Implementation of Regulation 1322 Requirements for Mandatory Minimum Payment Innovations in Health Insurance

DOMESTIC AND FOREIGN INSURERS BULLETIN NO. 138 TO: INSURERS, HEALTH SERVICE CORPORATIONS, AND MANAGED CARE ORGANIZATIONS THAT DELIVER OR ISSUE FOR DELIVERY IN THIS STATE INDIVIDUAL AND GROUP INSURANCE POLICIES OR PLANS SUBJECT TO REGULATION UNDER TITLE 18 OF THE DELAWARE CODE. RE: IMPLEMENTATION OF REGULATION 1322 REQUIREMENTS FOR MANDATORY MINIMUM PAYMENT INNOVATIONS IN HEALTH INSURANCE DATED: March 15, 2023 REVISED: March 15, 2024 and March 20, 2025 What is the purpose of this Bulletin? This Bulletin describes the procedures to be used by insurers and other entities subject to Regulation 1322 when completing the 2026 Affordability Standards Data Submission (ASDS) template. Regulation 1322, Requirements for Mandatory Minimum Payment Innovations in Health Insurance (18 DE Admin. Code 1322), became effective on August 11, 2022. Background on the regulation and on the underlying statute may be found in the public notices in which the Department proposed the new regulation, which were published in the Register of Regulations (see 25 DE Reg. 684 (January 1, 2022) and 25 DE Reg. 828 (March 1, 2022)). This Bulletin provides information on updates to the process for completing and submitting the ASDS template. Domestic & Foreign Bulletin No. 149, issued on March 18, 2025, outlines guidance on Qualified Health Plan (QHP) rate filing requirements. Which Carriers Are Required to Complete the ASDS Template? Any carrier making rate filings for health benefit plans, as defined in 18 Del. C. §§ 3342A(a)(3)a. and 3559(a)(3)a. Please note that carriers with fewer than 250 members in a market segment, Student Health Plans, and “expat plans” may request a waiver of the data submission completion requirement by completing the Waiver Request on the Office of Value Based Health Care Delivery (OVBHCD) website and emailing it to OVBHCD@delaware.gov. How has the ASDS template been updated? The Department’s OVBHCD has updated the ASDS template in the following ways: • Updated the primary care code set to reflect additional service, taxonomy, and place of service codes, including primary care and care management codes recently introduced by the Centers for Medicare and Medicaid Services (CMS) and other codes related to primary care and care management services aligned with the OVBHCD definition. What is the price growth limit for non-professional services for plan year 2026? • Compliance with Section 7.0 of 1322 dictates that carriers’ price trends must not exceed 5.50% for plan year 2026 for each of the following service categories: Inpatient Hospital, Outpatient Hospital, and Other Medical. What is the Process for Completing and Submitting the ASDS Template? • Carriers must complete the ASDS template annually, for each line of business and submit the completed ASDS template to the OVBHCD as part of their rate filings. • The ASDS template must exclude American Rescue Plan Act (ARPA) premium tax credit considerations. • A draft template and detailed instructions for completing the template are attached to this Bulletin and are also posted on the OVBHCD website. Questions regarding the template or its completion should be submitted to OVBHCD Director at OVBHCD@delaware.gov. • Carriers should send a copy of the completed template via secure email to the OVBHCD Director at OVBHCD@delaware.gov no later than the applicable submission deadline. Carriers are encouraged to submit the ASDS template before the deadline, even if the full corresponding rate filing is not complete. What are the completed ASDS template submission deadlines? The completed ASDS template submission deadlines are as follows: How should carriers implement inclusion of CMS’ Advanced Primary Care Management (APCM) codes? In 2025, the Medicare Physician Fee Schedule introduced Advanced Primary Care Management (APCM) codes.0F1 These codes simplify care management billing by bundling services into a monthly payment model, eliminating time-based billing requirements. 1 Federal Register. (2024, December 9). Medicare and Medicaid Programs; CY 2025 Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B Payment Policies; Final Rule. Retrieved from https://www.federalregister.gov/documents/2024/12/09/2024-25382/medicare-and-medicaid-programs-cy-2025- payment-policies-under-the-physician-fee-schedule-and-other Line of Business Deadline Individual June 20, 2025 Small Group June 20, 2025 Large Group September 19, 2025 • As defined in Section 5.1 of Regulation 1322, carriers are required to reimburse providers at least at Medicare rates for primary care and chronic care management services. Therefore, carriers must include these codes on their list of covered services and pay at least as much as Medicare would reimburse for these services. • The OVBHCD allows carriers to apply the same business rules as CMS in determining how to apply the Medicare Fee Schedule. • Carriers should contact OVBHCD for further details. The OVBHCD will evaluate each carrier’s compliance with Regulation 1322. Details on the evaluation of carrier-specific compliance with the regulation will be included in the OVBHCD annual report. Questions concerning this bulletin should be emailed to: OVBHCD@delaware.gov. This bulletin shall be effective immediately and shall remain in effect unless otherwise withdrawn or superseded by subsequent law, regulation, or bulletin. ____________________________ Trinidad Navarro Delaware Insurance Commissioner NOTE: This Bulletin is intended solely for informational purposes. It is not intended to set forth legal rights, duties, or privileges, nor is it intended to provide legal advice. Readers should consult applicable statutes and rules and contact the Delaware Department of Insurance if additional information is needed.