The national guide covers medical plan designs (indemnity, HMO, PPO, EPO, POS), cost-sharing, HSAs and FSAs. Delaware adds rules on dependent coverage, prompt payment, external review and arbitration, and underwriting limits. They come mainly from 18 Del. C. Chapters 23, 33, 35 and Regulations 1301 and 1310.

Dependents

• Newborns are covered from the moment of birth: injury, sickness, congenital defects and routine infant care. The policy may require notice and premium within 31 days of birth (18 Del. C. 3335).
• Dependent children stay covered until their 26th birthday, even if the contract says an earlier age (3570(b)).
• A child who can't support himself because of a mental or physical disability, and who depends chiefly on the insured, stays on family coverage. The insurer may require proof within 31 days (Reg. 1304).

Coverage continuity

• If a member is hospitalized when coverage ends, contracts from insurers, health service corporations and HMOs must continue coverage for that stay for 10 days at the same benefit level (3313(c), 3517(c)).
• Coverage can't be withdrawn because an insured turns 65, though benefits may be coordinated with government programs (2315).
• Individual hospital and surgical policies can't be refused because the applicant is blind or deaf (2316(a)).

Claims, appeals and arbitration

• Clean claims: within 30 days of receipt, the carrier pays, pays the allowable part with an explanation, denies in writing, or asks in writing for missing information (Reg. 1310-6.1).
• External review (Reg. 1301):
  • The member files the appeal with the carrier within four months of the final adverse decision.
  • The independent utilization review organization decides within 45 days. Expedited cases are decided within 72 hours.
• Department arbitration: a request must reach the Department within 60 days of the carrier's notice.

Underwriting limits

• Genetic information can't be used in issuing, renewing or pricing health insurance (2317).
• HIV testing (Chapter 74):
  • requires prior written informed consent
  • a positive ELISA must be confirmed by a Western Blot or equivalent test
  • after an adverse decision, the insurer tells the applicant in writing, but the specific results go to a physician the applicant chooses
• Life and health insurers may not deny, surcharge or limit coverage because a person is a victim of abuse, and may not ask about it (2304(24)).

Exam traps

• Newborn notice is due in 31 days, and dependents stay covered to 26.
• A hospital stay in progress gets 10 days of continued coverage.
• External review: file with the carrier within 4 months. Decision in 45 days, or 72 hours if expedited.
• Clean claims are handled within 30 days.