legal in Delaware. 4) Creates a cause of action for persons against whom a judgment was entered in another state based upon that person allegedly providing, receiving, or helping another person to provide healthcare services that are lawful in Delaware. (This does not apply to an action where no part of the acts that formed the basis for liability occurred in Delaware.) 5) Prohibits an insurer from taking an adverse action against a healthcare provider or organization for performing or providing healthcare services that are lawful in this State. 6) Prohibits any State or local agency, commission, board, or department from assisting a federal law-enforcement agency, another state’s law-enforcement agency, a private citizen, or a quasi-law-enforcement agency in relation to an investigation or inquiry concerning the lawfulness of healthcare services, if such services would be lawful as provided if they occurred entirely in the State.