Title 31, Insurance and Securities.

All individual and group health insurance policies providing coverage on an expense-incurred basis and individual and group service-or indemnity-type contracts issued by a nonprofit health service plan shall provide that health insurance benefits shall be payable with respect to …

(a) Except as provided in subsection (b) of this section, all individual and group health policies providing maternity and newborn care coverage on an expense-incurred basis and individual and group service or indemnity type contracts issued by a nonprofit health service plan, in…

If payment of a specific premium or subscription fee is required to provide coverage for a child, the policy or contract may require that notification of birth of a newly born child and payment of the required premium or fees must be furnished to the insurer or nonprofit service …

The requirements of this chapter shall apply: (1) To all insurance policies and subscriber contracts delivered or issued for delivery in the District more than 120 days after October 20, 1979. (2) To all such insurance policies and subscriber contracts renewed, amended or reissue…

Specifically excluded from the coverage requirements of this chapter are Medicare Supplement insurance policies, accident only policies, dread disease policies, student accident policies, nursing home policies, and home health care policies.

For the purposes of this chapter, the term: (1) “Aggregate attachment point” means the total amount of health claims incurred by a small employer in a policy year for all covered employees and their dependents, and covered by a stop-loss insurance policy, above which the stop-los…

(a) An insurer shall not issue or deliver to a small employer, as defined in §31-3301.01(42), a stop-loss insurance policy unless the employer has a fully-insured employee health benefit plan. (b) Stop-loss insurance is subject to the following: (1) The policy must be issued to a…

For the purposes of this chapter, the term: (1) “Commissioner” means Commissioner of the Department of Insurance and Securities Regulation. (2) “District” means the District of Columbia. (3) “Group health plan” means an employee welfare plan (as defined in section 3(1) of the Emp…

(a) An individual or group health plan which is a health benefit plan, and a health insurer providing health insurance coverage, that provides medical and surgical benefits with respect to a mastectomy shall, in a manner determined in consultation with the attending physician and…

(a) Written notice of the availability of coverage, as set forth in § 31-3832, shall be delivered to the participant and beneficiary under the health plan upon enrollment and annually thereafter. Notice of the benefits shall be prominently positioned in any literature or correspo…

An individual or group health plan, and a health insurer offering health care coverage that provides coverage for prescription drugs, shall provide benefits which cover any hormone replacement therapy that is prescribed or ordered for treating symptoms and conditions of menopause…

(a) An individual health plan or group health plan, a health insurer offering health insurance coverage for prescription drugs, and health insurance coverage through Medicaid and the D.C. Healthcare Alliance program shall provide coverage for a supply of contraceptives intended t…

(a) An individual health plan or group health plan and health insurance coverage through Medicaid or the D.C. Healthcare Alliance program shall provide coverage for, and shall not impose any cost-sharing requirements on, women for the following preventive health services and prod…

(a) Health insurance coverage through Medicaid or the D.C. Healthcare Alliance program shall also provide coverage for and shall not impose any cost-sharing requirements for the following: (1) Voluntary sterilization procedures and services; (2)(A) All contraceptive drugs, device…

(a)(1) An individual health plan or group health plan shall provide coverage for abortion and abortion-care services, including follow-up services, to an enrollee. (2) No individual health plan or group health plan shall impose any deductible, coinsurance, copayment, or other cos…

(a)(1) An employer organized and operating as a nonprofit entity and referred to in section 6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code of 1986, approved October 22, 1986 (100 Stat. 2740; 26 U.S.C. § 6033(a)(3)(A)(i) or (iii)), may be exempt from any requirement to cov…

(a) An insurer that is subject to §§ 31-3834.01, 31-3834.02, 31-3834.03, 31-3834.03a, 31-3834.06, or 31-3834.07 shall make readily accessible to enrollees and potential enrollees information regarding: (1) Full and accurate information relevant to coverage and cost-sharing for co…

(a)(1) Beginning January 1, 2025, a health insurer offering a large group health benefit plan shall provide coverage for the diagnosis and treatment of infertility, including in vitro fertilization and standard fertility preservation services, as provided in paragraph (2) of this…

(a) Except as otherwise provided in subsection (b) of this section, an individual health plan or group health plan shall provide coverage for voluntary sterilization procedures and services and shall not impose any cost-sharing requirements or impose any medically unnecessary res…

An individual or group health plan which is a health benefit plan, and a health insurer offering health care coverage, shall not: (1) Deny a patient eligibility, or continued eligibility, to enroll or renew coverage under terms of the health benefit plan, solely for the purpose o…

The Commissioner shall promulgate regulations necessary to implement the provisions of this chapter within 180 days after April 3, 2001.

The provisions of this chapter shall apply to group health benefit plans for years beginning on or after April 3, 2001.

