CHAPTER 40. HEALTH INSURANCE FOR CHILDREN AND PERSONS ON MEDICAID
§ 4001. Scope of chapter.
The provisions of this chapter shall apply to:
(1) Any insurer providing insurance of human beings against bodily injury, disablement or death by accident or accidental
means, or the expense thereof, or against disablement or expense resulting from sickness, and every insurance appertaining
thereto;
(2) A health service corporation, notwithstanding any provision to the contrary in Chapter 63 of this title;
(3) A health maintenance organization, notwithstanding any provision to the contrary in Chapter 64 of this title;
(4) A group health plan, as defined in § 607(1) of the federal Employee Retirement Income Security Act of 1974 [29 U.S.C.
§ 1167(1)];
(5) An entity offering a service benefit plan or a pharmacy benefit manager;
(6) A self-funded entity or group providing health care coverage;
(7) Any person or entity which provides coverage in this State for medical, surgical, chiropractic, physical therapy, speech
pathology, audiology, professional mental health, dental, hospital or optometric expenses, whether such coverage is by direct
payment, reimbursement or otherwise; and
(8) Any other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health
care item or service.
69 Del. Laws, c. 444, § 1; 76 Del. Laws, c. 190, §§ 2, 3.;
§ 4002. Health insurance for children.
(a) No health insurer shall deny enrollment of a child under the health coverage of the child's parent on the ground that:
(1) The child was born out of wedlock;
(2) The child is not claimed as a dependent on the parent's federal income tax return; or
(3) The child does not reside with the parent or in the insurer's service area.
(b) In any case in which a parent is required by a court or administrative order to provide health coverage for a child and
the parent is eligible for family health coverage through a health insurer, such health insurer shall:
(1) Permit such parent to enroll under such family coverage any such child who is otherwise eligible for such coverage (without
regard to any enrollment season restrictions);
(2) If such parent is enrolled but fails to make application to obtain coverage of such child, enroll such child under such
family coverage upon application by the child's other parent, the Family Court or by a state agency administering a program
under Part D, Title IV of the federal Social Security Act [42 U.S.C. § 651 et seq.], or Title XIX of the federal Social Security
Act [42 U.S.C. § 1396 et seq.]; and
(3) Not disenroll (or eliminate coverage of) such a child unless the health insurer is provided satisfactory written evidence
that:
a. Such court or administrative order is no longer in effect, or
b. The child is or will be enrolled in comparable health coverage through another health insurer which will take effect not
later than the effective date of such disenrollment.
(c) In any case in which a child has health coverage through the health insurer of a noncustodial parent, the insurer shall:
(1) Provide such information to the custodial parent as may be necessary for the child to obtain benefits through such coverage;
(2) Permit the custodial parent (or provider, with the custodial parent's approval) to submit claims for covered services
without the approval of the noncustodial parent; and
(3) Make payment on claims submitted in accordance with paragraph (2) directly to such custodial parent, the provider, or
the state agency administering a program under part D, Title IV of the federal Social Security Act [42 U.S.C. § 651 et seq.]
or Title XIX of the federal Social Security Act [42 U.S.C. § 1396 et seq.].
69 Del. Laws, c. 444, § 1; 71 Del. Laws, c. 216, § 12.;
§ 4003. Health insurance for persons on Medicaid.
(a) No health insurer, in enrolling an individual or in making any payments for benefits to the individual or on the individual's
behalf, shall take into account that the individual is eligible for or is provided medical assistance under a Medicaid Plan
of this State or any other state.
(b) Where a state agency has been assigned the rights of an individual eligible for medical assistance under Title XIX of
the federal Social Security Act [42 U.S.C. § 1396 et. seq.] and such individual is covered for health benefits from a health
insurer, no such health insurer shall impose requirements on the state agency that are different from requirements applicable
to an agent or assignee of any other individual so covered.
69 Del. Laws, c. 444, § 1.;
§ 4004. Definition.
(a) For the purposes of this chapter, the term "health insurer" includes, without limitation, an insurer providing insurance
of human beings against bodily injury, disablement or death by accident or accidental means, or the expense thereof, or against
disablement or expense resulting from sickness, and every insurance appertaining thereto; a health service corporation; a
health maintenance organization; a group health plan, as defined in § 607(1) of the federal Employee Retirement Income Security
Act of 1974 [29 U.S.C. § 1167(1)]; any entity offering a service benefit plan; a self-funded entity or group providing health
care coverage; a pharmacy benefit manager; any other parties that are, by statute, contract, or agreement, legally responsible
for payment of a claim for a health care item or service; and any person or other entity which provides coverage in this State
for medical, surgical, chiropractic, physical therapy, speech pathology, audiology, professional mental health, dental, hospital
or optometric expenses, whether such coverage is by direct payment, reimbursement or otherwise.
