Title 31, Insurance and Securities.

(a) Covered benefits for services set forth in this section shall be limited to coverage of treatment of clinically significant substance use disorders identified in the most recent edition of the International Classification of Diseases or of the Diagnostic and Statistical Manua…

(a) Covered benefits for services set forth in this section shall be limited to coverage of treatment of clinically significant mental illnesses identified in the most recent edition of the International Classification of Diseases or of the Diagnostic and Statistical Manual of th…

(a) Methods of determining levels of payment or reimbursement for services, or for the type of facility charge eligible for payment or reimbursement under this chapter, and shall be consistent with those for physical illnesses in general and shall take into consideration usual, c…

(a) The Mayor shall certify qualifying nonhospital residential facilities and outpatient treatment facilities in the District in accordance with rules issued pursuant to § 31-3111. (b) Each certification issued by the Mayor shall state whether the facility is certified as a provi…

Nothing in this chapter shall serve to diminish the benefits of any insured person or prevent the offering or acceptance of benefits that exceed the minimum benefits required by this chapter.

All individual and group health benefit plans shall contain statements, in easily readable type and in easily understandable language, approved by the Commissioner, to inform policyholders and beneficiaries of the coverage and benefits provided or offered pursuant to this chapter…

(a)(1) Notwithstanding the provisions of any other law, any health insurer that issues health benefits plan or certificates in the District shall file with the Commissioner all rates and rating plans, rules, and classifications that it proposes to use in providing or offering the…

(a) The requirements of this chapter shall apply to health maintenance organizations 5 years from February 28, 1987, unless the Mayor requests the Council to extend the exemption to a time certain and the Council, by resolution, approves the extension. (b) Upon becoming subject t…

(a) The Mayor shall, within 120 days from February 28, 1987, issue rules to implement all sections of this chapter except § 31-3110. The Mayor shall issue rules to implement § 31-3110 no later than 5 years from February 28, 1987. (b) The Mayor shall provide the coverage and benef…

This chapter shall not be applicable to the District of Columbia Alliance Program, Medicaid Program, and Post-1987 District of Columbia Employees’ Health Insurance Benefits Plan.

For the purposes of this chapter, the term: (1) “Clean claim” means a claim that has no material defect or impropriety, including any lack of reasonably required substantiating documentation, which substantially prevents timely payment from being made on the claim or with respect…

(a) For covered services rendered to its members, a health insurer shall reimburse any person entitled to reimbursement under the health benefits plan within 30 days after the receipt of a clean claim. (b) If a health insurer fails to comply with subsection (a) of this section, t…

(a) A health insurer may only retroactively deny reimbursement to a health care provider: (1) For services subject to coordination of benefits with another health insurer during the 18-month period after the date that the health insurer paid the health care provider; or (2) Excep…

(a) Except for Medicaid and Medicare provider panels, if a provider panel contract between a provider and a health insurer, or other entity that provides hospital, physician, or other health care services to a health insurer, require a provider, as a condition of participating in…

A health insurer shall include with its annual report filed with the Commissioner a claims payment report to include the: (1) Number of claims received in the previous calendar year; (2) Number of claims denied in the previous calendar year; (3) Number of claims paid: (A) In the …

An action by a health insurer that establishes a pattern or practice of repeated violation of this chapter, as determined by the Commissioner, shall constitute a violation as provided in Chapter 22A of this title.

The Commissioner may adopt rules and regulations as necessary to implement this chapter.

(a) This chapter shall apply to any individual and group health benefits plan issued or renewed in the District of Columbia. Health insurers shall comply with this chapter on the earlier of October 16, 2002, or the effective date of the claims payment standards in section 1173 of…

For the purposes of this chapter, the term: (1) “Application” means a carrier’s application pursuant to this chapter for approval to voluntarily withdraw from the District of Columbia health insurance market. (2) “Carrier” means any person or organization subject to the authority…

(a) A carrier shall give the Commissioner written notice, prior to notifying the members of the health benefit plan, of its intent to discontinue the offering of all health benefit plans in the District of Columbia and shall submit to the Commissioner an application with the foll…

(a) Any carrier aggrieved by any act, determination, rule, regulation, or order or any other action of the Commissioner pursuant to this chapter, and which was the subject of a contested case, may appeal to the District of Columbia Court of Appeals, in accordance with § 2-510. (b…

The Commissioner may promulgate rules and regulations necessary to implement the provisions of this chapter, including provisions for the disposal of books of business.

(a) For the purposes of this section, the term “health benefit plan” shall have the same meaning as provided in § 31-3001(1). (b) An individual health benefit plan offered, sold, issued, or renewed to a District resident shall not have a premium rate, or any other underwriting de…

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.

