reglab/statecodes huggingface dataset:
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 29C - Chemotherapy Pill Coverage › § 31–2995.01. Definitions

§ 31–2995.01. Definitions.
For the purposes of this chapter, the term:
(1) “Group health plan” means an employee welfare plan (as defined in section 3(1) of the Employee Retirement Income Security Act of 1974, approved September 2, 1974 (88 Stat. 829; 29 U.S.C. § 1002(1)), to the extent that the plan provides medical care and includes items and services paid for as medical care to employees or their dependents (as defined under the terms of the plan) directly or through insurance, reimbursement, or otherwise.
(2) “Health insurance coverage” means benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise and includes items and services paid for as medical care) under any hospital or medical service policy or certificate, hospital, or medical service plan contract, or health maintenance organization contract offered by a health insurer.
(3) “Health insurer” means any person that provides one or more health benefit plans or insurance in the District, including an insurer, a hospital and medical services corporation, a fraternal benefit society, a health maintenance organization, a multiple employer welfare arrangement, or any other person providing a plan of health insurance subject to the authority of the Commissioner of the Department of Insurance, Securities, and Banking.
(4) “Individual health plan” means a plan offering health insurance coverage offered to individuals other than in connection with a group health plan.
(Dec. 17, 2009, D.C. Law 18-98, § 2, 56 DCR 8530.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 29C - Chemotherapy Pill Coverage › § 31–2995.02. Chemotherapy pill coverage

§ 31–2995.02. Chemotherapy pill coverage.
(a) An individual health plan or group health plan, and a health insurer offering health insurance coverage that provides coverage for prescription drugs, shall provide health insurance coverage for prescribed, orally administered anticancer medication used to kill or slow the growth of cancerous cells and the person receiving such prescribed medication shall have the option of having it dispensed at any appropriately licensed pharmacy.
(b) The health insurance coverage provided under this section shall be on a basis no less favorable than coverage provided for intravenously administered or injected cancer medications, for purposes of determining deductibles, benefit year or lifetime durational limits, benefit year or lifetime dollar limits, lifetime episodes or treatment limits, copayment and coinsurance factors, and benefit year maximum for deductibles and copayments and coinsurance factors.
(Dec. 17, 2009, D.C. Law 18-98, § 3, 56 DCR 8530.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 29C - Chemotherapy Pill Coverage › § 31–2995.03. Applicability to group health plans

§ 31–2995.03. Applicability to group health plans.
This chapter shall apply to group health plans for years beginning on or after December 17, 2009.
(Dec. 17, 2009, D.C. Law 18-98, § 4, 56 DCR 8530.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 29D - Dependent Health Insurance › § 31–2996.02. Dependent child coverage

§ 31–2996.02. Dependent child coverage.
(a) A group health plan or an individual health plan, and a health insurer offering health insurance coverage that provides coverage for dependent children, that delivers, issues for delivery, amends, or renews a health insurance policy in the District of Columbia shall make health insurance coverage available and, if requested by the policyholder, extend coverage to any dependent child of a policyholder until the dependent child is no longer a dependent child.
(b) The health insurance coverage shall provide:
(1) The same health insurance coverage benefits to a dependent child that are available to any other covered dependent; and
(2) Health insurance coverage benefits to a dependent child at the same rate or premium applicable to any other covered dependent.
(c) Nothing in this chapter shall be construed to require:
(1) Coverage for services provided to a dependent before October 26, 2010; or
(2) That an employer or other group policyholder pay all or part of the cost of coverage for a dependent as provided pursuant to this section.
(Oct. 26, 2010, D.C. Law 18-252, § 3, 57 DCR 8064.)
Emergency Legislation
For temporary (90 day) addition, see § 3 of Health Insurance for Dependents Emergency Act of 2010 (D.C. Act 18-384, April 29,
Temporary Legislation
Section 3 of D.C. Law 18-203 added a section to read as follows:
“Sec. 3. Dependent child coverage.
“(a) A group health plan or an individual health plan, and a health insurer offering health insurance coverage that provides coverage for dependent children, that delivers, issues for delivery, amends, or renews a health insurance policy in the District of Columbia shall make health insurance coverage available and, if requested by the policyholder, extend health insurance coverage to any dependent child of a policyholder until the dependent child is no longer a dependent child.
“(b) The health insurance coverage shall provide:
“(1) The same health insurance coverage benefits to a dependent child that are available to any other covered dependent; and
“(2) Health insurance coverage benefits to a dependent child at the same rate or premium applicable to any other covered dependent.
“(c) Nothing in this act shall be construed to require:
“(1) Coverage for services provided to a dependent before the effective date of this act; or
“(2) That an employer or other group policyholder pay all or part of the cost of coverage for a dependent as provided pursuant to this section.”
Section 6(b) of D.C. Law 18-203 provided that the act shall expire after 225 days of its having taken effect.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 29D - Dependent Health Insurance › § 31–2996.03. Limitations on other coverage

