Primary care coverage [For applicability of section, see 84 Del. Laws, c. 25, § 2].
Del. Code tit. 18, § 3556A
in effect(a) For purposes of this section:
(1) a. “Carrier” means any entity that provides health insurance in this State. “Carrier” includes an insurance company, health service corporation, health maintenance organization, and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation. “Carrier” also includes any third-party administrator or other entity that adjusts, administers, or settles claims in connection with health benefit plans.
b. “Carrier” does not mean a plan of health insurance or health benefits designed for issuance to persons eligible for coverage under Titles XVIII, XIX, and XXI of the Social Security Act (42 U.S.C. §§ 1395 et seq., 1396 et seq. and 1397aa. et seq.), known as Medicare, Medicaid, or any other similar coverage under state or federal governmental plans.
(2) “Chronic care management” means the services in the Chronic Care Management Services Program, as administered by the Centers for Medicare and Medicaid Services, and includes Current Procedural Terminology (“CPT”) codes 99487, 99489, and 99490.
(3) “Medicare” means the federal Medicare Program (U.S. Public Law 89-87, as amended) (42 U.S.C. § 1395 et seq.).
(4) “Primary care” means health care provided by a physician or an individual licensed under Title 24 to provide health care, with whom the patient has initial contact and by whom the patient may be referred to a specialist and includes family practice, pediatrics, internal medicine, and geriatrics.
(b) (1) A carrier shall provide coverage for chronic care management and primary care at a reimbursement rate that is not less than the Medicare reimbursement for comparable services.
(2) This subsection applies to a group health insurance policy, plan, or contract that is delivered, issued for delivery, or renewed by a carrier on or after January 1, 2019.
(3) A carrier shall do the following:
a. By 2022, spend at least 7% of its total cost of medical care on primary care.
b. By 2023, spend at least 8.5% of its total cost of medical care on primary care.
c. By 2024, spend at least 10% of its total cost of medical care on primary care.
d. By 2025, spend at least 11.5% of its total cost of medical care on primary care.
e. By 2026 and each year thereafter, spend at least 11.5%, 5% of which must be via prospective primary care management payments, of its total cost of medical care on primary care.
(c) If a comparable Medicare reimbursement rate is not available, a carrier shall reimburse for services at the rates generally available under Medicare for services such as office visits and prolonged preventive services, which may be further delineated by regulation.
(d) (1) The Department shall arbitrate disagreements regarding rates under this section. The parties must pay the cost of the arbitration.
(2) The Department shall adopt regulations to implement the requirements of this subsection no later than March 31, 2019.
(e) The provisions of this section may not be waived by contract. Any contractual arrangement in conflict with the provisions of this section or that purports to waive any requirements of this section is void.
(f) Coverage for chronic care management must not be subject to patient deductibles, copayments, or fees.
(g) (1) A carrier shall offer value-based care programs that meet the program design element requirements issued by the Department by the first full plan year following the Department’s promulgation of regulations pursuant to § 334 of this title.
(2) A carrier may not deny a contracted provider the opportunity to participate in an offered value-based care program if the provider is willing to accept the terms and conditions established for other providers as a condition of program participation.
(h) In calculating total cost of medical care for purposes of this section, the Commissioner shall, by regulation, authorize the exclusion of high-cost claims and may authorize the exclusion of other costs actually incurred by carriers.
Source: DE Code (Official Site)URL: https://delcode.delaware.gov/title18/c035/sc03/index.htmlFetched: 10/4/2026