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) An “eligible pensioner” is one 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 one who is receiving retirement or disability benefits under the teachers' retirement and disability plan (Chapter 39 of Title 14). This paragraph shall not apply to members of boards or commissions. An “eligible pensioner” shall include those 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. An “eligible pensioner” shall include those employees who are receiving disability benefits pursuant to § 5253(c) of this title.

(4) “FDA” means the Food and Drug Administration.

(5) “Medicare” means the federal Medicare Program (U.S. Public Law 89-87, as amended) (42 U.S.C. § 1395 et seq.).

(6) “Plan” means the basic health-care insurance plan for state employees provided under this chapter.

(7) “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.

(8) A “regular officer or employee” means one 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) 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 of this paragraph. An employee appointed to temporary or seasonal positions and members of boards and commissions who were not receiving coverage under the State group health insurance contract on January 1, 1993, shall not be considered a “regular officer or employee” for the purposes of this chapter. A “regular officer or employee” called to active duty with Guard or Reserve for other than training purposes shall continue to receive state contributions toward health insurance coverage for a period of up to 2 years. A “regular officer or employee” shall also include an employee who is receiving disability benefits pursuant to § 5253(b) of this title.

(9) “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.

29 Del. C. 1953, §  5201;  57 Del. Laws, c. 319;  58 Del. Laws, c. 27;  62 Del. Laws, c. 158, §  1;  63 Del. Laws, c. 408, §  1;  64 Del. Laws, c. 297, §  1;  65 Del. Laws, c. 449, §§  1, 2;  67 Del. Laws, c. 47, §  61;  68 Del. Laws, c. 8, §  2;  69 Del. Laws, c. 64, §§  27, 65;  70 Del. Laws, c. 118, §  30;  71 Del. Laws, c. 132, §  35;  71 Del. Laws, c. 354, §  40;  72 Del. Laws, c. 94, §§  37, 41;  72 Del. Laws, c. 204, §  3;  74 Del. Laws, c. 421, §  3;  75 Del. Laws, c. 191, §  4;  75 Del. Laws, c. 227, §§  2, 3;  76 Del. Laws, c. 280, §  34;  78 Del. Laws, c. 18, §  1;  78 Del. Laws, c. 78, §  24;  78 Del. Laws, c. 179, §  275;  81 Del. Laws, c. 323, § 3;  81 Del. Laws, c. 392, §§   7, 10;  82 Del. Laws, c. 141, § 24;  83 Del. Laws, c. 237, § 8;  84 Del. Laws, c. 218, § 1; 

(a) The State shall pay premium or subscription charges for a regular officer or employee and eligible spouse and child dependents not eligible for federal Medicare as follows:

(1) Ninety-six percent of the total cost of the basic individual, individual and spouse, individual and child, or family health care insurance plan as set forth in § 5203 of this title;

(2) Ninety-five percent of the total cost of a consumer-directed health plan for individual, individual and spouse, individual and child, or family;

(3) Ninety-three and one-half percent of the total cost of an HMO plan for individual, individual and spouse, individual and child, or family;

(4) Eighty-six and three-quarter percent of the total cost of a comprehensive PPO plan for individual, individual and spouse, individual and child, or family; or

(5) Beginning January 1, 2006, employees identified under Title 14 who are receiving a short-term disability benefit for a period greater than 90 days pursuant to § 5253(b) of this title and have exhausted all of their paid leave, an amount equivalent to that provided under paragraph (a)(1), (2), (3) or (4) of this section.

