18 Del. Admin. Code § 1321-5.0

Current through Register Vol. 28, No. 5, November 1, 2024

Section 1321-5.0 - Unreasonable and Discriminatory Access to Physical Therapy Care or Services Prohibited

5.1 No carrier shall include in any insurance policy or contract delivered or issued for delivery in Delaware or in any certificate issued under such a policy or contract any provision that unreasonably discriminates against access to physical therapy care or services, including but not limited to:

5.1.1 A cost containment or managed care provision that denies or restricts access to physical therapy care or services in a manner that is more restrictive than a cost containment or managed care provision placed on a provider who is not licensed as a physical therapist but who is otherwise licensed to perform the same or substantially similar service, for the treatment of a patient with a condition that is within the scope of physical therapy practice;

5.1.2 A provision that classifies physical therapy care or services as "maintenance care" or "not medically necessary," solely for the purpose of denying access to physical therapy care or services;

5.1.3 A provision that requires a patient to pay a higher copay or deductible when being treated by a physical therapist than that patient would otherwise be require to pay for the same or substantially similar care or services had that care or services been rendered by a provider who is not licensed as a physical therapist but who is otherwise licensed to render that or a substantially similar care or service;

5.1.4 A provision that requires a patient to pay a copayment or coinsurance that is more than 25 percent of the fee due or to be paid to a physical therapist for physical therapy care or services;

5.1.5 A provision that contains a utilization or compensation restriction or practice for a physical therapist that is more restrictive than a utilization or compensation restriction or practice placed on a provider who is not licensed as a physical therapist but who is otherwise licensed to perform the same or substantially similar care or service for the treatment of patients with conditions within the scope of physical therapy care or services, including but not limited to:

5.1.5.1 Unreasonable or discriminatory restrictions on the number of compensated visits per condition, or per episode, year, or other period; or

5.1.5.2 Unreasonable or discriminatory precertification requirements and allowances for initial or subsequent visits, or for the determination of medical necessity; or

5.1.6 Including a provision that would unreasonably deny coverage for a physical therapy technique, method or diagnostic procedure if that physical therapy technique, method or diagnostic procedure is taught by an educational program described in 24 Del.C. § 2606 (a)(1), or has been approved by the Delaware Examining Board of Physical Therapists and Athletic Trainers.

5.2 No carrier shall include in any insurance policy or contract delivered or issued for delivery in Delaware or in any certificate issued under such a policy or contract any provision that places any annual or lifetime numerical limits on physical therapy visits for the treatment of back pain.

18 Del. Admin. Code § 1321-5.0

22 DE Reg. 1021 (6/1/2019) (final)