§ 31–2996.03. Limitations on other coverage.
This chapter shall not limit or alter any right to dependent coverage or to the continuation of coverage that is otherwise provided for in the District of Columbia.
(Oct. 26, 2010, D.C. Law 18-252, § 4, 57 DCR 8064.)
Emergency Legislation
For temporary (90 day) addition, see § 4 of Health Insurance for Dependents Emergency Act of 2010 (D.C. Act 18-384, April 29, 2010, 57 DCR 3835).
Temporary Legislation
Section 4 of D.C. Law 18-203 added a section to read as follows: “Sec. 4. Limitations on other coverage. ”This act shall not limit or alter any right to dependent coverage or to the continuation of coverage that is otherwise provided for in the District of Columbia.”
Section 6(b) of D.C. Law 18-203 provided that the act shall expire after 225 days of its having taken effect.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 30 - Diabetes Health Insurance Coverage › § 31–3001. Definitions

§ 31–3001. Definitions.
For the purposes of this chapter, the term:
(1) “Health benefit plan” means an accident and health insurance policy or certificate, hospital and medical services corporation contract, health maintenance organization subscriber contract, plan provided by a multiple employer welfare arrangement, or plan provided by another benefit arrangement. The term “health benefit plan” shall not mean accident only, credit, or disability insurance; coverage of medicare services or federal employee health plans under contracts with the United States Government; medicare supplement or long-term care insurance; specified disease insurance; hospital confinement indemnity coverage; limited benefit health coverage; coverage issued as a supplement to liability insurance; insurance arising out of a workers’ compensation or similar law; automobile medical payment insurance; medical expense and loss of income benefits; or insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in a liability insurance policy or equivalent self-insurance.
(2) “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 maintenance organization, a multiple employer welfare arrangement, or any other person providing a plan of health insurance subject to the authority of the Commissioner of the Department of Insurance, Securities, and Banking.
(3) “Insured” means a person covered by a health benefit plan.
(Oct. 21, 2000, D.C. Law 13-175, § 2, 47 DCR 6832; June 11, 2004, D.C. Law 15-166, § 4(q), 51 DCR 2817.)
Section References
This section is referenced in § 31-2803 and § 31-3161.
Effect of Amendments
D.C. Law 15-166, in par. (2), substituted “Department of Insurance, Securities, and Banking” for “Department of Insurance and Securities Regulation”.
Emergency Legislation
For temporary (90 day) amendment of section, see § 4(q) of Consolidation of Financial Services Emergency Amendment Act of 2004 (D.C. Act 15-381, February 27, 2004, 51 DCR 2653).
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 30 - Diabetes Health Insurance Coverage › § 31–3002. Payable benefits

§ 31–3002. Payable benefits.
A health benefit plan shall provide coverage for the equipment, supplies, and other outpatient self-management training and education, including medical nutritional therapy, for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes, and non-insulin using diabetes if prescribed by a health care professional legally authorized to prescribe such item.
(Oct. 21, 2000, D.C. Law 13-175, § 3, 47 DCR 6832.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 30 - Diabetes Health Insurance Coverage › § 31–3003. Nondiscrimination

§ 31–3003. Nondiscrimination.
No health insurer shall:
(1) Require an insured to pay a higher deductible, copayment, or coinsurance; require a longer waiting period; or impose any other condition for coverage of any of the benefits set forth in this chapter other than is required for other benefits covered by the insured’s health benefit plan;
(2) Refuse to issue a health benefit plan solely because an applicant may use any of the benefits covered by this chapter;
(3) Cancel a health benefit plan solely because an insured has used any of the benefits covered by this chapter;
(4) Offer to pay any type of material inducement or financial incentive to an insured to discourage the insured from using any of the benefits covered by this chapter; or
(5) Offer to pay any type of financial or other material incentive to a health care provider to deny, reduce, withhold, limit, or delay to an insured any of the benefits covered by this chapter.
(Oct. 21, 2000, D.C. Law 13-175, § 4, 47 DCR 6832.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 30 - Diabetes Health Insurance Coverage › § 31–3004. Applicability

