Title 31, Insurance and Securities.

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.

(a) 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. (b) Small group market…

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), as the law and its implementing regulations were in effect on December 15, 2017. (2) “Co…

The individual market requirements of this subchapter shall apply to a health benefit plan offered by a multiple employer welfare arrangement, including an association or any other entity, if the plan covers an individual in the District who is not an employee or dependent of a p…

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 …

(a) Any person may apply to the Commissioner for a certificate of authority to establish and operate a health maintenance organization in compliance with this chapter. No person shall establish or operate a health maintenance organization in the District without obtaining a certi…

(a) Upon receipt of an application for issuance of a certificate of authority, the Commissioner, in consultation with the Director of the Department of Health, shall determine whether the applicant, with respect to the health care services to be provided, has complied with § 31-3…

(a) Effective January 1, 2009, all health maintenance organizations shall pay to the District of Columbia, for each calendar year, a sum of money as taxes equal to 2% of their policy and membership fees and net premium receipts or consideration received in such calendar year, exc…

(a) The powers of a health maintenance organization include, but are not limited to, the following: (1) The purchase, lease, construction, renovation, operation, or maintenance of hospitals, medical facilities, or both, and their ancillary equipment, and such property and equipme…

(a) Any director, officer, employee, or partner of a health maintenance organization who receives, collects, disburses, or invests funds in connection with the activities of such organization shall be responsible for such funds in a fiduciary relationship to the organization. (b)…

(a) A health maintenance organization shall establish procedures to assure that the health care services provided to enrollees shall be rendered under reasonable standards of quality of care consistent with prevailing professionally recognized standards of medical practice. Such …

(a) Every group and individual contract holder is entitled to a group or individual contract. (1) The contract shall not contain provisions or statements which are unjust, unfair, inequitable, misleading, deceptive, or which encourage misrepresentation. (2) The contract shall con…

Health maintenance organizations shall comply with the following laws: (1) Chapter 3 of this title; (2) Chapter 19 of this title; (3) Chapter 14 of this title; (4) Subchapter I of Chapter 7 of this title; (5) Chapter 21 of this title; and (6) The Reasonable Health Insurance Ratem…

(a) A health maintenance organization shall provide to its enrollees a list of providers, upon enrollment and re-enrollment. (b) Every health maintenance organization shall provide to its enrollees within 30 days notice of any material change in the operation of the organization …

With the exception of investments made in accordance with § 31-3404(a)(1), the funds of a health maintenance organization shall be invested in accordance with NAIC Health Maintenance Organization Investment Guidelines adopted by the Commissioner.

(1) Before issuing any certificates of authority, the Commissioner shall require that the health maintenance organization have an initial net worth of $1,500,000 and shall thereafter maintain the minimum net worth required by paragraph (2) of this subsection. (2) Except as provid…

(a) If at any time uncovered expenditures exceed 10% of total health care expenditures, a health maintenance organization shall place an uncovered expenditures insolvency deposit with the Commissioner, or with any organization or trustee acceptable to the Commissioner through whi…

(1) In the event of the insolvency of a health maintenance organization, upon order of the Commissioner all other carriers that participated in the enrollment process with the insolvent health maintenance organization at a group’s last regular enrollment period shall offer such g…

(a) No fees may be used until either a schedule of enrollment fees or methodology for determining enrollment fees dues has been filed with and approved by the Commissioner. (b) Either a specific schedule of fees, or a methodology for determining fees, shall be established in acco…

(a) The Commissioner shall issue rules and regulations to provide for the licensing of health maintenance organization producers. The rules shall establish: (1) The requirements for licensure of resident health maintenance organization producers; (2) The conditions for entering i…

(a) An insurance company authorized to do business in the District may, either directly or through a subsidiary or affiliate, organize and operate a health maintenance organization under the provisions of this chapter. Notwithstanding any other provisions of law, any 2 or more su…

(a) Any certificate of authority issued under this chapter may be suspended or revoked, and any application for a certificate of authority may be denied, if the Commissioner finds that any of the conditions listed below exist: (1) A health maintenance organization is operating si…

(a) Any rehabilitation, liquidation, or conservation of a health maintenance organization shall be deemed to be the rehabilitation, liquidation, or conservation of an insurance company and shall be conducted under the supervision of the Commissioner pursuant to the law governing …

(a) Whenever the Commissioner determines that the financial condition of any health maintenance organization is such that its continued operation might be hazardous to its enrollees, creditors, or the general public, or that it has violated any provision of this chapter, the Comm…

