Title 18, Insurance Code

§ 3303A. Pharmacy benefit manager contract [For application of this section, see 80 Del. Laws, c. 245, § 2]. An amendment to pharmacy audit terms in a contract between a PBM and a pharmacy must be disclosed to the pharmacy at least 60 days prior to the effective date of the propo…

§ 3303B. Definitions [Effective Jan. 1, 2028]. As used in this chapter: (1) “Carrier” means any entity that provides or contracts for insurance or health benefits in this State. “Carrier” includes an insurance company, health service corporation, health maintenance organization, …

§ 3304. Required provisions; captions; omissions; substitutions. (a) Except as provided in subsection (b) of this section below, each such policy delivered or issued for delivery to any person in this State shall contain the provisions specified in §§ 3305-3316, inclusive, of thi…

§ 3304A. Procedure and process for conducting and reporting an audit [For application of this section, see 80 Del. Laws, c. 245, § 2; 85 Del. Laws, c. 481, § 7]. (a) Audit procedures. — Unless otherwise prohibited by federal requirements or regulations, any entity conducting a ph…

§ 3304B. General responsibilities of carriers [Effective Jan. 1, 2028]. (a) A carrier that requires provider credentialling prior to the reimbursement or settlement of claims shall do all of the following: (1) Establish written policies and procedures for credentialing of health-…

§ 3305. Entire contract; changes. There shall be a provision as follows: “Entire Contract; Changes: This policy, including the endorsements and the attached papers, if any, constitutes the entire contract of insurance. No change in this policy shall be valid until approved by an …

§ 3305A. Requirements for recoupment or chargeback [For application of this section, see 80 Del. Laws, c. 245, § 2]. For recoupment or chargeback, the following criteria apply: (1) Audit parameters must consider consumer-oriented parameters based on manufacturer listings. (2) The…

§ 3305B. Application for credentialing, recredentialing [Effective Jan. 1, 2028]. (a) Beginning January 1, 2028, a carrier or its credentialing intermediary may not use any credentialing application other than the uniform credentialing application. (b) A carrier shall do all of t…

§ 3306. Time limit on certain defenses. (a) There shall be a provision as follows: “Time Limit on Certain Defenses: (1) After 2 years from the date of issue of this policy, no misstatements, except fraudulent misstatements, made by the applicant in the application for such policy…

§ 3306A. Documentation [For application of this section, see 80 Del. Laws, c. 245, § 2]. (a) To validate the pharmacy record and delivery, the pharmacy may use authentic and verifiable statements or records including medication administration records of a nursing home, assisted l…

§ 3306B. Health-care professional’s right to review credentialing information [Effective Jan. 1, 2028]. (a) Each health-care professional subject to credentialing has the right to review all information, including the source of that information, obtained by the carrier to satisfy…

§ 3307. Grace period. There shall be a provision as follows: “A grace period of . . . (insert a number not less than “7” for weekly premium policies, “10” for monthly premium policies and “31” for all other policies) days will be granted for the payment of each premium falling du…

§ 3307A. Appeals process [For application of this section, see 80 Del. Laws, c. 245, § 2]. The entity conducting the audit must establish a written appeals process which must include appeals of preliminary reports and final reports.80 Del. Laws, c. 65, § 1; 80 Del. Laws, c. 245, …

§ 3307B. Credentialing and recredentialing [Effective Jan. 1, 2028]. (a) Within 15 days of receipt of a uniform credentialing application, a carrier shall send to the health-care professional notice of either of the following: (1) The carrier’s confirmation that the submission wa…

§ 3308. Reinstatement. (a) There shall be a provision as follows: “Reinstatement: If any renewal premium be not paid within the time granted the insured for payment, a subsequent acceptance of premium by the insurer or by any agent duly authorized by the company to accept such pr…

§ 3308A. Audit information and reports [For application of this section, see 80 Del. Laws, c. 245, § 2]. (a) A preliminary audit report must be delivered to the pharmacy within 30 days after the conclusion of the audit. The preliminary audit report shall contain claim level infor…

§ 3308B. Provisional credentialing [Effective Jan. 1, 2028]. (a) Carriers must provide provisional credentials to health-care professionals who have submitted the uniform credentialing application from the date of notice of a clean application, effective until the credentialing a…

§ 3309. Notice of claim. (a) There shall be a provision as follows: “Notice of Claim: Written notice of claim must be given to the company within twenty days after the occurrence or commencement of any loss covered by the policy, or as soon thereafter as is reasonably possible. N…

§ 3309A. Disclosures to plan sponsor [For application of this section, see 80 Del. Laws, c. 245, § 2; 85 Del. Laws, c. 481, § 7]. Where contractually required, an auditing entity must provide a copy to the plan sponsor of all claims that were included in the audit, and any recoup…

§ 3309B. Payments to health-care professionals for services rendered during pendency of credentialing [Effective Jan. 1, 2028]. (a) A carrier must pay claims for services rendered by a health-care professional prior to credentialing from the date a complete application for creden…

§ 3310. Claim. There shall be a provision as follows: “Claim Forms: The company, upon receipt of a notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within fifteen days after the givi…

§ 3310A. Applicability of other laws and regulations [For application of this section, see 80 Del. Laws, c. 245, § 2; 85 Del. Laws, c. 481, § 7] The provisions of this subchapter do not apply to an investigative audit of pharmacy records when any of the following apply: (1) Fraud…

§ 3310B. Denial, suspension, nonrenewal, and termination of credentialing [Effective Jan. 1, 2028]. (a) (1) A carrier may not deny, suspend, nonrenew, or terminate a health-care professional’s credentials unless the carrier provides a written explanation prior to the termination …