(b) "Department" means the Delaware Department of Health and Social Services.
69 Del. Laws, c. 444, § 1; 76 Del. Laws, c. 190, §§ 4, 5.;
§ 4005. Administrative procedures.
The Commissioner may issue regulations in accordance with § 314 of this title and Chapter 101 of Title 29 for the implementation
and administration of this chapter.
69 Del. Laws, c. 444, § 1.;
§ 4006. Data sharing.
The Department is authorized to require any health insurer to provide, upon the request of the Department, eligibility and
coverage information (including, but not limited to the name, address, date of birth, Social Security number, policy number,
group identification number, types of covered services under the policy, effective dates of coverage, and termination date
for each client) that will enable the Department to determine during what period Medicaid recipients may be or may have been
covered by the health insurer and the nature of the coverage that is or was provided. This information shall be referred to
as the "Plan Eligibility Data Elements." The Department may enter into agreements with the health insurers for the purpose
of carrying out the provisions of this section. The agreement shall provide for the electronic exchange of data between the
parties at a mutually agreed upon frequency and in a format specified by the Department designed to verify that an individual
has coverage, but no less frequently than once every 2 months. The agreement shall specify the data elements that shall be
included on the electronic file from the health insurer. No health insurer that provides data required by the Department,
whether confidential or not, shall be held liable for the provision of such data to the Department or for any use made thereof.
The Department shall have procedures in place to ensure compliance with the requirements of the Health Insurance Portability
and Accountability Act of 1996 [P.L. 104-191] relating to the privacy and security of individually identifiable health information,
as applicable.
CHAPTER 40. HEALTH INSURANCE FOR CHILDREN AND PERSONS ON MEDICAID
§ 4001. Scope of chapter.
The provisions of this chapter shall apply to:
(1) Any insurer providing insurance of human beings against bodily injury, disablement or death by accident or accidental
means, or the expense thereof, or against disablement or expense resulting from sickness, and every insurance appertaining
thereto;
(2) A health service corporation, notwithstanding any provision to the contrary in Chapter 63 of this title;
(3) A health maintenance organization, notwithstanding any provision to the contrary in Chapter 64 of this title;
(4) A group health plan, as defined in § 607(1) of the federal Employee Retirement Income Security Act of 1974 [29 U.S.C.
§ 1167(1)];
(5) An entity offering a service benefit plan or a pharmacy benefit manager;
(6) A self-funded entity or group providing health care coverage;
(7) Any person or entity which provides coverage in this State for medical, surgical, chiropractic, physical therapy, speech
pathology, audiology, professional mental health, dental, hospital or optometric expenses, whether such coverage is by direct
payment, reimbursement or otherwise; and
(8) Any other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health
care item or service.
69 Del. Laws, c. 444, § 1; 76 Del. Laws, c. 190, §§ 2, 3.;
§ 4002. Health insurance for children.
(a) No health insurer shall deny enrollment of a child under the health coverage of the child's parent on the ground that:
(1) The child was born out of wedlock;
(2) The child is not claimed as a dependent on the parent's federal income tax return; or
(3) The child does not reside with the parent or in the insurer's service area.
(b) In any case in which a parent is required by a court or administrative order to provide health coverage for a child and
the parent is eligible for family health coverage through a health insurer, such health insurer shall:
(1) Permit such parent to enroll under such family coverage any such child who is otherwise eligible for such coverage (without
regard to any enrollment season restrictions);
(2) If such parent is enrolled but fails to make application to obtain coverage of such child, enroll such child under such
family coverage upon application by the child's other parent, the Family Court or by a state agency administering a program
under Part D, Title IV of the federal Social Security Act [42 U.S.C. § 651 et seq.], or Title XIX of the federal Social Security
Act [42 U.S.C. § 1396 et seq.]; and
(3) Not disenroll (or eliminate coverage of) such a child unless the health insurer is provided satisfactory written evidence
that:
a. Such court or administrative order is no longer in effect, or
b. The child is or will be enrolled in comparable health coverage through another health insurer which will take effect not
later than the effective date of such disenrollment.
(c) In any case in which a child has health coverage through the health insurer of a noncustodial parent, the insurer shall:
(1) Provide such information to the custodial parent as may be necessary for the child to obtain benefits through such coverage;
(2) Permit the custodial parent (or provider, with the custodial parent's approval) to submit claims for covered services
without the approval of the noncustodial parent; and
(3) Make payment on claims submitted in accordance with paragraph (2) directly to such custodial parent, the provider, or
the state agency administering a program under part D, Title IV of the federal Social Security Act [42 U.S.C. § 651 et seq.]
or Title XIX of the federal Social Security Act [42 U.S.C. § 1396 et seq.].
69 Del. Laws, c. 444, § 1; 71 Del. Laws, c. 216, § 12.;
§ 4003. Health insurance for persons on Medicaid.