§ 31–3004. Applicability.
(a) The requirements of this chapter shall apply to all health benefit plans issued, delivered, renewed, or reissued on the 91st day after October 21, 2000.
(b) All health benefit plans other than the health benefit plans specified in subsection (a) of this section shall comply with the requirements of this chapter within 180 days after the date specified in subsection (a) of this section.
(Oct. 21, 2000, D.C. Law 13-175, § 5, 47 DCR 6832.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 30A - Discontinuance of Class of Health Insurance Policies › § 31–3012. Rules

§ 31–3012. Rules.
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.
(Apr. 8, 2011, D.C. Law 18-360, § 403, 58 DCR 896.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 30A - Discontinuance of Class of Health Insurance Policies › § 31–3013. Application

§ 31–3013. Application.
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.
(Apr. 8, 2011, D.C. Law 18-360, § 404, 58 DCR 896.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31 - Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage › § 31–3104. Mental illness benefits

§ 31–3104. Mental illness benefits.
(a) Covered benefits for services set forth in this section shall be limited to coverage of treatment of clinically significant mental illnesses identified in the most recent edition of the International Classification of Diseases or of the Diagnostic and Statistical Manual of the American Psychiatric Association.
(b) Treatment under this section shall be covered pursuant to § 31-3102 for a minimum of 60 days per year for inpatient or residential care in a hospital or nonhospital residential facility, and at a minimum rate of 75% for the first 40 outpatient visits per year and at a minimum rate of 60% for any outpatient visits thereafter for that year.
(Feb. 28, 1987, D.C. Law 6-195, § 5, 34 DCR 491; Mar. 8, 2007, D.C. Law 16-242, § 2(d), 54 DCR 601.)
Prior Codifications
1981 Ed., § 35-2304.
Section References
This section is referenced in § 31-3102, § 31-3105, § 31-3106, and § 31-3110.
Effect of Amendments
D.C. Law 16-242, in subsec. (b), substituted “60 days” for “45 days”.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31 - Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage › § 31–3106. Certification of nonhospital residential facilities and outpatient treatment facilities

§ 31–3106. Certification of nonhospital residential facilities and outpatient treatment facilities.
(a) The Mayor shall certify qualifying nonhospital residential facilities and outpatient treatment facilities in the District in accordance with rules issued pursuant to § 31-3111.
(b) Each certification issued by the Mayor shall state whether the facility is certified as a provider of treatment for drug abuse, alcohol abuse, mental illness, or a combination of these that shall be specified.
(c) To qualify for certification, a nonhospital residential facility or outpatient treatment facility shall demonstrate that:
(1) It offers an organized program for the treatment of drug abuse, alcohol abuse, mental illness, or any combination of these;
(2) It operates under the day-to-day supervision of an individual with demonstrable training and experience in the treatment of drug abuse, alcohol abuse, or mental illness;
(3) It employs sufficient numbers of professional staff members to deliver adequately the services offered to its patient caseload; and
(4) It offers and has the capacity to provide services for the durations specified in §§ 31-3103 and 31-3104.
(d) Nothing in this section shall be construed as superseding the requirements of chapter 5 of Title 44.
(e) Any certification issued pursuant to this section shall be issued as a Public Health: Human Services Facility endorsement to a basic business license under the basic business license system as set forth in subchapter I-A of Chapter 28 of Title 47.
(Feb. 28, 1987, D.C. Law 6-195, § 7, 34 DCR 491; Apr. 20, 1999, D.C. Law 12-261, § 2003(kk), 46 DCR 3142; Oct. 28, 2003, D.C. Law 15-38, § 3(y), 50 DCR 6913.)
Prior Codifications
1981 Ed., § 35-2306.
Section References
This section is referenced in § 44-1204.
Effect of Amendments
D.C. Law 15-38, in subsec. (e), substituted “Public Health: Human Services Facility endorsement to a basic business license under the basic” for “Class A Public Health: Human Services Facility endorsement to a master business license under the master”.
Cross References
Substance abuse treatment certification requirements, see § 44-1204.
Emergency Legislation
For temporary (90 day) amendment of section, see § 3(y) of Streamlining Regulation Emergency Act of 2003 (D.C. Act 15-145, August 11, 2003, 50 DCR 6896).
Delegation of Authority
Delegation of authority pursuant to D.C. Law 6-195, “Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Act of 1986.”, see Mayor’s Order 88-50, February 25, 1988.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31 - Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage › § 31–3107. Preservation of certain benefits

§ 31–3107. Preservation of certain benefits.
Nothing in this chapter shall serve to diminish the benefits of any insured person or prevent the offering or acceptance of benefits that exceed the minimum benefits required by this chapter.
(Feb. 28, 1987, D.C. Law 6-195, § 8, 34 DCR 491.)
Prior Codifications
1981 Ed., § 35-2307.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31 - Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage › § 31–3108. Notification of coverage and benefits