(b) (1) For eligible pensioners not eligible for federal Medicare and their eligible dependents who were first employed by the State on or before June 30, 1991, or who are receiving a disability pension or primary survivors receiving a survivor’s pension under § 8372(a) of Title 11, due to death in the line of duty of the employee, the State shall pay premium or subscription charges for the following, whichever is applicable:

a. Ninety-six percent of the total cost of the basic individual, individual and spouse, individual and child, or family health-care insurance plan as set forth in § 5203 of this title;

b. Ninety-five percent of the total cost of a consumer-directed health plan for individual, individual and spouse, individual and child, or family;

c. Ninety-three and one-half percent of the total cost of an HMO plan for individual, individual and spouse, individual and child, or family; or

d. Eighty-six and three-quarter percent of the total cost of a comprehensive PPO plan for individual, individual and spouse, individual and child, or family.

(2) For eligible pensioners who are eligible for federal Medicare and their eligible dependents:

a. Who retire before July 1, 2012, or who are receiving a disability pension or primary survivors receiving a survivor’s pension under § 8372(a) of Title 11, due to death in the line of duty of the employee, the State shall pay 100% of the premium or subscription charges for the coverage provided, unless they are subject to the schedule based on years of service, as set forth in paragraph (b)(3) of this section.

b. Who retire after July 1, 2012, the State shall pay 95% of the premium or subscription charges for the coverage provided, unless they are subject to the schedules based on years of service, as set forth in paragraph (b)(3) or (b)(4) of this section.

(3) For eligible pensioners who were first employed by the State on or after July 1, 1991, and before January 1, 2007, except those receiving a disability pension or primary survivors receiving a survivor’s pension under § 8372(a) of Title 11, due to death in the line of duty of the employee, the State shall pay premium and subscription charges as follows:

a. For eligible pensioners employed by the State for at least 10 but less than 15 years at the time of retirement, 50 percent of premium or subscription charges as set forth in paragraphs (b)(1) and (b)(2) of this section; or

b. For eligible pensioners employed by the State for at least 15 but less than 20 years at the time of retirement, 75 percent of the premium or subscription charges as set forth in paragraphs (b)(1) and (b)(2) of this section; or

c. For eligible pensioners employed by the State for 20 or more years at the time of retirement, 100 percent of the premium or subscription charges as set forth in paragraphs (b)(1) and (b)(2) of this section.

(4) For eligible pensioners who were first employed by the State on or after January 1, 2007, the State shall pay premium and subscription charges as follows:

a. For eligible pensioners employed by the State for at least 15 but less than 17.5 years at the time of retirement, 50 percent of premium or subscription charges paid for by the State as set forth in paragraphs (b)(1) and (b)(3) of this section;

b. For eligible pensioners employed by the State for at least 17.5 but less than 20 years at the time of retirement, 75 percent of the premium or subscription charges as set forth in paragraphs (b)(1) and (b)(3) of this section; or

c. For eligible pensioners employed by the State for 20 or more years at the time of retirement, 100 percent of the premium or subscription charges as set forth in paragraphs (b)(1) and (b)(3) of this section.

(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, a husband and wife 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 following options are set forth:

(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 Advantage 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 percent 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 percent of the employee or non-Medicare cost share premium per month, or $25 per month, whichever is greater for the plans chosen.

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 Advantage Plan. The non-Medicare pensioner shall be charged 50 percent of the cost share premium, or $25 per month, whichever is greater.

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 percent 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 percent of the employee and Medicare Advantage Plan cost share premium per month, or $25 per month, whichever is greater for the plans chosen.

If both spouses are Medicare eligible and 1 or both retired on or after July 1, 2017, only 1 50 percent pensioner only, or $25 per month premium, whichever is greater, shall apply when separate contracts are required for a Medicare Advantage Plan.

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 Advantage 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 himself/herself, his/her spouse or his/her dependents, the regular officer or employee may enter into a written agreement with the State whereby he/she agrees to reduce his/her 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.

