Commercial and public worker plans would limit some hospital payments

Commercial insurers would limit hospital service costs in health plan rate filings. The limits cover inpatient, outpatient, and emergency department services in affected commercial health plans. Independent children's hospitals have separate limits. Certain rural and urban hospitals are exempt. One rural group also needs a state finding that it has made progress with care payment programs. The limits do not apply when an insurer and a hospital or provider group take part in an approved program with a shared budget for care. The limits begin with 2028 filings for 2029 plans.

Delaware's public worker health plan would limit hospital payments and extra bills to members. The rules cover inpatient, outpatient, and emergency department services under Delaware's health plan for public officers and employees. Members would still owe their plan's copays, deductibles, and coinsurance, based on whether the provider is in the plan's network. Independent children's hospitals have separate limits. Certain rural and urban hospitals are exempt; one rural group needs a state finding of progress with care payment programs. The rules do not apply when an insurer and a hospital or provider group take part in an approved program with a shared budget for care. The limits start with the 2030 plan year. The final listed targets start with the 2034 plan year.

Covered commercial insurers would spend a set share on primary care and offer state-designed payment programs. The rules cover the individual and group commercial health insurers addressed in the bill. The bill calls for 5% of the required primary care share to be upfront payments for primary care management. State rules must let insurers leave out high-cost claims when calculating medical costs and may let them leave out other costs they paid. Insurers could not deny a contracted provider the chance to join an offered program if the provider accepts the same terms as other participants. The spending target names 2026 and each later year. Insurers would offer the programs by the first full plan year after the state issues its rules.

Delaware's public worker plan and public assistance insurers would raise primary care spending toward 11.5%. The targets cover Delaware's health plan for public officers and employees and insurers providing state public assistance coverage. The public assistance requirements apply only as far as federal law permits. The public worker plan must leave out certain high-cost claims when the state benefits committee authorizes it. The Medicaid division may leave out certain high-cost claims. The worker plan would start its increases in plan year 2029. Public assistance insurers would start in their third year, after two reporting years.

The insurance commissioner could impose certain penalties that would go to a primary care fund. These penalties apply to violations of four insurance code provisions named in the bill. The commissioner may impose a penalty after notice and a hearing. Each penalty cannot exceed the amount of money tied to its violation. State benefits and Medicaid offices could use the fund for related work only if lawmakers approve yearly funding. Any uncommitted year-end balance above $5 million goes to the state fund for retiree benefits. The $5 million balance limit is checked at the end of each fiscal year.