{"data":{"id":"us-de/29-del.-c.-5204","jurisdiction":"us-de","citation":"29 Del. C. § 5204","heading":"Selection of the group insurance carrier.","body":"(a) The health-care insurance coverage shall be provided through a carrier incorporated under the laws of this State or legally authorized to transact business within this State, having adequate servicing facilities to carry out the terms of the contract.\n(b) The health-care insurance coverage shall be provided by a carrier offering, at the employee’s or pensioner’s own expense, optional supplemental or extended benefits coverage to each regular employee or eligible pensioner and similar hospital, surgical/medical and supplemental or extended coverage for such employee’s or pensioner’s spouse and dependents.\n(c) (1) For plan year 2030 and thereafter, as set forth in paragraphs (c)(16) and (c)(17) of this section, health-care insurance shall be provided by a carrier whose cost per inpatient hospital service, outpatient service, and emergency department service may not exceed the applicable Medicare reference-based pricing target set forth in paragraph (c)(16) of this section, as of the date of service, for comparable services for the applicable plan year, and free-standing children's hospital outpatient Medicare rates may not exceed the applicable Medicare reference-based pricing target set forth in paragraph (c)(17) of this section, as of the date of service. For such services under the Group Health Insurance Plan, a covered individual is not liable for payment of any amount other than the copayments, coinsurance, and deductibles applicable under the terms of the covered individual’s health benefit plan, as determined by the network status of the provider. Any such cost sharing shall be calculated based on the carrier’s allowed payment amount. A covered individual shall not be billed or charged any amount in excess of the carrier’s allowed payment for such services.\n(2) “Emergency department service” means services generally performed in an emergency department, including trauma services, triage, and observation.\n(3) “Free-standing children's hospital” means a dedicated, independent pediatric facility, not integrated within a general adult hospital, identified by the Center for Medicaid and CHIP Services (CMCS) as a hospital that provides specialized care for infants, children, teens, and individuals predominately under 18 years of age.\n(4) “Free-standing children's hospital Medicare outpatient payment rate” means, for purposes of free-standing children's hospitals, payments for free-standing children's hospitals that include all payments made under the Medicare Outpatient Prospective Payment System (OPPS), as established August 1, 2000, and codified at 42 C.F.R. Part 419.\n(5) “Full Medicare rate” means the applicable wage-adjusted Medicare rate, inclusive of any applicable adjustments, as updated by the Centers for Medicare and Medicaid Services (CMS) on an annual basis.\n(6) “Inpatient hospital service” means services generally performed in an inpatient acute hospital care setting, including general inpatient hospital services covered under Medicare Part A, labor and delivery, and intensive care.\n(7) “Medicare” means the federal Medicare Program (U.S. Public Law 89-87, as amended; 42 U.S.C. § 1395 et seq.).\n(8) “Medicare-dependent rural hospital” means a hospital that meets at least 1 of the following requirements for the applicable plan year:\na. The hospital meets the definition of a Medicare-dependent hospital as defined under 42 C.F.R. § 412.108 for at least 3 of the 5 years immediately preceding the applicable plan year.\nb. The hospital operates solely within a county that is classified by the federal Health Resources and Services Administration (HRSA) as a rural health area, a medically underserved area, and a health professional shortage area for primary care, and the hospital’s gross patient revenue attributed to Medicare patients accounts for more than 60% of its total gross patient revenue.\n(9) “Medicare reference-based (RBP) target” means a percentage of the full Medicare rate as set forth in paragraph (c)(5) of this section. With respect to free-standing children's hospitals, “Medicare reference-based (RBP) targets” has the meaning as defined in paragraph (c)(17) of this section.\n(10) “Nonprofessional services” means services categorized as inpatient hospital, outpatient hospital, and other medical services. “Nonprofessional services” does not include professional services.\n(11) “Outpatient service” means nonprofessional services not otherwise captured in the definition of Inpatient Hospital Service or emergency department service.\n(12) “Professional services” includes primary care, dental, specialist, therapy, the professional component of laboratory and radiology, and similar services, other than the facility fee component of hospital-based services.