DelawareSB 12153rd General Assembly (2024–2026)SenateWALLET

AN ACT TO AMEND TITLE 18 AND TITLE 29 OF THE DELAWARE CODE RELATING TO THE DELAWARE PRE AUTHORIZATION ACT OF 2025.

Sponsored By: Bryan Townsend (Democratic)

Signed by Governor

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Bill Overview

Analyzed Economic Effects

9 provisions identified: 8 benefits, 0 costs, 1 mixed.

Advance warning protects patients with approved care

These protections cover policies issued, renewed, changed, or reissued after December 31, 2026. Plans must give at least 60 days' written notice before introducing or changing prior approval requirements or restrictions. Notice goes to patients already approved for the affected service and its contracted providers. Changes to review terms, including clinical criteria, require at least 6 months' notice and cannot affect existing approvals until reauthorization. The 6-month notice rule has exceptions for clinical guideline status changes, recalls, market withdrawals, and relevant FDA safety information.

Faster care approval decisions for patients

These rules cover Delaware policies issued, renewed, changed, or reissued after December 31, 2026. Review entities must decide complete routine-care requests within 3 business days through the law's standard electronic service, or 5 otherwise. The old limits were 5 and 8 business days; medicine requests still have a 2-business-day deadline. Urgent-care and patient-transfer decisions are due within 24 hours through that electronic service, or 48 hours otherwise. Requests must include any required exam or second-opinion results, and providers must receive notice of denials within these deadlines. Urgent care qualifies when the treating doctor determines that delay risks serious long-term harm or materially worsens the patient's condition and outlook.

Longer approvals and fewer repeat patient requests

For policies issued, renewed, changed, or reissued after December 31, 2026, care approvals must last a reasonable, customary period. The minimum rises from 60 to 90 days after the provider receives approval, subject to continued coverage, eligibility, and properly notified policy changes. Plans generally cannot require more than one approval for an in-network episode of care for one condition. Separate approval remains allowed for new treatment, tests, or procedures, even when related to that condition. Approval for one service in a payment bundle also approves the bundle's other covered services provided in-network.

No approval hurdle for qualifying patient transport

The law bars prior approval requirements for medically necessary transport between care facilities in a specific situation. The health plan must have determined that a lower level of care is clinically appropriate. This protection applies to policies issued, renewed, changed, or reissued after December 31, 2026.

Patients get clearer appeals and weekend reviews

For policies issued, renewed, changed, or reissued after December 31, 2026, patients get at least 30 days to appeal denials. Review entities must accept appeals in writing, electronically, or by phone and notify patients and submitting providers within 15 days. If more records are needed, entities must request them in writing within those 15 days and decide within 15 days after receipt. Written decisions must explain findings, reviewer qualifications, how the diagnosis relates to review criteria, and the specific decision basis. Reviews must occur on weekends, with clinical decision-makers available weekdays from 7 a.m. to 7 p.m. and reasonable weekend business hours.

Qualified clinicians review patient denials and appeals

These safeguards cover complete requests under policies issued, renewed, changed, or reissued after December 31, 2026. A U.S.-licensed doctor must make denials of doctor-submitted requests, with relevant specialty expertise or consultation with a qualified provider. Pay for the reviewing doctor and consulting provider cannot depend on the outcome. Appeals require a different qualified doctor with an unrestricted license in good standing, who reviews clinical facts and submitted medical records. Nonphysician requests require denial and appeal review by a similarly licensed professional, or a licensed provider consulting a qualified third-party specialist.

New Medicaid contracts include feasible approval protections

Beginning January 1, 2027, Delaware's health department must include these approval rules in new Medicaid-related carrier contracts when feasible. The duty applies to contracts awarded after the effective date. This contracting rule does not change who qualifies for Medicaid or benefit amounts.

State employee plans must follow approval protections

Beginning January 1, 2027, Delaware's State Employee Benefits Committee must ensure state employee health plan carriers follow these approval rules. This gives the committee responsibility for enforcing compliance by carriers serving those group plans.

New online approval tools and provider rules

By January 1, 2027, plans and review entities must accept electronic approval requests and reply through the same submission method. Provider portals must offer request submission, medical policies, peer-to-peer review information, clinical and administrative contacts, forms, and outage instructions. Plans may require portal use within 12 months of setup, except during outages, without provider access, or when alternatives are allowed. Fax, proprietary payer portals, and nonstandard electronic forms do not count as the law's standard electronic transmission.

Sponsors & Cosponsors

Sponsor

Bryan Townsend
Democratic • Senate

Cosponsors

William J. Carson
Democratic • House
Mara Gorman
Democratic • House
Krista Griffith
Democratic • House
Kyra L. Hoffner
Democratic • Senate
Russell Huxtable
Democratic • Senate
Melissa Minor-Brown
Democratic • House
Eric Morrison
Democratic • House
Nicole Poore
Democratic • Senate
Bryant L. Richardson
Republican • Senate
Cyndie Romer
Democratic • House
Melanie Ross Levin
Democratic • House
Ray Seigfried
Democratic • Senate
David P. Sokola
Democratic • Senate
John "Jack" Walsh
Democratic • Senate

Roll Call Votes

All Roll Calls

Yes: 59 • No: 0

House vote • 6/25/2025

Passed (SM required)

Yes: 39 • No: 0

Senate vote • 5/15/2025