(1) “American Health Benefit Exchange” means an entity established pursuant to § 31-3171.04, and section 1311(b) of the Federal Act. (2) “Authority” means the District of Columbia Health Benefit Exchange Authority established by § 31-3171.02. (2A) "Basic health program" means a p…

(a) There is established, as an independent authority of the District government, the District of Columbia Health Benefit Exchange Authority. The Authority shall be an instrumentality, created to effectuate the purposes stated in this chapter, that shall have a legal existence se…

(a) There is established as a nonlapsing fund the District of Columbia Health Benefit Exchange Authority Fund (“Fund”), which shall be administered by the Authority in accordance with generally accepted accounting principles and which shall be used solely for the purposes set for…

(a) The Authority shall: (1) Establish the American Health Benefit Exchange to assist qualified individuals in the District with enrollment in qualified health plans; (1A) Establish and operate a basic health program, established pursuant to section 1331 of the Federal Act (42 U.…

(a) There is established an executive board to govern the Authority consisting of: (1) Seven voting members, who shall be residents of the District of Columbia, appointed by the Mayor, with the advice and consent of the Council pursuant to § 1-523.01(f). (2) Four nonvoting, ex-of…

(a) Subject to any limitations under this chapter, or other applicable law, the executive board shall have all the powers necessary to carry out the functions authorized by the Federal Act and consistent with the purposes of the Authority. (b) The enumeration of specific powers i…

(a) In addition to the executive board, there shall be a standing advisory board consisting of 9 members, who shall be residents of the District. (b) The executive board may create additional advisory boards as it considers appropriate. (c) The executive board shall solicit the r…

(a) The executive board shall hire an executive director within 60 days of a majority of executive board members being confirmed to organize, administer, and manage the operations of the Authority. (1) The executive director shall not be an employee in the career service and shal…

(a) To be certified as a qualified health plan, a health benefit plan shall, at a minimum: (1) Provide the essential health benefits package described in section 1302(a) of the Federal Act; except, that the plan is not required to provide essential benefits that duplicate the min…

(a) A carrier that offers individual or small group health benefit plans shall offer such plans solely through the American Health Benefit Exchange, as established pursuant to § 31–3171.04(a), subject to the following transition provisions: (1) Individual health benefit plans wit…

(a) An insurance producer that is licensed in the District and authorized by the Commissioner to sell, solicit, or negotiate health insurance pursuant to Chapter 11A of Title 31 [§ 31-1131.02 et seq.], may sell any qualified health plan offered in the American Health Benefit Exch…

(a)(1) A member of the executive board or of the staff of the Authority shall not be employed by, a consultant to, a member of the board of directors of, affiliated with, or otherwise a representative of, a health carrier or other insurer, an agent or broker, a health professiona…

The executive and advisory boards shall be subject to subchapter IV of Chapter 5 of Title 2 [§ 2-571 et seq.]; except, that the executive board may hold closed sessions when considering matters related to litigation, personnel, contracting, or rates.

There shall not be any liability, in a private capacity, on the part of the executive or advisory board members, or any officer, or employee of the executive or advisory board, for or on account of any act performed or obligation entered into in an official capacity when done in …

(a) Nothing in this chapter, and no action taken by the Authority pursuant to this chapter, shall be construed to preempt or supersede the authority of the Commissioner to regulate the business of insurance within the District. Except as expressly provided to the contrary in this…

Notwithstanding any other provision of this chapter, all powers and authority vested by this chapter in the Authority shall remain with the Mayor until: (1) A majority of members of the executive board have been confirmed by the Council; and (2) The executive board has hired an e…

Upon dissolution, liquidation, or other termination of the Authority: (1) All rights and properties of the Authority shall pass to and be vested in the District, subject to the rights of lien holders and other creditors; (2) Any net earnings of the Authority, beyond that necessar…

(a) The executive board shall: (1) Study, in consultation with the advisory boards established under this chapter and with other stakeholders: (A) The feasibility and desirability of the Authority engaging in: (i) Selective contracting, either through competitive bidding or a neg…

(a) The Authority, pursuant to subchapter I of Chapter 5 of Title 2 [§ 2-501 et seq.], shall issue rules to implement the provisions of this chapter and as authorized by § 47-5109. (b) The Authority shall submit all proposed rules adopted by the Authority to the Council for a 30-…

For the purposes of this chapter, the term: (a)(1) "Benefits" means the health care services covered by a health insurer under a health benefits plan. (2) "Department" means the Department of Insurance, Securities, and Banking. (3) "Health benefits plan" shall have the same meani…

(a) All health insurers offering health benefits plans, including Medicaid, in the District that provide mental health condition and substance use disorder benefits, shall comply with the requirements of MHPAEA. (b) The Department shall enforce the requirements of this chapter by…