Title 31, Insurance and Securities.

This subchapter shall apply to health insurers beginning with referrals issued 120 days after the promulgation of final regulations under § 31-3233.

For the purposes of this subchapter, the term: (1) “Commissioner” means Commissioner of the Department of Insurance and Securities Regulation. (2) “Credentialing intermediary” means a person to whom a health insurer has delegated credentialing or recredentialing authority and res…

(a) A health insurer or its credentialing intermediary shall accept the uniform credentialing form as the sole application for a health care provider to become credentialed or recredentialed for a provider panel of the health insurer. (b) A health insurer or its credentialing int…

The Commissioner may impose a penalty not to exceed $500 against any health insurer for each violation of this subchapter by the health insurer or its credentialing intermediary.

The Commissioner shall promulgate rules and regulations to implement the provisions of this subchapter.

This subchapter shall apply, 120 days after the promulgation of the final regulations pursuant to § 31-3254, to health insurers, as defined in § 31-3251(5), and any agency, organization, facility, or distinct part thereof, licensed pursuant to subchapter I of Chapter 5 of Title 4…

For the purposes of this chapter, the term: (1)(A) “Adverse decision” means a utilization review determination by a private review agent, a carrier, or a health care provider acting on behalf of a carrier that: (i) A proposed or delivered health care service covered under the mem…

(a) A health insurer shall: (1) Provide coverage of habilitative services for children under the age of 21 years and may do so through a managed care system; (2) Not be required to provide reimbursement for habilitative services actually delivered through early intervention or sc…

For the purposes of this chapter, the term: (1) “Affiliation period” means a period which, under the terms of the health insurance coverage offered by a health maintenance organization, must expire before the health insurance coverage becomes effective. The health maintenance org…

(a) This subchapter applies only to those health insurers that offer individual health insurance coverage in the District of Columbia. Nothing in this subchapter shall require health insurers participating only in the group health insurance market to offer individual health insur…

(a) A health insurer that offers health insurance coverage in the individual market may: (1) Limit the individuals who may be enrolled under such coverage to those who live, reside, or work within the service area for such network plan; and (2) Within the service area of such pla…

(a) A health insurer may deny health insurance coverage in the individual market to an eligible individual if the health insurer has demonstrated to the satisfaction of the Commissioner that: (1) It does not have the financial reserves necessary to underwrite additional coverage;…

(a) The provisions of this chapter shall not be construed to require that a health insurer offering health insurance coverage only in connection with group health plans or through one or more bona fide associations, or both, offer such health insurance coverage in the individual …

(a) Except as provided in this section, a health insurer that provides individual health insurance coverage shall renew or continue in force such coverage at the option of the individual. (b) A health insurer may nonrenew or discontinue health insurance coverage of an individual …

The provisions of § 31-3303.07(j) shall apply to health insurance coverage offered by a health insurer in the individual market in the same manner as they apply to health insurance coverage offered by a health insurer in connection with a group health plan in the small or large g…

(a) The Commissioner may adopt regulations to enable him or her to establish and administer such standards relating to the provisions of this chapter as may be necessary to (i) implement the requirements of this chapter, and (ii) assure that the District of Columbia’s regulation …

Unless otherwise specifically provided in this chapter, the provisions of this subchapter shall apply to individual health benefit plans issued or renewed on or after January 1, 1998.

Nothing in this subchapter shall be construed to: (1) Restrict the amount of the premium rates that an issuer may charge an individual for health insurance coverage provided in the individual market; or (2) Prevent a health insurer offering health insurance coverage in the indivi…

This subchapter applies to health insurers offering group health insurance coverage. Each insurer proposing to issue group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense incurred basis, each corporation pr…

In order to ensure the broadest availability of health benefit plans to small employers, the Commissioner shall set market conduct and other requirements for health insurers, agents, and third-party administrators, including requirements relating to the following: (1) Registratio…

(a) Every health insurer that offers health insurance coverage in the group market in the District of Columbia shall renew such coverage with respect to all insureds at the option of the employer except: (1) For nonpayment of the required premiums by the policyholder or contract …

In applying this subchapter in the case of health insurance coverage that is made available by a health insurer in the group market to employers only through one or more associations, a reference to “plan sponsor” is deemed, with respect to coverage provided to an employer member…

If coverage to the small or large employer market pursuant to this subchapter ceases to be written, administered, or otherwise provided, such coverage shall continue to be governed by this subchapter with respect to business conducted under this subchapter that was transacted pri…

(a) If coverage is offered to small employers under this subchapter, such coverage shall be offered and made available to every small employer that applies for such coverage. Participation in such plan shall be made available to all the eligible employees of a covered small emplo…

