TITLE 18

Insurance Code

Insurance

CHAPTER 40. HEALTH INSURANCE FOR CHILDREN AND PERSONS ON MEDICAID


The provisions of this chapter shall apply to:

(1) Any insurer providing insurance of human beings against bodily injury, disablement or death by accident or accidental means, or the expense thereof, or against disablement or expense resulting from sickness, and every insurance appertaining thereto;

(2) A health service corporation, notwithstanding any provision to the contrary in Chapter 63 of this title;

(3) A health maintenance organization, notwithstanding any provision to the contrary in Chapter 64 of this title;

(4) A group health plan, as defined in § 607(1) of the federal Employee Retirement Income Security Act of 1974 [29 U.S.C. § 1167(1)];

(5) An entity offering a service benefit plan or a pharmacy benefit manager;

(6) A self-funded entity or group providing health care coverage;

(7) Any person or entity which provides coverage in this State for medical, surgical, chiropractic, physical therapy, speech pathology, audiology, professional mental health, dental, hospital or optometric expenses, whether such coverage is by direct payment, reimbursement or otherwise; and

(8) Any other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service.

69 Del. Laws, c. 444, § 1; 76 Del. Laws, c. 190, §§ 2, 3.;

(a) No health insurer shall deny enrollment of a child under the health coverage of the child's parent on the ground that:

(1) The child was born out of wedlock;

(2) The child is not claimed as a dependent on the parent's federal income tax return; or

(3) The child does not reside with the parent or in the insurer's service area.

(b) In any case in which a parent is required by a court or administrative order to provide health coverage for a child and the parent is eligible for family health coverage through a health insurer, such health insurer shall:

(1) Permit such parent to enroll under such family coverage any such child who is otherwise eligible for such coverage (without regard to any enrollment season restrictions);

(2) If such parent is enrolled but fails to make application to obtain coverage of such child, enroll such child under such family coverage upon application by the child's other parent, the Family Court or by a state agency administering a program under Part D, Title IV of the federal Social Security Act [42 U.S.C. § 651 et seq.], or Title XIX of the federal Social Security Act [42 U.S.C. § 1396 et seq.]; and

(3) Not disenroll (or eliminate coverage of) such a child unless the health insurer is provided satisfactory written evidence that:

a. Such court or administrative order is no longer in effect, or

b. The child is or will be enrolled in comparable health coverage through another health insurer which will take effect not later than the effective date of such disenrollment.

(c) In any case in which a child has health coverage through the health insurer of a noncustodial parent, the insurer shall:

(1) Provide such information to the custodial parent as may be necessary for the child to obtain benefits through such coverage;

(2) Permit the custodial parent (or provider, with the custodial parent's approval) to submit claims for covered services without the approval of the noncustodial parent; and

(3) Make payment on claims submitted in accordance with paragraph (2) directly to such custodial parent, the provider, or the state agency administering a program under part D, Title IV of the federal Social Security Act [42 U.S.C. § 651 et seq.] or Title XIX of the federal Social Security Act [42 U.S.C. § 1396 et seq.].

69 Del. Laws, c. 444, § 1; 71 Del. Laws, c. 216, § 12.;

(a) No health insurer, in enrolling an individual or in making any payments for benefits to the individual or on the individual's behalf, shall take into account that the individual is eligible for or is provided medical assistance under a Medicaid Plan of this State or any other state.

(b) Where a state agency has been assigned the rights of an individual eligible for medical assistance under Title XIX of the federal Social Security Act [42 U.S.C. § 1396 et. seq.] and such individual is covered for health benefits from a health insurer, no such health insurer shall impose requirements on the state agency that are different from requirements applicable to an agent or assignee of any other individual so covered.

69 Del. Laws, c. 444, § 1.;

(a) For the purposes of this chapter, the term "health insurer" includes, without limitation, an insurer providing insurance of human beings against bodily injury, disablement or death by accident or accidental means, or the expense thereof, or against disablement or expense resulting from sickness, and every insurance appertaining thereto; a health service corporation; a health maintenance organization; a group health plan, as defined in § 607(1) of the federal Employee Retirement Income Security Act of 1974 [29 U.S.C. § 1167(1)]; any entity offering a service benefit plan; a self-funded entity or group providing health care coverage; a pharmacy benefit manager; any other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service; and any person or other entity which provides coverage in this State for medical, surgical, chiropractic, physical therapy, speech pathology, audiology, professional mental health, dental, hospital or optometric expenses, whether such coverage is by direct payment, reimbursement or otherwise.

(b) "Department" means the Delaware Department of Health and Social Services.

69 Del. Laws, c. 444, § 1; 76 Del. Laws, c. 190, §§ 4, 5.;

The Commissioner may issue regulations in accordance with § 314 of this title and Chapter 101 of Title 29 for the implementation and administration of this chapter.

69 Del. Laws, c. 444, § 1.;

The Department is authorized to require any health insurer to provide, upon the request of the Department, eligibility and coverage information (including, but not limited to the name, address, date of birth, Social Security number, policy number, group identification number, types of covered services under the policy, effective dates of coverage, and termination date for each client) that will enable the Department to determine during what period Medicaid recipients may be or may have been covered by the health insurer and the nature of the coverage that is or was provided. This information shall be referred to as the "Plan Eligibility Data Elements." The Department may enter into agreements with the health insurers for the purpose of carrying out the provisions of this section. The agreement shall provide for the electronic exchange of data between the parties at a mutually agreed upon frequency and in a format specified by the Department designed to verify that an individual has coverage, but no less frequently than once every 2 months. The agreement shall specify the data elements that shall be included on the electronic file from the health insurer. No health insurer that provides data required by the Department, whether confidential or not, shall be held liable for the provision of such data to the Department or for any use made thereof. The Department shall have procedures in place to ensure compliance with the requirements of the Health Insurance Portability and Accountability Act of 1996 [P.L. 104-191] relating to the privacy and security of individually identifiable health information, as applicable.

76 Del. Laws, c. 190, § 6.;