(a) (1) Except as provided in subsection (b) of this section, a group health plan, or a health insurance issuer offering group or individual health insurance coverage, may not establish any lifetime limit on the dollar amount of benefits for any individual.
(2) a. Except as provided in paragraph (a)(2)b., subsections (b) and (d) of this section, a group health plan, or a health insurance issuer offering group or individual health insurance coverage, may not establish any annual limit on the dollar amount of benefits for any individual.
b. A health flexible spending arrangement (as defined in § 106(c)(2) of the Internal Revenue Code) [26 U.S.C. § 106(c)(2)] is not subject to the requirement in paragraph (a)(2)a. of this section.
(b) (1) The rules of this section do not prevent a group health plan, or a health insurance issuer offering group or individual health insurance coverage, from placing annual or lifetime dollar limits with respect to any individual on specific covered benefits that are not essential health benefits to the extent that such limits are otherwise permitted under applicable federal or state law.
(2) The rules of this section do not prevent a group health plan, or a health insurance issuer offering group or individual health insurance coverage, from excluding all benefits for a condition. However, if any benefits are provided for a condition, then the requirements of this section apply. Other requirements of federal or state law may require coverage of certain benefits.
(c) The term “essential health benefits” as used in this section means essential health benefits under § 1302(b) of the Patient Protection and Affordable Care Act [42 U.S.C. § 18022(b)], as the law and its implementing regulations were in effect on January 1, 2018; Delaware law; and applicable state regulations.
(d) (1) With respect to plan years beginning prior to January 1, 2014, a group health plan, or a health insurance issuer offering group or individual health insurance coverage, may establish, for any individual, an annual limit on the dollar amount of benefits that are essential health benefits, provided the limit is no less than the following amounts:
a. For a plan year beginning on or after September 23, 2010, but before September 23, 2011, $750,000.
b. For a plan year beginning on or after September 23, 2011, but before September 23, 2012, $1,250,000.
c. For plan years beginning on or after September 23, 2012, but before January 1, 2014, $2,000,000.
(2) In determining whether an individual has received benefits that meet or exceed the applicable amount described in paragraph (d)(1) of this section, a plan or issuer must take into account only essential health benefits.
Structure Delaware Code
Chapter 35. GROUP AND BLANKET HEALTH INSURANCE
Subchapter III. Provisions Applicable to Group and Blanket Health Insurance
§ 3552. Cancer screening tests.
§ 3553. Midwife services reimbursement.
§ 3555. Coverage of cancer monitoring tests.
§ 3555A. Equal reimbursement for oral and intravenous anticancer medication.
§ 3556. Obstetrical and gynecological coverage.
§ 3557. Child abuse or neglect — Group coverage.
§ 3558. Immunizations and preventive services.
§ 3559. Contraceptive coverage.
§ 3560. Insurance coverage for diabetes.
§ 3560A. Cost sharing in prescription insulin drugs.
§ 3560B. Coverage for insulin pumps.
§ 3561. Annual pap smear coverage reimbursement.
§ 3562. Colorectal cancer screening.
§ 3563. Required coverage for reconstructive surgery following mastectomy.
§ 3565A. Required coverage for volunteer ambulance company services.
§ 3566. Prescription medication.
§ 3567B. Experimental treatment coverage.
§ 3568. Newborn and infant hearing screening; coverage and reimbursement.
§ 3569. Use of Social Security numbers on insurance cards.
§ 3570A. Autism spectrum disorders coverage.
§ 3571. Phenylketonuria (PKU) and other inherited metabolic diseases.
§ 3571A. Hearing aid coverage.
§ 3571B. Required coverage for scalp hair prosthesis.
§ 3571C. Dental services for children with a severe disability.
§ 3571D. Screening of infants and toddlers for developmental delays.
§ 3571E. Reimbursement for orthotic and prosthetic services.
§ 3571G. School-based health centers.
§ 3571H. Payment for emergency medical services.
§ 3571P. Rating factors [For application of this section, see 79 Del. Laws, c. 99, § 19].
§ 3571R. Telehealth and telemedicine.
§ 3571S. Network disclosure and transparency.
§ 3571U. Mental Health Parity and Addiction Equity Act reporting requirements.
§ 3571V. Time of submitting claim for reimbursement.
§ 3571W. Electronic medical claims.
§ 3571X. Medication assisted treatment for drug and alcohol dependencies.
§ 3571Y. Coverage for epinephrine autoinjectors.
§ 3571Z. Annual behavioral health well check [Effective Jan. 1, 2024].