CHAPTER 178

FORMERLY

SENATE BILL NO. 78

AS AMENDED BY SENATE AMENDMENT NO. 1 AND

HOUSE AMENDMENT NO. 1

AN ACT TO AMEND TITLE 18 OF THE DELAWARE CODE RELATING TO HEALTH INSURANCE.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF DELAWARE.

Section 1. Amend Chapter 33, Title 18 of the Delaware Code to add a new section thereto to read as follows:

§3340. Obstetrical and Gynecological Coverage.

(a) This section applies to every individual policy or contract of health insurance, or certificate issued thereunder, which is delivered or issued for delivery in this State that requires an insured, participant, policyholder, subscriber, or beneficiary to designate a participating primary care provider.

(b) Any such policy or contract shall permit each female enrolled insured participant, policyholder, subscriber or beneficiary to designate a participating, in network, obstetrician-gynecologist as the enrollee's primary care provider if: the obstetrician-gynecologist meets the standards established by the insurance plan for primary care providers; (ii) the obstetrician-gynecologist requests that the insurer makes the obstetrician-gynecologist available for designation as a primary care provider; (iii) the obstetrician-gynecologist agrees to accept the payment terms applicable under the plan to primary care providers for services other than obstetrician-gynecological services and; (iv) the obstetrician-gynecologist agrees to abide by all other terms and conditions applicable to primary-care physicians under the plan generally.

(c) If a female enrolled insured, participant, policyholder, subscriber, or beneficiary has designated a primary care provider who is not an obstetrician-gynecologist, then the policy or contract shall not require as a condition to the coverage of the services of a participating in-network obstetrician-gynecologist that a female enrollee first obtain a referral from another primary care physician, and shall permit the female enrolled insured, participant, policyholder, subscriber, or beneficiary to have direct access to the health care services of an in-network obstetrician-gynecologist participating the plan, within the benefits provided under that plan. In such cases the obstetrician-gynecologist shall consult with the primary care physician with respect -to the care given and any follow up care, and the plan may require a visit to the primary care physician, if necessary, before the patient may be directed to another specialty provider, or for inpatient hospitalization or outpatient surgical procedures.

(d) For purposes of this section, 'health care services' means the Mil scope of medically necessary services provided by the participating obstetrician, gynecologist within the benefits provided under that plan.

() This section shall not be construed to require an individual
obstetrician-gynecologist to accept primary care physician status if the obstetrician-gynecologist does not wish to be designated as a primary care physician, nor to interfere with the credentialing and other selection criteria usually applied by a health benefit plan with respect to other physicians within its network.

(f) Any such policy or contract may not impose a copayment, coinsurance requirement, or deductible for directly accessed obstetric and gynecologic services as required in this section, unless such additional cost sharing is imposed for access to health care practitioners for other types of health care services

(g) If a policy or contract limits an insured's access to a network of participating providers for other health care services, then it may limit access for obstetric and gynecologic services, but the policy or contract shall include in all its provider networks sufficient numbers of obstetrician-gynecologists to accommodate the direct access needs of their female enrollees.

(h) Each such policy or contract shall provide notice to female enrolled participants, policyholders, subscribers, and beneficiaries regarding the coverage required by this act. The notice shall be in writing, printed in type not less than eight-point, and prominently positioned in any literature or correspondence, including benefit handbooks and enrollment materials. Policies or contracts shall include an explanation of any voluntary process of pre-authorization of services available to female enrollees and obstetrician-gynecologists. The enrollee handbook explanation shall include information regarding any limitation to direct access, including, but not limited to, a closed network of providers, or any limitation on access to an obstetrician-gynecologist based on a female's choice of primary care provider."

Section 2. Amend Chapter 35, Title 78 of the Delaware Code to add a new section thereto to read as follows;

"§3556. Obstetrical and Gynecological Coverage,

(a) This section applies to every group or blanket policy or contract of health insurance, or certificate issued thereunder, which is delivered or issued for delivery in this State that requires an insured, participant, policyholder, subscriber, or beneficiary to designate a participating primary care provider.