§ 3311. Proofs of loss. There shall be a provision as follows: “Proofs of Loss: Written proof of loss must be furnished to the company at its said office in case of claim for loss for which this policy provides any periodic payment contingent upon continuing loss within ninety da…

§ 3311B. Complaints and penalties [Effective Jan. 1, 2028]. (a) Complaints and allegations of violations of this chapter may be filed with the state agency regulating relevant carrier activities. If the agency to whom the complaint is addressed determines it to be more appropriat…

§ 3312. Time of payment of claims. There shall be a provision as follows: “Time of Payment of Claims: Indemnities payable under this policy for any loss other than loss for which this policy provides any periodic payment will be paid immediately upon receipt of due written proof …

§ 3312B. Certification of workers compensation health-care providers [Effective Jan. 1, 2028]. (a) Nothing in this chapter may be construed to supersede, limit, or otherwise interfere with the provisions set forth in §§ 2322A through 2322F of Title 19 relating to the certificatio…

§ 3313. Payment of claims. (a) There shall be a provision as follows: “Payment of Claims: Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time …

§ 3314. Physical examination; autopsy. There shall be a provision as follows: “Physical Examinations and Autopsy: The company at its own expense shall have the right and opportunity to examine the person of the insured when and as often as it may reasonably require during the pen…

§ 3315. Legal actions. There shall be a provision as follows: “Legal Actions: No action at law or in equity shall be brought to recover on this policy prior to the expiration of sixty days after written proof of loss has been furnished in accordance with the requirements of this …

§ 3316. Change of beneficiary. (a) There shall be a provision as follows: “Change of Beneficiary: Unless the insured make an irrevocable designation of beneficiary, the right to change the beneficiary is reserved to the insured and the consent of the beneficiary or beneficiaries …

§ 3317. Optional policy provisions. Except as provided in § 3304 of this title, no such policy delivered or issued for delivery to any person in this State shall contain provisions respecting the matters set forth in §§ 3318-3325, inclusive, of this title unless such provisions a…

§ 3318. Change of occupation. There may be a provision as follows: “Change of Occupation: If the insured be injured or contract sickness after having changed his/her occupation to one classified by the company as more hazardous than that stated in this policy or while doing for c…

§ 3319. Misstatement of age. There may be a provision as follows: “Misstatement of Age: If the age of the insured has been misstated, all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age.”18 Del. C. 1953, § 3319; 56 Del. …

§ 3320. Overinsurance; all coverages. (a) There may be a provision as follows: “Overinsurance: If, with respect to a person covered under this policy, benefits for allowable expense incurred during a claim determination period under this policy together with benefits for allowabl…

§ 3321. Relation of earnings to insurance. (a) There may be a provision as follows: “After the loss-of-time benefit of this policy has been payable for 90 days, such benefit will be adjusted, as provided below, if the total amount of unadjusted loss-of-time benefits provided in a…

§ 3321A. Definitions [For application of this section, see 80 Del. Laws, c. 245, § 2; 85 Del. Laws, c. 481, § 7] For purposes of this subchapter: (1) “Claim” means a request from a pharmacy or pharmacist to be reimbursed for the cost of filling or refilling a prescription for a d…

§ 3322. Unpaid premiums. There may be a provision as follows: “Unpaid Premium: Upon the payment of a claim under this policy, any premium then due and unpaid or covered by any note or written order may be deducted therefrom.”18 Del. C. 1953, § 3323; 56 Del. Laws, c. 380, § 1; 80 …

§ 3322A. Exclusions [For application of this section, see 80 Del. Laws, c. 245, § 2]. This subchapter does not apply to the Department of Health and Human Services in the performance of its duties in administering fee-for-service Medicaid under Titles XIX and XXI of the Social Se…

§ 3323. Conformity with state statutes. There may be a provision as follows: “Conformity with State Statutes: Any provision of this policy which, on its effective date is in conflict with the statutes of the state in which the insured resides on such date is hereby amended to con…

§ 3323A. Requirements for maximum allowable cost pricing [For application of this section, see 80 Del. Laws, c. 245, § 2; and 83 Del. Laws, c. 256, § 15]. (a) To place a drug on a maximum allowable cost list, a pharmacy benefits manager must ensure that the drug meets all of the …

§ 3324. Illegal occupation. There may be a provision as follows: “Illegal Occupation: The company shall not be liable for any loss to which a contributing cause was the insured’s commission of or attempt to commit a felony or to which a contributing cause was the insured’s being …

§ 3324A. Appeals [For application of this section, see 80 Del. Laws, c. 245, § 2; 83 Del. Laws, c. 256, § 15; 85 Del. Laws, c. 481, § 7]. (a) (1) a. A pharmacy benefits manager must establish a process by which a contracted pharmacy can appeal the amount of the provider’s reimbur…

§ 3325. Intoxicants and narcotics. There may be a provision as follows: “Intoxicants and Narcotics: The company shall not be liable for any loss sustained or contracted in consequence of the insured’s being intoxicated or under the influence of any narcotic unless administered on…

§ 3325A. Reimbursement for and provision of pharmacy goods or services For application of this section, see 83 Del. Laws, c. 256, § 15]. (a) For purposes of this section: (1) “Affiliate” means a pharmacy or pharmacist that directly or indirectly, through 1 or more intermediaries,…

§ 3326. Renewability. Health insurance policies, other than accident insurance only policies, in which the insurer reserves the right to refuse renewal on an individual basis, shall provide in substance in a provision thereof or in an endorsement thereon or rider attached thereto…