Delaware General Assembly

CHAPTER 276

FORMERLY

HOUSE BILL NO. 303

AN ACT TO AMEND TITLE 18 OF THE DELAWARE CODE RELATING TO SCHOOL BASED HEALTH CENTERS AND INSURANCE.

WHEREAS, School Based Health Centers are recognized by the federal government as an important means of providing preventative and primary medical care to school age children; and

WHEREAS, national and multi-state studies of SBHCs have found that students with access to SBHCs are more likely to visit a health care professional and less likely to be hospitalized for certain acute illnesses; and

WHEREAS, national and multi-state studies have also found that students are more likely to seek assistance for conditions such as depression and obesity from an SBHC than from other medical providers; and

WHEREAS, SBHCs exist in 28 of Delaware’s schools, and provide a significant benefit to the students who use them; and

WHEREAS, the federal government requires all providers to bill private insurance for medical visits before Medicaid if Medicaid participants also have other insurance; and

WHEREAS, the federal government is requiring that Delaware change how it bills Medicaid for services provided at SBHCs; and

WHEREAS, implementing a billing system will also give SBHCs the ability to bill private insurance carriers for services that are provided in school to students whose families are already paying for private insurance; and

WHEREAS, proper billing of private insurance companies for services provided in SBHCs will allow the state to focus its limited public health resources on those students who do not have access to private insurance; and

WHEREAS, integration of SBHCs into the private health insurance market also affords the opportunity to more closely integrate the care provided at SBHCs with the care provided by pediatricians and family doctors;

NOW, THEREFORE:

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

Section 1. Amend Title 18 of the Delaware Code by making insertions as shown by underlining as follows:

§3365. School Based Health Centers.

(a) For purposes of this Section, a School Based Health Center is a health clinic that (i) is located in or near a school facility, (ii) is organized through school and health provider relationships, (iii) provides through licensed professionals primary health services to children, including comprehensive health assessments, diagnosis, and treatment of minor, acute, and chronic medical conditions, referrals to and follow-up for specialty care and oral and vision health services, mental health and substance use disorder assessments, crisis intervention, counseling, treatment, and referral to a continuum of mental health and substance abuse services including emergency psychiatric care, community support programs, inpatient care, and outpatient programs; and (iv) is recognized by the State of Delaware pursuant to relevant regulations and law.

(b) The Delaware Division of Public Health shall have sole authority to determine whether a facility is an SBHC as defined in paragraph (a) of this Section.

(c) Except as noted herein, benefits provided under insurance contracts delivered, issued for delivery, or renewed in this State shall reimburse SBHCs for covered services provided by SBHCs as if those services were provided by a network provider under the relevant contract of insurance. In the absence of an agreement between a carrier and a SBHC on reimbursement, reimbursement for such services shall be at the rate established by the Division of Medicaid and Medical Assistance for those services. Any insurance contract term purporting to exclude otherwise covered services on the basis that they are performed by a SBHC shall be void except as specifically permitted under this Chapter.

(d) If DPH has approved an SBHC, that approval shall be deemed sufficient to meet the carrier’s standards for inclusion in its network or for being eligible for payment by the carrier.

(e) SBHCs shall not charge co-pays or any other out-of-pocket fees to students for use of SBHC services. Insurance carriers shall not incur any additional financial liability by virtue of this subsection.

(f) The Delaware Division of Public Health, in coordination with the state’s SBHCs, insurance carriers, and the Department of Insurance, shall issue regulations to ensure that SBHCs are properly integrated into the state’s spectrum of health care providers that provide covered services to youth. These regulations shall include, but are not limited to:

(g) Nothing in this chapter shall prevent the enforceability of an agreement negotiated between a SBHC and an insurance carrier governing claims submission, reimbursement, quality standards, credentialing and similar matters, provided, however, that in the absence of such agreement the terms of this chapter shall govern.

Section 2. Amend Title 18 of the Delaware Code by making insertions as shown as follows:

§ 3571F. School Based Health Centers.

(a) For purposes of this Section, a School Based Health Center is a health clinic that (i) is located in or near a school facility, (ii) is organized through school and health provider relationships, (iii) provides through licensed professionals primary health services to children, including comprehensive health assessments, diagnosis, and treatment of minor, acute, and chronic medical conditions, referrals to and follow-up for specialty care and oral and vision health services, mental health and substance use disorder assessments, crisis intervention, counseling, treatment, and referral to a continuum of mental health and substance abuse services including emergency psychiatric care, community support programs, inpatient care, and outpatient programs; and (iv) is recognized by the State of Delaware pursuant to relevant regulations and law.

(b) The Delaware Division of Public Health shall have sole authority to determine whether a facility is an SBHC as defined in paragraph (a) of this Section.

(c) Except as noted herein, benefits provided under any group or blanket health insurance policy which is delivered, issued for delivery, or renewed in this State shall reimburse SBHCs for covered services provided by SBHCs as if those services were provided by a network provider under the relevant contract of insurance. In the absence of an agreement between a carrier and a SBHC on reimbursement, reimbursement for such services shall be at the rate established by the Division of Medicaid and Medical Assistance for those services. Any insurance contract term purporting to exclude otherwise covered services on the basis that they are performed by a SBHC shall be void except as specifically permitted under this Chapter.

(d) If DPH has approved an SBHC, that approval shall be deemed sufficient to meet the carrier’s standards for inclusion in its network or for being eligible for payment by the carrier.

(e) SBHCs shall not charge co-pays or any other out-of-pocket fees to students for use of SBHC services. Insurance carriers shall not incur any additional financial liability by virtue of this subsection.

(f) The Delaware Division of Public Health, in coordination with the state’s SBHCs, insurance carriers, and the Department of Insurance, shall issue regulations to ensure that SBHCs are properly integrated into the state’s spectrum of health care providers that provide covered services to youth. These regulations shall include, but are not limited to:

(g) Nothing in this chapter shall prevent the enforceability of an agreement negotiated between a SBHC and an insurance carrier governing claims submission, reimbursement, quality standards, credentialing and similar matters, provided, however, that in the absence of such agreement the terms of this chapter shall govern.

Section 3. § 6309, Title 18 of the Delaware Code by making insertions as shown as follows:

§ 6309. Other provisions applicable.

Such corporations shall be subject to this chapter and to the following chapters of this title, to the extent applicable and not in conflict with the express provisions of this chapter:

(1) Chapter 1 (General Definitions and Provisions).

(2) Chapter 3 (The Insurance Commissioner).

(3) Chapter 23 (Unfair Practices in the Insurance Business).

(4) Chapter 25 (Rates and Rating Organizations).

(5) Chapter 59 (Rehabilitation and Liquidation).

(6) Chapter 34 (Medicare Supplement Insurance Minimum Standards).

(7) Chapter 36 (Individual Health Insurance Minimum Standards).

Such corporations shall also be subject to Sections 3365 and 3571F of this Title.

Section 4. This law shall take effect six (6) months from the date of enactment, with the exception of the provisions authorizing and requiring promulgation of regulations which shall take effect immediately.

Section 5. The Department of Insurance may issue regulations to effectuate any provision of this Act for which regulatory authority is not specifically assigned to the Division of Public Health. All regulations promulgated with respect to this Act shall be consistent with applicable federal law.

Approved June 26, 2012