(a) For the purposes of this chapter, the term: (1) "Health insurer" means a person that provides one or more health benefit plans or insurance in the District of Columbia, including an insurer, a hospital and medical services corporation, a fraternal benefit society, a health ma…

(a) A health insurer shall allow for a special enrollment period for a pregnant individual for: (1) Sixty days when offering individual health insurance coverage from the date of confirmation of pregnancy, as certified by a licensed healthcare professional acting within the scope…

(a) For the purposes of this chapter, the term: (1) “Health benefits plan” shall have the same meaning as provided in § 31-3131(4). (2) “Health insurer” shall have the same meaning as provided in § 31-3131(5). (2A) "Postpartum" means the time after delivery when maternal physiolo…

(a) A health insurer offering a health benefits plan in the District may not deny coverage for a healthcare service on the basis that the service is provided through telehealth if the same service would be covered when delivered in person. (b) A health insurer shall reimburse the…

Medicaid shall cover and reimburse for healthcare services appropriately delivered through telehealth if the same services would be covered when delivered in person.

(a) A health benefits plan issued, renewed, extended, or modified in the District by a health insurer after December 31, 2022, shall provide coverage for the cost of medically necessary food ordered as necessary by a provider for the following diseases or conditions: (1) Inflamma…

(a) For purposes of this chapter, the term: (1) "Adverse determination" means a decision by a utilization review entity that the health care services furnished or proposed to be furnished to an enrollee is denied, reduced, or terminated as being not medically necessary or experim…

(a)(1) A utilization review entity may only require prior authorization for a covered health care service based on a determination of medical necessity for different care or that the proposed care is experimental or investigational in nature. (2) A utilization review entity may n…

(a) If a utilization review entity requires prior authorization of a health care service, the utilization review entity shall, after receiving all required information to make its decision, make an approval or adverse determination and notify the enrollee, representative, and the…

(a) Except as otherwise provided in subsection (b) of this section, approval shall be valid for at least one year from the date the enrollee receives notice of the approval and shall remain valid regardless of any changes in dosage for a prescription drug prescribed by the health…

(a) A utilization review entity shall provide an enrollee with at least 15 calendar days from the date the enrollee receives notice of an adverse determination to appeal the decision via the utilization review entity's website, facsimile, or mail; provided, that an appeal submitt…

(a)(1) A utilization review entity shall ensure that an adverse determination is made by a physician who: (A) Possesses a current and valid non-restricted license to practice medicine in the District, Maryland, or Virginia; and (B) Is of the same or similar specialty as a physici…

(a)(1) A utilization review entity shall honor an approval granted by a previous utilization review entity for at least the initial 60 days of an enrollee's coverage under the new health benefits plan; provided, that the utilization review entity may condition honoring the approv…

(a) Any failure by a utilization review entity to comply with the requirements specified in this chapter shall result in the health care service in question being deemed approved. (b) An action by a utilization review entity that establishes a pattern or practice of repeated viol…

(a)(1) Beginning January 1, 2025, a utilization review entity shall make available on its website, or by phone upon request, to an enrollee, representative, and health care provider, the information required by paragraph (2) of this subsection regarding the enrollee's active prio…

The Mayor, pursuant to subchapter I of Chapter 5 of Title 2, may issue rules to implement the provisions of this chapter.

For the purposes of this chapter, the term: (a)(1) “Affiliated company” means a company in the same corporate system as its parent or a member organization by virtue of common ownership, control, operation, or management. (2) “Agency captive insurer” means a captive insurer that …

(a) A captive insurer may be organized and operated in any form of business organization authorized by the Commissioner and may, pursuant to this chapter, transact any insurance or annuity business. (b) Notwithstanding subsection (a) of this section, a captive insurer shall not: …

(a) A captive insurer may be organized in the District in any form of authorized by the Commissioner. (a-1) The articles of incorporation of a captive insurer shall become effective when approved by the Commissioner. (b) The articles of incorporation or organizational documents o…

(a) For the purposes of this chapter, the term: (1) “Incorporated protected cell” means a protected cell that is established as a corporation or other legal entity separate from the protected cell captive insurer of which it is a part. (2) “Protected cell” means a separate accoun…

(a) If a protected cell captive insurer with one or more protected cells is being liquidated under this chapter, the protected cell captive insurer shall not be deemed to have no assets and no liabilities if the protected cell captive insurer continues to have a protected cell. (…

(a)(1) In addition to any other capital required to be maintained pursuant to subsection (c) of this section, a captive insurer (except a protected cell captive insurer) authorized to do business in the District shall at all times maintain a minimum unimpaired capital of $ 100,00…

(a) A captive insurer shall file with the Commissioner a schedule of its proposed investments, and any material changes thereto, which the Commissioner may approve if he or she determines that the investments do not threaten the solvency or liquidity of the captive insurer. The C…

(a) A captive insurer or protected cell may provide reinsurance on risks ceded by any other insurer, captive insurer, or protected cell. (b) A captive insurer or protected cell may take credit for the reinsurance of risks or portions of risks ceded to reinsurers in compliance wit…