(b) Any such policy or contract shall permit each female enrolled insured participant, policyholder, subscriber or beneficiary to designate a participating, in network, obstetrician-gynecologist as the enrollee's primary care provider if: (I) the obstetrician-gynecologist meets the standards established by the insurance plan for primary care providers; (ii) the obstetrician-gynecologist requests that the insurer makes the obstetrician-gynecologist available for designation as a primary care provider; (iii) the obstetrician-gynecologist agrees to accept the payment terms applicable under the plan to primary care providers for services other than obstetrician-gynecological services and; (iv) the obstetrician-gynecologist agrees to abide by all other terms and conditions applicable to primary-care physicians under the plan generally.

(c) If a female enrolled insured, participant, policyholder, subscriber, or beneficiary has designated a primary care provider who is not an obstetrician-gynecologist, then the policy or contract shall not require as a condition to the coverage of the services of a participating in-network obstetrician-gynecologist that a female enrollee first obtain a referral from another primary care physician, and shall permit the female enrolled insured, participant, policyholder, subscriber, or beneficiary to have direct access to the health care services of an in-network obstetrician-gynecologist participating in the plan, within the benefits provided under that plan, In such cases the obstetrician-gynecologist shall consult with the primary care physician with respect to the care given and any follow up care, and the plan may require a visit to the primary care physician, if necessary, before the patient may be directed to another specialty provider, or for inpatient hospitalization or outpatient surgical procedures.

(d) For purposes of this section, 'health care services' means the full scope of medically necessary services provided by the participating obstetrician-gynecologist within the benefits provided under that plan.

(e) This section shall not be construed to require an individual obstetrician-gynecologist to accept primary care physician status if the obstetrician-gynecologist does not wish to be designated as a primary care physician, nor to interfere with the credentialing and other selection criteria usually applied by a health benefit plan with respect to other physicians within as network.

(f) Any such policy or contract may not impose a copayment, coinsurance requirement, or deductible for directly accessed obstetric and gynecologic services as required in this section, unless such additional cost sharing is imposed for access to health care practitioners for other types of health care services.

(g) If a policy or contract limits an insured's access to a network of participating providers for other health care services, then it may limit access for obstetric and gynecologic services, but the policy or contract shall include in all its provider networks sufficient numbers of obstetrician-gynecologists to accommodate the direct access needs of their female enrollees.

(h) Each such policy or contract shall provide notice to female enrolled participants, policyholders, subscribers, and beneficiaries regarding the coverage required by this act. The notice shall be in writing, printed in type not less than eight-point, and prominently positioned in any literature or correspondence, including benefit handbooks and enrollment materials. Policies or contracts shall include an explanation of any voluntary process of pre-authorization of services available to female enrollees and obstetrician-gynecologists. The enrollee handbook explanation shall include information regarding any limitation to direct access, including, but not limited to, a closed network or providers, or any limitation on access to an obstetrician-gynecologist based on a female's choice of primary care provider."

Section 3. The effective date of this Act is September I, 1997. The provisions of this Act shall apply to policies, contracts of health insurance or certificates issued thereunder, delivered or issued for delivery in Delaware on and after the effective date of this Act.

Section 4. STATEMENT OF PURPOSE: It is the purpose of this act to facilitate the unique physician-patient relationship between and among Obstetrician-Gynecologists and their patients without unduly inhibiting the beneficial market forces that have reformed and are currently reforming, the financing and delivery of health care in Delaware. In that regard. the General Assembly expressly finds that the physician-patient relationship at issue in this Act is unlike other specialist-patient relationships, in that obstetrician-gynecologists more frequently deliver "primary care" to their patients than other medical specialties, warranting the unique treatment outlined in this act. It is not the intent of the Delaware General Assembly to expand the provisions of this act to other medical specialties.

Section 5. All provisions of this Act apply as well to health service corporations as defined and regulated by Chapter 63 of Title 18 of the Delaware Code.

Section 6. If any section, subsection, paragraph, or provision of this Act or the application thereof to any person or circumstance is held invalid, such invalidity shall not affect other sections, subsections, paragraphs, or provisions of this Act or the application thereof which can be given effect without the invalid section, subsection, paragraph, provision or application. and to that end the provisions of this Act are declared to be severable.

Approved July 15, 1997