Title 31 — Insurance and Securities.

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 …

(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…

Repealed Repealed.

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 …

Repealed Repealed.

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…

Repealed Repealed.

(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…