29 Del. C. 1953, §  5202;  57 Del. Laws, c. 319;  62 Del. Laws, c. 158, §§  3, 4;  62 Del. Laws, c. 294, §  1;  63 Del. Laws, c. 79, §  1;  63 Del. Laws, c. 155, §  1;  65 Del. Laws, c. 87, §  80;  66 Del. Laws, c. 85, §  93;  67 Del. Laws, c. 324, §  1;  68 Del. Laws, c. 84, §§  65, 66;  68 Del. Laws, c. 178, §§  1-3;  69 Del. Laws, c. 291, §  34;  70 Del. Laws, c. 61, §  1;  70 Del. Laws, c. 186, §  1;  72 Del. Laws, c. 94, §  75;  75 Del. Laws, c. 88, §§  20(6), 21(13), 26(2);  75 Del. Laws, c. 114, §§  1, 2;  75 Del. Laws, c. 227, §  4;  76 Del. Laws, c. 280, §  22;  78 Del. Laws, c. 14, §§  1-5;  78 Del. Laws, c. 78, §  25;  78 Del. Laws, c. 254, §  1;  81 Del. Laws, c. 58, §  24;  81 Del. Laws, c. 323, § 3;  83 Del. Laws, c. 325, § 116; 

(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) The plan shall be for regular employees and eligible pensioners under 65 years of age and for employees and eligible pensioners over 65 years of age who are not entitled to services, rights or benefits under the federal Medicare Program (U.S. Public Law 89-97, as amended) [42 U.S.C. § 1395 et seq.]; and a plan which is supplemental to Medicare parts A and B, or constructed as a plan under Medicare part C, for eligible pensioners entitled to services, rights or benefits under the federal Medicare Program.

(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.

29 Del. C. 1953, §  5203;  57 Del. Laws, c. 319;  57 Del. Laws, c. 350;  69 Del. Laws, c. 64, §  66;  72 Del. Laws, c. 204, §  4;  78 Del. Laws, c. 14, §§  6, 7;  81 Del. Laws, c. 323, § 3;  81 Del. Laws, c. 392, §§   8, 10;  81 Del. Laws, c. 430, §§   4, 7;  82 Del. Laws, c. 141, § 24;  83 Del. Laws, c. 237, § 8; 

(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.

81 Del. Laws, c. 323, § 3;  70 Del. Laws, c. 186, §  1; 

(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.

29 Del. C. 1953, §  5204;  57 Del. Laws, c. 319;  68 Del. Laws, c. 84, §  24;  69 Del. Laws, c. 64, §  67;  72 Del. Laws, c. 204, §  5; 

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

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.

29 Del. C. 1953, §  5206;  57 Del. Laws, c. 319;  62 Del. Laws, c. 158, §  2;  72 Del. Laws, c. 94, §  76;  72 Del. Laws, c. 204, §  6; 

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.

64 Del. Laws, c. 145, §  1;  70 Del. Laws, c. 186, §  1; 

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.

69 Del. Laws, c. 291, §  36; 

(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.

70 Del. Laws, c. 118, §  33;  70 Del. Laws, c. 425, §§  35, 36;  71 Del. Laws, c. 132, §  39;  71 Del. Laws, c. 354, §  41;  71 Del. Laws, c. 372, §  1;  72 Del. Laws, c. 94, §  40;  72 Del. Laws, c. 204, §  15;  72 Del. Laws, c. 258, §  30;  73 Del. Laws, c. 74, §  81;  73 Del. Laws, c. 233, §  1;  74 Del. Laws, c. 226, §  1;  80 Del. Laws, c. 298, §  22;  81 Del. Laws, c. 49, §  3; 

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 State employees group health insurance program.

(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.

72 Del. Laws, c. 204, §  7;  76 Del. Laws, c. 70, §  10; 

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.

81 Del. Laws, c. 400, § 3; 

(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.

82 Del. Laws, c. 250, § 3; 

(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.

83 Del. Laws, c. 42, § 3;  84 Del. Laws, c. 36, § 3; 

(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.

83 Del. Laws, c. 241, § 3; 

(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.

83 Del. Laws, c. 388, § 4; 

(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.

83 Del. Laws, c. 521, § 3; 

(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.

84 Del. Laws, c. 121, § 3;