18 Del. Admin. Code § 1405-8.0

Current through Register Vol. 28, No. 5, November 1, 2024

Section 1405-8.0 - Benefit Requirements

8.1 Each health benefit plan coverage offered to an association or MEWA in compliance with 18 Del.C. § 3506 shall, at a minimum, provide:

8.1.1 Essential Health Benefits as defined in 42 USC §18022(b)(1) (see Pub. L. 111-148, Title I, §1302, Title X, §10104(b), Mar. 23, 2010, 124 Stat. 163, 896, incorporated herein by reference), except that pediatric dental and vision coverage as required in this subsection may be offered to the association in either a stand-alone dental or vision plan or as a benefit embedded in the health benefit plan;

8.1.2 Cost sharing requirements of 42 USC §18022(c)(1), (c)(3) (see Pub. L. 111-148, Title I, §1302, Title X, §10104(b), Mar. 23, 2010, 124 Stat. 163, 896, incorporated herein by reference);

8.1.3 Lifetime and annual limits as prescribed in 29 CFR 2590.715-2711 (see 80 FR 72261, Nov. 18, 2015, as amended at 81 FR 75325, Oct. 31, 2016, incorporated herein by reference);

8.1.4 A level of coverage designed to provide benefits that are actuarially equivalent to 60 percent of the full actuarial value of the benefits provided under the plan;

8.1.5 All other insurance requirements and benefit mandates for health insurers as provided in 18 Del.C. Chs. 35 and 72, as applicable and as may be amended, any regulations promulgated pursuant thereto, and as specified by regulation by the Commissioner; and

8.1.6 All other benefits required to comply with applicable federal laws and regulations.

8.2 Every health benefit plan offered by any insurer to an association or a MEWA shall include a process for subscribers to appeal adverse benefit determinations that complies with the requirements of 18 Del.C. § 6418 and 18 DE Admin. Code 1301.

8.3 An insurer shall not deliver or issue for delivery an association or MEWA health benefit plan covering lives located in Delaware that contains an exclusion or limitation for pre-existing conditions or a waiting period on the coverage of pre-existing conditions.

8.4 Regardless of the collective size of the fully insured association or MEWA, health benefit plans issued to small employers shall comply with all insurance laws applicable to small employer groups as required by 18 DE Admin. Code 1308-3.3

18 Del. Admin. Code § 1405-8.0

22 DE Reg. 509 (12/1/2018) (Final)