Delaware Statutes

This law amends section 3343, Title 18 and section 3571V, Title 18 of the Delaware Code by requiring health benefit plans that cover prescription drugs to place at least one formulation of each of the FDA-approved MAT drugs on the lowest tier of the carrier’s prescription drug formulary. Such drugs must be covered without prior authorization. Additionally, the law requires that at least one formulary of each medication within each tier be available without step-therapy requirements.  Finally, plans must provide coverage for fees associated with the dispensing and administration of methadone at opioid treatment programs.

Enacted by HB 220

S.B. 230 amended Title 18 of the Delaware Code, §3343, by inserting a new provision, §3343(g), which requires insurers to submit annual reports to demonstrate compliance with the Federal Parity Law. S.B. 230 also amended Chapter 35, Title 18 of the Delaware Code by adding a new §3571T, which sets reporting requirements for private insurers. This bill also amends Title 31 of the Delaware Code, §525, to set the same requirements for public insurers.

16 Del. C. §§ 5195, 5196, 5197

16 Del. C. §§ 5195, 5196, 5197 establishes a Behavioral Health Consortium that will develop a statewide integrated plan for addressing the prevention and treatment of substance use and mental health, and provide oversight and coordination of the State’s private and public bodies to address behavioral health issues in Delaware. As a coordinate body, the Consortium will streamline processes to better address potential gaps and ensure quality delivery of care across the State. Emphasis will be placed on assuring that behavioral health related public commissions and committees do not operate in siloes, but instead have a resource for policy and practice recommendations.
The Consortium reports to the Governor or General Assembly and makes recommendations for legislative action to ensure quality delivery and expanded access to behavioral healthcare. There are 25 members in the Consortium, which includes diverse stakeholders to ensure geographical representation, subject matter experience and cultural competence. Representation includes members from government, hospitals, behavioral health providers, education, advocacy, insurance, and private citizens. Nine of the members are appointed by virtue of their respective positions, twelve are appointed by the Governor, two Senators are appointed by the President Pro Tempore of the Senate, and two members of the House of Representatives are appointed by the Speaker of the House.

Enacted by SB 111 on August 16, 2017, which created 16 Del. C. §§ 5195, 5196, 5197, further modified by SB 143 which was enacted on April 5, 2018.

• Specifies that substance use disorder coverage must include inpatient care and residential treatment that complies with the Federal Parity Law.
• Requires individual plans and large group plans that cover prescription medications to provide 5 days of “emergency” prescription medications without prior authorization for the treatment of behavioral health conditions, including medications used to treat opioid use disorders. This includes withdrawal and management medications along with overdose reversal medications.
• Prohibits individual plans and large group plans from requiring prior authorization for any substance use disorder treatment, including inpatient treatment.
• Prohibits individual plans and large group plans from requiring concurrent review of inpatient substance use disorder treatment for the first 14 days provided that the facility contacts the insurer within 48 hours of admission and so long as the facility is using clinical review tool of the American Society of Addiction Medicine (ASAM).
• Allows individual plans and large group plans to perform retrospective review on the first 14 days of inpatient substance use disorder treatment but only may deny reimbursement if the treatment was not medically necessary according to the ASAM clinical review tool.
• Specifies that an individual receiving treatment in an inpatient behavioral health facility does not have to pay for any care provided other than copays, coinsurance, or deductibles.

• Specifies that substance use disorder coverage must include intensive outpatient programs and inpatient withdrawal management that complies with the Federal Parity Law.
• Prohibits individual plans and large group plans from requiring concurrent review for the first 30 days of intensive outpatient programs for substance use disorder treatment and the first 5 days of inpatient withdrawal management.
• Allows individual plans and large group plans to perform retrospective review on the first30 days of intensive outpatient programs for substance use disorder treatment and the first 5 days of inpatient withdrawal management but only may deny reimbursement if the treatment was not medically necessary according to the ASAM clinical review tool.
• Applies all of the commercial insurance behavioral health coverage requirements to Medicaid managed care plans.

This bill added the sections to the state insurance law about autism coverage (these sections are summarized at the bottom of this page under “Delaware Parity Law,” “Autism Coverage”).