Title 31 — Insurance and Securities.

(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. (3) “Commissioner” means the Commissi…

(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; (2) Establish a SHOP Exchange through which qualified employers may access coverage for their employees and shall…

(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. (b) The Authority shall submit all proposed rules adopted by the Authority to the Council for a 30-day period of review, excluding…

(a) This chapter shall apply through September 30, 2014. (b) Beginning on October 1, 2014, this chapter shall apply upon the inclusion of its fiscal effect in an approved budget and financial plan.

(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…

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 …