Title 31, Insurance and Securities.

(a) The HCFA 1500 and UB 92 claims forms, or their successor forms as they may be amended from time to time, shall serve as the official health insurance claims forms of the District of Columbia for hospitals and other medical providers and governmental agencies, and such forms s…

For the purposes of this subchapter, the term: (1) “Health benefit plan” means any accident and health insurance policy or certificate, hospital and medical services corporation contract, health maintenance organization subscriber contract, plan provided by a multiple employer we…

(a) This subchapter shall apply to all health insurers that issue or deliver individual or group health benefit plans in the District of Columbia. (b) All health insurers that require the insured to have a written referral to receive consultation services shall use the uniform co…

(a) The Commissioner shall promulgate regulations to implement the provisions of this subchapter. The regulations shall include a uniform consultation referral form for use by health insurers that require enrollees or subscribers to have a written referral to receive consultation…

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…

(a) 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 corporatio…

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.

The Commissioner may issue rules to create a grandfathered status with respect to any of the requirements of this chapter for multiple employer welfare arrangements that existed and operated in the District as of December 15, 2017, and comply with federal law and regulations appl…

No multiple employer welfare arrangement located outside of the District may conduct any business in the District, including marketing, offering, or issuing a health benefit plan to any individual or employer, unless licensed as an insurer, a hospital and medical services corpora…

(a) A multiple employer welfare arrangement that is not fully insured, as described in subsection (c) of this section, shall not operate in the District or market, offer, or issue a health benefit plan to any individual or employer in the District without first meeting the requir…

(a) An insurer shall not provide short-term, limited-duration health insurance policies, certificates of coverage, or contracts unless the insurer obtains a certificate of authority from the Commissioner to offer health insurance. (b) An insurer offering for sale a short-term, li…

(a) When a negotiated health benefit plan differs in coverage of health services from the standard health benefit plan or formulary offered by the health insurer, the employer shall provide notice to all employees, regardless of whether they are enrolled in the negotiated health …

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…