The Commissioner, within 120 days of April 9, 1997, shall issue rules and regulations necessary to implement the provisions of this chapter. To facilitate the timely issuance of rules and regulations, the Commissioner may contract out for the drafting of rules and regulations pur…

(a) The Commissioner, after giving reasonable written notice of intent and providing a reasonable time within which the health maintenance organization may respond, in lieu of suspension or revocation of a certificate of authority under § 31-3419, may levy an administrative penal…

(a) Except as otherwise provided in this chapter, provisions of insurance laws and provisions of hospital or medical service corporation laws shall not be applicable to any health maintenance organization granted a certificate of authority under this chapter. This provision shall…

All applications, filings, and reports required under this chapter shall be treated as public documents, except those which are trade secrets or privileged or confidential quality assurance, commercial, and financial information, other than any annual financial statement that may…

(a) Any data or information pertaining to the diagnosis, treatment, or health of any enrollee or applicant obtained from such person or from any provider by any health maintenance organization shall be held in confidence and shall not be disclosed to any person except to the exte…

(a) No person may make a tender for or a request or invitation for tenders of, or enter into an agreement to exchange securities for or acquire in the open market or otherwise, any voting security of a health maintenance organization, or enter into any other agreement if, after t…

(a) If an employer, association, or other private group arrangement offers health benefit plan coverage to employees or individuals only through a health maintenance organization, the health maintenance organization with which the employer, association, or other private group arr…

(a) Any health maintenance organization domiciled in the District or hereafter formed or organized in the District to engage in the health care business as a health maintenance organization shall maintain its principal office within the District, shall keep its books, records, an…

For the purposes of this chapter, the term: (1) “Adjusted RBC report” means an RBC report which has been adjusted by the Commissioner in accordance with § 31-3451.02(c). (2) “Authorized Control Level Event” means any of the following events: (A) The filing of an RBC report by the…

(a) A domestic health organization shall, prior to each March 2 (“filing date”), prepare and submit to the Commissioner a report of its RBC levels as of the end of the previous calendar year, in a form and containing such information as is required by the RBC instructions. In add…

(a) If a Company Action Level Event occurs, the health organization shall prepare and submit to the Commissioner an RBC plan that shall: (1) Identify the conditions that contributed to the Company Action Level Event; (2) Contain proposals of corrective actions that the health org…

(a) If a Regulatory Action Level Event occurs, the Commissioner shall: (1) Require the health organization to prepare and submit an RBC plan or, if applicable, a revised RBC plan; (2) Perform such examination or analysis as the Commissioner considers necessary of the assets, liab…

(a) If an Authorized Control Level Event occurs, the Commissioner shall: (1) Take such actions as are required under § 31-3451.04 with respect to a Regulatandy Action Level Event; and (2) If the Commissioner considers it to be in the best interests of the policyholders and credit…

(a) If a Mandatory Control Level Event occurs, the Commissioner shall take such action as is necessary to place the health organization under regulatory control under Chapter 34 of this title or Chapter 13 of this title. In such event, the Mandatory Control Level Event shall be s…

(a) A health organization may request a confidential department hearing, on a record, to challenge a determination or action if the Commissioner notifies it of the following: (1) An adjusted RBC report; (2)(A) The health organization’s RBC plan or revised RBC plan is unsatisfacto…

(a) All RBC reports (to the extent the information is not required to be set forth in a publicly available annual statement schedule) and RBC plans (including the results or report of any examination or analysis of a health organization performed under this chapter and any correc…

(a)(1) A foreign health organization shall, upon the written request of the Commissioner, submit to the Commissioner an RBC report as of the end of the previous calendar year upon the later of: (A) The date that an RBC report would be required to be filed by a domestic health org…

(a) This chapter shall supplement the other provisions of the laws of the District and shall not preclude or limit any other powers or duties of the Commissioner under such laws, including Chapter 34 of this title and Chapter 13 of this title. (b) The Commissioner may promulgate …

The Commissioner, the Department of Insurance and Securities Regulation, or its employees or agents shall not be liable for any action taken by them in the performance of their powers and duties under this chapter.

All notices by the Commissioner to a health organization that may result in regulatory action under this chapter shall be effective upon mailing if transmitted by registered or certified mail or, in the case of any other transmission, shall be effective upon the health organizati…

For RBC reports required to be filed by health organizations with respect to 2002, the following requirements shall apply in lieu of the provisions of §§ 31-3451.03, 31-3451.04, 31-3451.05, and 31-3451.06: (1) In the event of a Company Action Level Event with respect to a domesti…