(a) Subject to subsection (b) of this section, a health insurer offering group health insurance coverage may, with respect to a participant or beneficiary, impose a preexisting limitation only if (i) such exclusion relates to a condition (whether physical or mental), regardless o…

(a) Any health insurer offering health insurance coverage to a small employer shall make a reasonable disclosure of the availability of information to such an employer, as part of its solicitation and sales materials, and upon request of such an employer, information concerning: …

(a) A group health plan, and a health insurer offering group health insurance coverage, may not establish rules for eligibility (including continued eligibility) of any individual to enroll under the terms of the plan based on any of the health status-related factors. (b) The pro…

The provisions of this subchapter shall not apply to: (1) Any group health benefit plan for any plan year if, on the first day of such plan year, such plan has less than 2 participants who are current employees; or (2) Any health benefit plan for any of the excepted benefits.

(a) All employers treated as a single employer under subsection (b), (c), (m), or (o) of § 414 of the Internal Revenue Code of 1986 (26 U.S.C. § 414) shall be treated as one employer. (b) In the case of an employer which was not in existence throughout the preceding calendar year…

(a) A health maintenance organization which does not impose any preexisting condition exclusion, with respect to any particular coverage option, may impose an affiliation period for such coverage option, but only if such period is applied uniformly without regard to any health st…

A health maintenance organization may use alternative methods to an affiliation period to address adverse selection provided that they are approved by the Commissioner prior to their use.

Unless otherwise specifically provided in this chapter, the provisions of this subchapter shall apply to group health benefit plans issued or renewed after July 1, 1997.

(a) All insurance premium rates and fees shall be made in accordance with the principles and standards set forth in this section. Uniformity among insurers in matters within the scope of this section shall not be required or prohibited. (b) Due consideration shall be given to: (1…

(a) For each calendar year, an insurer shall maintain an aggregate minimum medical loss ratio, as defined by rule, of 80% for individual policies, as defined by rule, 80% for small group policies, as defined by rule, and 85% for large group policies, as defined by rule. The medic…

Policies, certificates, and marketing materials shall prominently display medical loss ratio disclosure, as defined by rule.

(a) Consistent with federal law, the Commissioner, with the approval of the Executive Board of the Health Benefit Exchange Authority, shall, by rule, select the benchmark plan for the individual and small group market for purposes of establishing the essential health benefits in …

(a) To implement section 1201 of the Affordable Care Act, the Commissioner, with the approval of the Executive Board of the Health Benefit Exchange Authority, shall have the authority to establish by rule: (1) The geographic rating area for the District; (2) The age rating or cur…

All insurers subject to this chapter shall file annually its rates, rating schedule, and supporting documentation, including ratios of incurred losses to earned premiums by policy form or certificate form, for approval by the Commissioner. The supporting documentation shall demon…

(a) The Commissioner may, at any time, require any insurer subject to this chapter to demonstrate that its rates and method for setting rates are in compliance with this chapter, notwithstanding that the filings then in effect had previously been approved. Any rates previously ap…

(a) An insurer shall not rescind an enrollee’s plan or coverage once the enrollee is covered under the plan or coverage involved; provided, that this section shall not apply to a covered individual who has performed an act or practice that constitutes fraud or makes an intentiona…

The Commissioner shall, as soon as practicable, make all rate filings, including all supporting documentation, amended filings, and reports filed pursuant to this chapter, available for public inspection either at the Department of Insurance, Securities, and Banking or on its web…

On June 1, 2011, and every year thereafter, the Commissioner shall report to the Council any significant National Association of Insurance Commissioners adoptions related to health care reform, including medical loss ratios and loss ratio disclosure, and any recommendations if th…

The Mayor, pursuant to subchapter I of Chapter 5 of Title 2 [§ 2-501 et seq.], shall issue rules to implement the provisions of this chapter.

This chapter shall apply to policies and certificates of insurance that are health benefit plans as defined under § 31-3271(4) that are issued 90 days after April 8, 2011. This chapter shall not apply to short-term limited duration health benefit plans.

For the purposes of this chapter, the term: (a)(1) “Affordable Care Act” means the Patient Protection and Affordable Care Act approved March 23, 2010 (124 Stat. 111; 42 U.S.C. § 18001, note). (2) “Commissioner” means the Commissioner of the Department of Insurance, Securities, an…

For the purposes of this chapter, the term: (1) “Administrative services provider contract” means a contract entered into between a health maintenance organization and a contracting provider in which the contracting provider accepts payments for certain covered services provided …