(a) No health insurer, in enrolling an individual or in making any payments for benefits to the individual or on the individual's
behalf, shall take into account that the individual is eligible for or is provided medical assistance under a Medicaid Plan
of this State or any other state.
(b) Where a state agency has been assigned the rights of an individual eligible for medical assistance under Title XIX of
the federal Social Security Act [42 U.S.C. § 1396 et. seq.] and such individual is covered for health benefits from a health
insurer, no such health insurer shall impose requirements on the state agency that are different from requirements applicable
to an agent or assignee of any other individual so covered.
69 Del. Laws, c. 444, § 1.;
§ 4004. Definition.
(a) For the purposes of this chapter, the term "health insurer" includes, without limitation, an insurer providing insurance
of human beings against bodily injury, disablement or death by accident or accidental means, or the expense thereof, or against
disablement or expense resulting from sickness, and every insurance appertaining thereto; a health service corporation; a
health maintenance organization; a group health plan, as defined in § 607(1) of the federal Employee Retirement Income Security
Act of 1974 [29 U.S.C. § 1167(1)]; any entity offering a service benefit plan; a self-funded entity or group providing health
care coverage; a pharmacy benefit manager; any other parties that are, by statute, contract, or agreement, legally responsible
for payment of a claim for a health care item or service; and any person or other entity which provides coverage in this State
for medical, surgical, chiropractic, physical therapy, speech pathology, audiology, professional mental health, dental, hospital
or optometric expenses, whether such coverage is by direct payment, reimbursement or otherwise.
(b) "Department" means the Delaware Department of Health and Social Services.
69 Del. Laws, c. 444, § 1; 76 Del. Laws, c. 190, §§ 4, 5.;
§ 4005. Administrative procedures.
The Commissioner may issue regulations in accordance with § 314 of this title and Chapter 101 of Title 29 for the implementation
and administration of this chapter.
69 Del. Laws, c. 444, § 1.;
§ 4006. Data sharing.
The Department is authorized to require any health insurer to provide, upon the request of the Department, eligibility and
coverage information (including, but not limited to the name, address, date of birth, Social Security number, policy number,
group identification number, types of covered services under the policy, effective dates of coverage, and termination date
for each client) that will enable the Department to determine during what period Medicaid recipients may be or may have been
covered by the health insurer and the nature of the coverage that is or was provided. This information shall be referred to
as the "Plan Eligibility Data Elements." The Department may enter into agreements with the health insurers for the purpose
of carrying out the provisions of this section. The agreement shall provide for the electronic exchange of data between the
parties at a mutually agreed upon frequency and in a format specified by the Department designed to verify that an individual
has coverage, but no less frequently than once every 2 months. The agreement shall specify the data elements that shall be
included on the electronic file from the health insurer. No health insurer that provides data required by the Department,
whether confidential or not, shall be held liable for the provision of such data to the Department or for any use made thereof.
The Department shall have procedures in place to ensure compliance with the requirements of the Health Insurance Portability
and Accountability Act of 1996 [P.L. 104-191] relating to the privacy and security of individually identifiable health information,
as applicable.
CHAPTER 40. HEALTH INSURANCE FOR CHILDREN AND PERSONS ON MEDICAID
§ 4001. Scope of chapter.
The provisions of this chapter shall apply to:
(1) Any insurer providing insurance of human beings against bodily injury, disablement or death by accident or accidental
means, or the expense thereof, or against disablement or expense resulting from sickness, and every insurance appertaining
thereto;
(2) A health service corporation, notwithstanding any provision to the contrary in Chapter 63 of this title;
(3) A health maintenance organization, notwithstanding any provision to the contrary in Chapter 64 of this title;
(4) A group health plan, as defined in § 607(1) of the federal Employee Retirement Income Security Act of 1974 [29 U.S.C.
§ 1167(1)];
(5) An entity offering a service benefit plan or a pharmacy benefit manager;
(6) A self-funded entity or group providing health care coverage;
(7) Any person or entity which provides coverage in this State for medical, surgical, chiropractic, physical therapy, speech
pathology, audiology, professional mental health, dental, hospital or optometric expenses, whether such coverage is by direct
payment, reimbursement or otherwise; and
(8) Any other parties that are, by statute, contract, or agreement, legally responsible for payment of a claim for a health
care item or service.
69 Del. Laws, c. 444, § 1; 76 Del. Laws, c. 190, §§ 2, 3.;
§ 4002. Health insurance for children.
(a) No health insurer shall deny enrollment of a child under the health coverage of the child's parent on the ground that:
(1) The child was born out of wedlock;
(2) The child is not claimed as a dependent on the parent's federal income tax return; or
(3) The child does not reside with the parent or in the insurer's service area.
