Health plans - Delaware

Summary of differences between federal and state regulations

Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income Security Act (ERISA).

Federal ERISA plans generally do not have to comply with state laws. ERISA rules preempt or block state laws that relate to ERISA plans. State insurance laws, however, do apply.

State

Contact

Delaware Insurance Department

Regulations

http://delcode.delaware.gov/title18/index.shtml

Employees covered under a group health care plan may include retirees, former employees, or employees of subsidiaries, affiliated corporations, proprietorships or partnerships. If the employer pays 100 percent of the premiums, the policy must insure all eligible employees, except those who reject such coverage in writing. §3502

Policies may be extended to employees’ family members or dependents. §3511

Policies must provide for a grace period of 31 days for the payment of any premium due except the first. § 3513

The validity of a policy that has been in force for at least two years from date of issue must not be contested except for nonpayment of premiums. §3513

A written notice of claim must be given to the insurer within 20 days after the occurrence or commencement of any loss covered by the policy. §3520

In cases of lost time for disability, written proof of such loss must be furnished to the insurer within 90 days after the commencement of the period, as well as subsequent written proofs of the continuance of the disability. §3522

All benefits, other than benefits for loss of time, are payable not more than 60 days after receipt of proof. All accrued benefits for loss of time will be paid at least monthly. §3523

Group health insurance policies must indicate that benefits for loss of life of the person insured are payable to the beneficiary designated by the person insured. §3524

Group health insurance policies must provide that the insurer may examine the individual for whom a claim is made, and make an autopsy in the case of death. §3525

Policies may payment for services directly to the hospital or person rendering the services. However, policies may not require that the service be rendered by a particular hospital or person. §3528

Group policies that cover family members must cover newly born children from the moment of birth, and include necessary care and treatment of medically diagnosed congenital defects and birth abnormalities as well as routine care. §3335, §3550

Children are covered even if:

• The child was born out of wedlock;
• The child is not claimed as a dependent on the parent's federal income tax return; or
• The child does not reside with the parent or in the insurer's service area. §4002

Group policies must also cover the following:

• Prostate cancer screening for those 50 years old or above. §3552
• If outpatient services are covered, baseline lead poisoning screening test for children at or around 12 months of age, along with lead screening and diagnostic evaluations for children under the age of 6 years. §3554
• Immunizations for children through 18 years of age. §3558
• If prescription drugs are covered, for prescription contraceptive drugs and devices, and for outpatient contraceptive services including consultations, examinations, procedures, and medical services related to the use of contraceptive methods to prevent unplanned pregnancy. §3559
• If outpatient services or prescriptions are covered, equipment and supplies for the treatment of diabetes. §3560
• Colorectal cancer screening. §3562
• Emergency care services performed by non-network providers at an agreed-upon or negotiated rate, regardless of whether the physician or provider furnishing the services has a contractual or other arrangement with the insurer. However, this applies only to conditions for which coverage is provided by the policies. §3565
• If prescription drugs are covered, drugs prescribed to treat a chronic, disabling, or life-threatening illness. §3566
• Routine care costs for clinical trials for treatment of life threatening diseases. §3567
• Phenylketonuria (PKU) and other inherited metabolic diseases. §3571
• Podiatrists. Title 24, §511
• Chiropractors. Title 24, §717
• Optometrists. Title 24, §2101

Participants may select the pharmacy of their choice as long as the pharmacy has agreed to participate in the plan. §7303

Discrimination is prohibited on the basis of age, §2315; deafness or blindness, § 2316; or genetics, §2317.

Plans cannot place a greater financial burden for covered services for serious mental illnesses than for covered services of any other illness or disease. § 3577

Applicants need not submit to an HIV test unless the insurer obtains the applicant's prior written informed consent, reveals how the results may be used, to whom the results may be disclosed; and provide the applicant with written information. §7403

If medically necessary covered services are not available through network providers, or the network providers are not available within a reasonable period of time, the insurer, on the request of a network provider, within a reasonable period, must allow referral to a non-network physician or provider and must reimburse the non-network physician or provider at a previously agreed-upon or negotiated rate. §3564

Policies that cover children can limit coverage for children referred by the Division of Family Services or law enforcement agency for suspected child abuse or neglect, including requiring referral by a primary physician. §3557

For more information on health benefits for women in Delaware, see the topic Women’s Health Rights.

Federal

Contact

Employee Benefits Security Administration (EBSA)

Regulations

29 CFR chapter XXV (Parts 2509 – 2590)