Title 44 — Charitable and Curative Institutions.

Repealed Repealed.

For the purposes of this chapter, the term (1) “Adverse benefit determination” means a denial, reduction, limitation, termination, failure to make a payment for a benefit, or a delay of a benefit to a member, regarding determinations about: (A) The medical necessity, appropriaten…

(a) The provisions of subchapter I of this chapter shall not apply in cases directly involving coverage determinations or benefit requirements under the federal Medicare program. The provisions of subchapters II and III of this chapter shall not apply in cases directly involving …

(a)(1) A member or member representative shall have a right to file an appeal with an insurer for a review of an adverse benefit determination. An insurer’s health benefits plan shall include an appeal system that provides for the presentation and resolution of appeals brought by…

(a) A member or member representative may appeal any adverse benefit determination decision resulting in a rescission, denial, termination, or other limitation of a benefit in accordance with the provisions of this chapter. (b) At the time an insurer denies, reduces, terminates, …

Repealed Repealed.

(a)(1) An insurer shall establish and maintain an internal appeals process whereby a member or member representative who has received an adverse benefit determination can have the opportunity to pursue an appeal before a reviewer or panel of physicians, a mental health profession…

If an insurer denies a member or member representative’s appeal of a rescission, the insurer shall provide the member or member representative and the Department of Insurance, Securities, and Banking with a written explanation of why the insurer found that there was fraud or misr…

(a) The Director shall establish and maintain an external appeals process whereby a member or member representative who is dissatisfied with a decision rendered in an internal appeals process shall have the opportunity to pursue an external appeal before an independent review org…

(a) Each independent review organization selected by the Director to review external appeals must be certified every 2 years by the Director. (b) The Director shall be responsible for developing, applying, and enforcing certification standards for independent review organizations…

The Mayor shall assess all insurers to cover all the costs of administering this chapter. The Mayor shall promulgate regulations to determine the assessment formula.

(a) Every insurer shall submit to the Director, an annual grievance report, that chronicles all grievance activity during the preceding year. The Director shall develop a system for classifying and categorizing grievances and appeals that all insurers and independent review organ…

A group health plan that is located in the District but that is not subject to District regulation may voluntarily use the District’s external review system; provided, that it pays the full costs of external review and adheres to the procedures set forth in § 44-301.07.

(a) A health benefits plan shall permit a member with chronic disabling or life threatening conditions to choose a health care specialist as the member’s primary care provider. The specialist must be a participant in the health benefits plan and be available to attend to the memb…

(a) In general, subject to subsection (b) of this section, a health benefits plan shall permit a member to receive medically necessary or appropriate specialty care for more than one visit without having to obtain the insurer’s approval for subsequent visits authorized by a prima…

(a) Every health benefits plan that requires or provides a member with the opportunity to designate a participating primary care provider, shall permit a member who is female to designate as her primary care provider a participating physician or advance practice registered nurse …

If a contract between an insurer and a health care provider is terminated by either party for any reason other than termination for failure to meet applicable quality standards of care or fraud, and a member is undergoing a course of treatment from the physician at the time of th…

(a) Within 120 days of April 27, 1999, the Director shall promulgate any regulations and standards as may be necessary to carry out the purposes of this chapter. (b) Health benefits plans and insurers subject to this chapter shall comply with the regulations promulgated pursuant …

(a) For the purposes of this chapter, the term: (1) “Acquiring of effective control” means: (A) Any transfer, assignment or other disposition of 50% or more of the stock, voting rights thereunder, ownership interest, or operating assets of a corporation or other entity which is a…

(a)(1) There is established, in the Commission on Public Health, a State Health Planning and Development Agency (“SHPDA”). (2) Revenues, not to exceed fees collected pursuant to § 44-420, shall be utilized to fund 4 staff positions to administer SHPDA (Project Review Division—Cer…

(a) The SHPDA shall establish a Statewide Health Coordinating Council (“SHCC”), which shall consist of 15 members appointed by the Mayor, with the advice and consent of the Council of the District of Columbia. (b) The SHCC shall: (1) Assist the SHPDA in the development of the HSP…

(a) The SHPDA, with the advice and recommendation of the SHCC, shall develop a proposed HSP, which shall be adopted in accordance with rules issued pursuant to § 44-421, to guide health policy in the District of Columbia. The HSP shall present data collected pursuant to § 44-405 …

(a) The SHPDA shall develop and maintain the Health Planning Data System (“HPDS”). In order to implement the HPDS, as necessary for the development of the HSP, the SHPDA shall require each health care facility to submit, in writing or other uniform media, data related to the util…

(a) Except as provided in § 44-407, all persons proposing to offer or develop in the District a new institutional health service, or to obligate a capital expenditure to obtain an asset to be located in the District shall, prior to proceeding with that offering, development, or o…

(a) HCFs and persons proposing projects exempted from certificate of need review must file with the SHPDA a letter of notice in accordance with rules promulgated pursuant to § 44-421. (b) The following projects are exempt from certificate of need review: (1) The upgrading, mainte…

(a) Proposals for major medical equipment and new institutional health services for which there is an explicit finding of need in the HSP shall be eligible for expedited administrative review without referral to the SHCC, in accordance with rules promulgated pursuant to § 44-421.…