(b) In any case in which a parent is required by a court or administrative order to provide health coverage for a child and
the parent is eligible for family health coverage through a health insurer, such health insurer shall:
(1) Permit such parent to enroll under such family coverage any such child who is otherwise eligible for such coverage (without
regard to any enrollment season restrictions);
(2) If such parent is enrolled but fails to make application to obtain coverage of such child, enroll such child under such
family coverage upon application by the child's other parent, the Family Court or by a state agency administering a program
under Part D, Title IV of the federal Social Security Act [42 U.S.C. § 651 et seq.], or Title XIX of the federal Social Security
Act [42 U.S.C. § 1396 et seq.]; and
(3) Not disenroll (or eliminate coverage of) such a child unless the health insurer is provided satisfactory written evidence
that:
a. Such court or administrative order is no longer in effect, or
b. The child is or will be enrolled in comparable health coverage through another health insurer which will take effect not
later than the effective date of such disenrollment.
(c) In any case in which a child has health coverage through the health insurer of a noncustodial parent, the insurer shall:
(1) Provide such information to the custodial parent as may be necessary for the child to obtain benefits through such coverage;
(2) Permit the custodial parent (or provider, with the custodial parent's approval) to submit claims for covered services
without the approval of the noncustodial parent; and
(3) Make payment on claims submitted in accordance with paragraph (2) directly to such custodial parent, the provider, or
the state agency administering a program under part D, Title IV of the federal Social Security Act [42 U.S.C. § 651 et seq.]
or Title XIX of the federal Social Security Act [42 U.S.C. § 1396 et seq.].
69 Del. Laws, c. 444, § 1; 71 Del. Laws, c. 216, § 12.;
§ 4003. Health insurance for persons on Medicaid.
(a) No health insurer, in enrolling an individual or in making any payments for benefits to the individual or on the individual's
behalf, shall take into account that the individual is eligible for or is provided medical assistance under a Medicaid Plan
of this State or any other state.
(b) Where a state agency has been assigned the rights of an individual eligible for medical assistance under Title XIX of
the federal Social Security Act [42 U.S.C. § 1396 et. seq.] and such individual is covered for health benefits from a health
insurer, no such health insurer shall impose requirements on the state agency that are different from requirements applicable
to an agent or assignee of any other individual so covered.
69 Del. Laws, c. 444, § 1.;
§ 4004. Definition.
(a) For the purposes of this chapter, the term "health insurer" includes, without limitation, an insurer providing insurance
of human beings against bodily injury, disablement or death by accident or accidental means, or the expense thereof, or against
disablement or expense resulting from sickness, and every insurance appertaining thereto; a health service corporation; a
health maintenance organization; a group health plan, as defined in § 607(1) of the federal Employee Retirement Income Security
Act of 1974 [29 U.S.C. § 1167(1)]; any entity offering a service benefit plan; a self-funded entity or group providing health
care coverage; a pharmacy benefit manager; any other parties that are, by statute, contract, or agreement, legally responsible
for payment of a claim for a health care item or service; and any person or other entity which provides coverage in this State
for medical, surgical, chiropractic, physical therapy, speech pathology, audiology, professional mental health, dental, hospital
or optometric expenses, whether such coverage is by direct payment, reimbursement or otherwise.
(b) "Department" means the Delaware Department of Health and Social Services.
69 Del. Laws, c. 444, § 1; 76 Del. Laws, c. 190, §§ 4, 5.;
§ 4005. Administrative procedures.
The Commissioner may issue regulations in accordance with § 314 of this title and Chapter 101 of Title 29 for the implementation
and administration of this chapter.
69 Del. Laws, c. 444, § 1.;
§ 4006. Data sharing.
The Department is authorized to require any health insurer to provide, upon the request of the Department, eligibility and
coverage information (including, but not limited to the name, address, date of birth, Social Security number, policy number,
group identification number, types of covered services under the policy, effective dates of coverage, and termination date
for each client) that will enable the Department to determine during what period Medicaid recipients may be or may have been
covered by the health insurer and the nature of the coverage that is or was provided. This information shall be referred to
as the "Plan Eligibility Data Elements." The Department may enter into agreements with the health insurers for the purpose
of carrying out the provisions of this section. The agreement shall provide for the electronic exchange of data between the
parties at a mutually agreed upon frequency and in a format specified by the Department designed to verify that an individual
has coverage, but no less frequently than once every 2 months. The agreement shall specify the data elements that shall be
included on the electronic file from the health insurer. No health insurer that provides data required by the Department,
whether confidential or not, shall be held liable for the provision of such data to the Department or for any use made thereof.
The Department shall have procedures in place to ensure compliance with the requirements of the Health Insurance Portability
and Accountability Act of 1996 [P.L. 104-191] relating to the privacy and security of individually identifiable health information,
as applicable.