\n(13) “TEFRA rate” means the target amount under the federal Tax Equity and Fiscal Responsibility Act (TEFRA) Waiver Program applicable to free-standing children's hospitals set forth in 42 U.S.C. § 1395ww(b), including any updates and adjustments thereto.\n(14) “Urban Medicaid DSH hospital” means a hospital that met the criteria described in § 1923(b) of the federal Social Security Act (42 U.S.C. § 1369r-4(b)) and received Medicaid Disproportionate Share Hospital Program (DSH) payments from this State between July 1, 2021, and July 1, 2026.\n(15) If a comparable Medicare reimbursement rate is not available, reimbursement for services under the State Group Health Insurance Plan shall be determined using the Medicare rates generally applicable to similar services, as reasonably determined by the Statewide Benefits Office.\n(16) Applicable Medicare reference-based pricing targets for inpatient hospital services, outpatient services, and emergency department services. Unless otherwise specified in this section, services provided by non-free-standing children’s hospitals shall reflect Medicare reference-based pricing targets as follows:\na. For plan years 2030 and 2031, all of the following apply:\n1. 275% of the full Medicare rate for outpatient services.\n2. 310% of the full Medicare rate for inpatient hospital services and emergency department services.\nb. For plan years 2032 and 2033, all of the following apply:\n1. 250% of the full Medicare rate for outpatient services.\n2. 275% of the full Medicare rate for inpatient hospital services and emergency department services.\nc. Beginning with plan year 2034, 250% of the full Medicare rate for inpatient hospital services, outpatient services, and emergency department services.\n(17) Applicable Medicare reference-based pricing targets for free-standing children’s hospitals. Unless otherwise specified in this section, services provided by free-standing children’s hospitals shall reflect Medicare reference-based pricing targets as follows:\na. For plan years 2030 and 2031, all of the following apply:\n1. 275% of the free-standing children’s hospital Medicare outpatient payment rate for outpatient services.\n2. 310% of the TEFRA rate for inpatient hospital services.\n3. 310% of the free-standing children’s hospital Medicare outpatient payment rate for emergency department services.\nb. For plan years 2032 and 2033, all of the following apply:\n1. 250% of the free-standing children’s hospital Medicare outpatient payment rate for outpatient services.\n2. 275% of the TEFRA rate for inpatient hospital services.\n3. 275% of the free-standing children’s hospital Medicare outpatient payment rate for emergency department services.\nc. Beginning with plan year 2034, all of the following apply:\n1. 250% of the free-standing children’s hospital Medicare outpatient payment rate for outpatient services.\n2. 250% of the TEFRA rate for inpatient hospital services.\n3. 250% of the free-standing children’s hospital Medicare outpatient payment rate for emergency department services.\n(18) Reference-based pricing target exemptions and modifications. —\nParagraphs (c)(1) through (c)(17) of this section do not apply in any of the following circumstances:\na. When a hospital meets the definition of a Medicare-dependent rural hospital pursuant to paragraph (c)(8)a. of this section.\nb. When a hospital meets the definition of a Medicare-dependent rural hospital pursuant to paragraph (c)(8)b. of this section and the Office of Value-Based Health Care Delivery has determined that the hospital has made demonstrative progress in adopting and implementing value-based payment models.\nc. When a hospital meets the definition of an urban Medicaid DSH hospital under this section.\nd. When the carrier and the hospital or applicable contracting provider entity are participants in a federal or state multi-payer global budget model approved by the Department under § 2503(a)(15)o.3. and (a)(15)p. of Title 18. The Department shall provide notice annually of global budget models that are approved pursuant to this paragraph (c)(18)d.\n(d) The health-care insurance coverage shall be provided by a carrier offering value-based care programs equivalent to those required by §§ 3342B and 3556A of Title 18.","path":["Title 29. State Government","Public Officers and Employees","CHAPTER 52. Health Care Insurance"],"source_url":"https://delcode.delaware.gov/title29/c052/index.html#5204","current_through":"2026-08-10 (85 Del. Laws, c. 421, 424)","vintage":"","retrieved_at":"2026-09-05T23:02:33Z","sha256":"3acaae2fc859287cff83f816b1656d9c13747c6c3251daebf618314c0ab9b559","source_id":"us-de","stale":true,"prev":"us-de/29-del.-c.-5203a","next":"us-de/29-del.-c.-5205"},"notice":"GroundRules: Original legal text. Not legal advice."}