Primary Care Insurance/Updates

This Act amends Titles 16, 18, 29, and 31 of the Delaware Code and Chapter 237, Volume 83 of the Laws of Delaware relating to primary care insurance. Among other things, the Act does the following: Section 1 of the Act amends § 9903 of Title 16 of the Delaware Code to provide that the Health Care Commission, in coordination with the Primary Care Reform Collaborative, will monitor compliance of primary care providers with value-based care delivery models established under the Office of Value-Based Health Care Delivery (OVBHCD). Section 2 of the Act amends § 9904A of Title 16 to remove a time frame limitation for the period during which the Health Care Commission is authorized to request written reports by health insurers regarding progress in adopting and implementing value-based payment models. Under the Act, the PCRC may continue to request such reporting going forward. Section 3 of the Act amends § 329 of Title 18 to provide that administrative penalties for violations of §2503(a)(12), §2503(a)(15), § 3342B, and § 3556A of Title 18 may be equivalent to the amount of the violation, and that penalties imposed for such violations are to be deposited into a Primary Care Fund, which will be used by the Statewide Benefits Office and the Division of Medicaid and Medical Assistance. Section 4 of the Act amends § 334 of Title 18 to clarify that the OVBHCD has the ability to promulgate regulations necessary to accomplish the stated goals of reducing health-care costs by increasing the availability of high quality, cost-efficient health insurance products that have stable, predictable, and affordable rates. Section 5 of the Act amends § 2503 of Title 18 to extend current cost containment calculations to rate filing year 2027. In rate filing year 2028 and thereafter, it specifies that cost per service for health benefit plans may not exceed 250% of Medicare reimbursement for comparable services, or a rate further delineated by regulation for similar services, unless operating under a federal or state global budget model approved by the Department. Carriers issuing plans in the commercial market for 2 consecutive years and that cover more than 5,000 members must meet minimum percentages of alternative payment model contracting, as specified. Section 6 of the Act amends § 3342B of Title 18 concerning primary care coverage offered by individual insurance plans. Under the Act, starting in 2026, carriers must spend at least 11.5% of their total cost of medical care on primary care, at least 5% of which must be via prospective primary care management payments. Carriers must offer value-based care programs and may not deny contracted providers the opportunity to participate in an offered value-based care program. In addition, the Commissioner is required to issue regulations regarding the calculation of total cost of care. Section 7 of the Act applies the same changes as Section 6 of the Act to § 3556A of Title 18, concerning primary care coverage offered by group insurance plans. Section 8 of the Act deletes a sunsetting clause contained in Section 14, Chapter 237, Volume 83 of the Laws of Delaware, which would have repealed § 2503(a)(12)a., § 3442B(b)(3), and § 3556A(b)(3) of title 18, effective January 1, 2027. Section 9 of the Act amends § 5204 of Title 29 to provide that health-insurance coverage for public officers and employees shall be provided by a carrier whose cost per service may not exceed 250% of Medicare reimbursement for comparable services beginning in Fiscal Year 2029 unless operating under a federal or state global budget model approved by the SEBC, and provides balance billing protections. In addition, Section 9 of the Act specifies that coverage shall be provided by a carrier offering value-based care programs equivalent to the commercial market requirements. Section 10 of the Act amends §5224 of Title 29 concerning primary care coverage of insurance coverage for public officers and employees, to require plans to report data on the percentage of primary care spending as a percentage of total medical costs for plan years 2027 and 2028 and to increase spending on primary care by 1% per year thereafter until primary care spending reaches 11.5% of total medical costs. Section 11 of the Act creates §539 of Title 31, concerning state public assistance, to require entities providing health insurance under § 505(3) to report data on the percentage of primary care spending as a percentage of total medical costs for 2 plan years and, in subsequent years, increase primary care spending by 1% until primary care spending reaches 11.5% of total medical costs. Section 12 of the Act provides that the Department of Insurance shall promulgate regulations pursuant to the Act within 18 months of enactment.

• David P. SokolaD
• Madinah Wilson-AntonD
• S. Elizabeth LockmanD