Delaware Health Study Guide

Delaware’s health section runs 42 scored questions, separately timed and separately scored, and it carries the heaviest pretest load of any Delaware line — 13 unscored items you cannot tell apart from the real ones. Treat every question as live, and start with the three areas Delaware writes differently from the federal baseline: continuation coverage, claim payment, and appeals.

Mini-COBRA — small numbers, and none of them the federal ones

Federal COBRA applies at 20 or more employees. Delaware’s mini-COBRA fills in underneath it, and every figure is its own:

• Employers with 1 to 19 employees — note that it starts at one, where several states start at two
• The insured must have had at least 3 months of prior coverage
• Continuation runs up to 9 months
• The premium may be up to 102% of the group premium

Prompt pay — one deadline, plus an acknowledgement duty

Many states give electronic claims a shorter payment clock than paper ones. Delaware does not. A clean claim must be paid, denied, or met with a request for more information within 30 calendar days, and that applies to paper and electronic alike (Reg. 1310 § 6.0).

What electronic claims add is a separate obligation: they must be acknowledged within 2 business days (§ 3359B). Acknowledgement is not payment, and the two run on different clocks. Where the insurer has requested further information, a further 15 days runs from receiving it.

Late payment on a clean claim carries interest at the maximum legal lending rate — and Delaware adds a structural teeth: three violations within 36 months are presumed to be an unfair claim settlement practice under § 2304.

External review — binding, and on a four-month clock

Delaware runs its own Independent Health Care Appeals Program, using an Independent Utilization Review Organization, and the IURO’s decision binds the carrier (§§ 6416, 6417). A member must file within 4 months of the final internal denial.

Do not soften “binding” to “advisory”. The whole architecture of a state external-review programme is that the independent decision ends the matter.

The public programmes — and a naming trap

Delaware expanded Medicaid effective 1 January 2014, and runs its managed-care programme as the Diamond State Health Plan through the Division of Medicaid & Medical Assistance. Its CHIP is the Delaware Healthy Children Program.

And here is the trap. Delaware uses the federally-facilitated marketplace at HealthCare.gov. It is not a state-based exchange. “Choose Health Delaware” is an outreach brand — a website that helps Delawareans enrol — and its existence has convinced more than one candidate that Delaware runs its own exchange. It does not.

Long-term care — a modest requirement, strictly framed

A health-licensed producer who solicits long-term care must complete at least 3 hours of Delaware long-term care training in each biennium in which they sell it. Note the framing: it is not a one-time course and not a lifetime credential — it attaches to the cycles in which you actually transact LTC business. The LTC free look is 30 days (§ 7105(f)).