Delaware General Assembly

Senate Banking, Business, Insurance & Technology 6/8/23

Awaiting consideration in Committee

6/8/23

Townsend

Reps. Minor-Brown, Baumbach

Sen. Huxtable

AN ACT TO AMEND TITLE 18 OF THE DELAWARE CODE RELATING TO HEALTH INSURANCE AND PRE-AUTHORIZATION REQUIREMENTS.

This legislation is the Delaware Pre-Authorization Reform Act of 2023. Section 1 of the Act applies to Health Insurance Contracts regulated under Chapter 33 of Title 18. Section 1 provides that changes in coverage terms for a health-care service or in the clinical criteria used to conduct pre-authorization reviews for a health-care service will not apply until the next plan year, for any covered person who received pre-authorization for the service prior to the change. It also requires the Delaware Department of Insurance to publish on its website information concerning the aggregate number of pre-authorization approvals, denials, and appeals for each insurer, health-benefit plan, or health-care service corporation using pre-authorization review. 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 pre-authorization 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 4 days of receipt of the request; for requests submitted electronically, notification must be given within 72 hours of receipt. For requests for pre-authorization for urgent health-care services, notification must be given within 24 hours of receipt. By January 1, 2024, 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. Further, an insurer, health-benefit plan, or health-service corporation may not deny or limit coverage of a service already provided on the grounds that pre-authorization was not obtained, if such services would have been covered had pre-authorization been obtained. In addition, Section 1 extends the time period that a pre-authorization is valid for from 60 days to 7 months. If a covered person changes insurers, health-benefit plans, or health-service corporations, the new insurer, health-benefit plan, or health-service corporation must comply with any existing pre-authorizations during the first 60 days of the new coverage. 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 services 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 take effect on January 1 of the calendar year following enactment and will apply to policies, contracts, or certificates issued or renewed after that effective date. 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 of the Act provides that the Department of Insurance will promulgate a uniform pre-authorization form within 180 days of enactment. Section 7 provides that this Act is known as the "Delaware Pre-Authorization Reform Act of 2023."

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Takes effect upon being signed into law

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