(a) All applications for a certificate of need shall be reviewed by the SHPDA. (b) Existing procedures and criteria in effect on April 9, 1997, are valid insofar as they are not inconsistent with this chapter, until new rules of procedures and criteria are adopted. (c) In accorda…

(a) In order to grant a certificate of need, except for a certificate of need to decrease the bed capacity of a HCF, the SHPDA shall, upon review of an applicant, make a written finding that the proposed HCF, health service, major medical equipment, or capital expenditure meets t…

(a) A certificate of need shall be effective for the period that the applicant states is necessary to complete the project for which the certificate of need is granted; except that no certificate of need shall be effective for more than 3 years from the original date of issuance.…

(a) After a decision on an application for a new or renewal certificate of need is made by the SHPDA, the SHPDA shall notify the applicant, the SHCC, all previously appearing parties, and contiguous health planning agencies of the decision. The SHPDA shall give any person, for go…

(a) Following reconsideration by the SHPDA, or if the SHPDA denies a request for consideration, or has not granted a request for reconsideration pursuant to § 44-412(a) within 30 days after the request for reconsideration, the final decision of the SHPDA on the application for a …

Any person who contests the final decision on an application for a certificate of need, or for exemption from certificate of need review under this chapter, after the exhaustion of all administrative remedies, is entitled to judicial review thereof upon filing in the District of …

The issuance of a certificate of need, if required under this chapter, shall be a condition precedent to the issuance of any license, permit, and any other type of official approval, except zoning approval, by an agency or officer or employee of the District government which is n…

(a) It shall be unlawful for any person to proceed with any project which under this chapter would require a certificate of need without applying for and obtaining a certificate of need. (b) The Office of [the] Attorney General for the District of Columbia may seek injunctive rel…

No member of the SHCC or the SHPDA may be held personally liable in any civil action taken in the course of carrying out his or her official duties and responsibilities as set forth in this chapter or the rules issued pursuant to this chapter.

The SHPDA may impose a moratorium for up to 120 days on the issuance of certificates of need for any specific type of new institutional health service, if the SHPDA requires additional time to develop and adopt criteria and standards for a new institutional health service. A mora…

The SHPDA shall prepare and publish annually a report on the status of health systems development in the District, including the health plan development and implementation program, the health data and information program, and the certificate of need program. The report shall incl…

(a) The SHPDA shall collect application fees from persons that request a certificate of need. The fee required for an application shall be the greater of 3% of the proposed capital expenditure or $5,000, with a maximum of $300,000. The SHPDA is authorized to establish a fee sched…

(a) There is established as a nonlapsing, revolving fund in the Department of Health the State Health Planning and Development Fund (“SHPDA Fund”), to be administered by the Mayor as an agency fund as defined in § 47-373(2)(I), to which all fees, civil fines, and interest relatin…

The SHPDA shall, in accordance with subchapter I of Chapter 5 of Title 2, issue proposed rules to implement the provisions of this chapter. The proposed rules shall be submitted to the Council for a 45-day period of review, excluding Saturdays, Sundays, legal holidays, and days o…

Repealed Repealed.

(a) For the purposes of this subchapter the term: (1) “Hospital” means a facility that provides 24-hour inpatient care, including diagnostic, therapeutic, and other health-related services, for a variety of physical or mental conditions, and may in addition provide outpatient ser…

(a) Except as provided in subsections (b), (c), and (d) of this section, it shall be unlawful to operate a facility or agency in the District of Columbia, whether public or private, for profit or not for profit, without being licensed by the Mayor. (b) This subchapter shall not a…

(a) The Mayor shall: (1) Ensure that licensing rules are consistent with certificate of need rules and that both are designed to facilitate the goals and objectives of the District of Columbia’s state health plan and certificate of need program; and (2) Conduct an initial invento…

(a) The Mayor shall issue rules, consistent with other provisions of this chapter and pursuant to subchapter I of Chapter 5 of Title 2, establishing: (1) License fees for private facilities and agencies reasonably calculated to reflect a facility’s or agency’s respective share of…

(a) To ensure that each new facility and agency will be in compliance with the provisions of this subchapter, rules adopted pursuant to this subchapter, and all other applicable laws and rules, the Mayor shall conduct an on-site inspection prior to a facility’s or agency’s initia…

(a) As an alternative to denial, nonrenewal, suspension, or revocation of a license when a facility or agency has numerous deficiencies or a serious single deficiency with respect to the standards to be established under § 44-504(a)(3), the Mayor may: (1) Issue a provisional lice…

(a) The accordance and delineation of clinical privileges shall be determined on an individual basis and commensurate with an applicant’s education, training, experience, and demonstrated current competence. In implementing these criteria, each facility and agency shall formulate…

(a) Except as provided in subsection (b) of this section, in the event that a health professional’s: (1) clinical privileges are reduced, suspended, revoked, or not renewed; or (2) employment or staff membership is involuntarily terminated or restricted for reasons of, or volunta…

(a) Any person who intentionally impedes a District of Columbia official or employee in the performance of his or her authorized duties under this subchapter, or any rule issued pursuant to this subchapter, shall be subject to a fine not exceeding $1,000 per day of violation, imp…