§ 31–3108. Notification of coverage and benefits.
All individual and group health benefit plans shall contain statements, in easily readable type and in easily understandable language, approved by the Commissioner, to inform policyholders and beneficiaries of the coverage and benefits provided or offered pursuant to this chapter.
(Feb. 28, 1987, D.C. Law 6-195, § 9, 34 DCR 491; May 21, 1997, D.C. Law 11-268, § 10(w), 44 DCR 1730; Mar. 8, 2007, D.C. Law 16-242, § 2(f), 54 DCR 601.)
Prior Codifications
1981 Ed., § 35-2308.
Section References
This section is referenced in § 31-3110.
Effect of Amendments
D.C. Law 16-242 substituted “health benefit plans” for “health insurance policies”.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31 - Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage › § 31–3110. Health maintenance organizations

§ 31–3110. Health maintenance organizations.
(a) The requirements of this chapter shall apply to health maintenance organizations 5 years from February 28, 1987, unless the Mayor requests the Council to extend the exemption to a time certain and the Council, by resolution, approves the extension.
(b) Upon becoming subject to the requirements of this chapter, each health maintenance organization shall:
(1) Provide to its members the coverage and benefits required by §§ 31-3102, 31-3103, and 31-3104;
(2) Ensure that deductible or copayment plans, durational limits, and methods of determination adopted with respect to coverage of the benefits required by §§ 31-3102, 31-3103, and 31-3104 result in coverage that is determined by the Commissioner to be at least equivalent in actuarial value to the average actuarial value of the plans provided by the health insurer with the largest number of enrollees in the District; and
(3) Provide the notification of coverage and benefits required by § 31-3108.
(c) Each health maintenance organization may provide the treatment required by §§ 31-3103 and 31-3104 directly by its staff or by referring its members to a hospital or other treatment facility that provides those services under a contract or agreement with the health maintenance organization. Nothing in this chapter shall require the alteration of any terms and conditions of the health maintenance organization membership contract relating to prior approval by the health maintenance organization for treatment provided to its members by other treatment facilities.
(d)(1) Each health maintenance organization, within 120 days after becoming subject to the requirements of this chapter, shall file with the Commissioner the membership contracts it proposes to use, identifying its charges for all services and the portion of charges attributable to the services required by this chapter.
(2) The provisions of § 31-3109, except for subsection (b)(2) of this section, shall apply thereafter to the membership contracts and charges filed and implemented by health maintenance organizations. Rates and charges for the coverage required by this chapter shall not be excessive and shall be reasonably related to the cost of providing the coverage.
(Feb. 28, 1987, D.C. Law 6-195, § 11, 34 DCR 491; May 21, 1997, D.C. Law 11-268, § 10(w), 44 DCR 1730; Mar. 8, 2007, D.C. Law 16-242, § 2(h), 54 DCR 601.)
Prior Codifications
1981 Ed., § 35-2310.
Section References
This section is referenced in § 31-3101, § 31-3109, and § 31-3111.
Effect of Amendments
D.C. Law 16-242, in subsec. (b)(2), substituted “health insurer” for “insurer”.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31 - Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage › § 31–3111. Duties of Mayor

§ 31–3111. Duties of Mayor.
(a) The Mayor shall, within 120 days from February 28, 1987, issue rules to implement all sections of this chapter except § 31-3110. The Mayor shall issue rules to implement § 31-3110 no later than 5 years from February 28, 1987.
(b) The Mayor shall provide the coverage and benefits set forth in this chapter to employees of the District and their dependents who are insured through the District of Columbia Employees’ Health Benefits Program. For District employees and their dependents who are insured through the Federal Employees’ Health Benefits Program, the Mayor shall provide supplemental coverage and benefits that comply with the requirements of this chapter no later than February 28, 1994.
(Feb. 28, 1987, D.C. Law 6-195, § 12, 34 DCR 491; Mar. 16, 1993, D.C. Law 9-192, § 2(d), 39 DCR 9007.)
Prior Codifications
1981 Ed., § 35-2311.
Section References
This section is referenced in § 31-3106 and § 31-3109.
Delegation of Authority
Delegation of authority pursuant to D.C. Law 6-195, “Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Act of 1986.”, see Mayor’s Order 88-50, February 25, 1988.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31 - Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage › § 31–3112. Excluded programs

§ 31–3112. Excluded programs.
This chapter shall not be applicable to the District of Columbia Alliance Program, Medicaid Program, and Post-1987 District of Columbia Employees’ Health Insurance Benefits Plan.
(Feb. 28, 1987, D.C. Law 6-195, § 12a; as added Mar. 8, 2007, D.C. Law 16-242, § 2(i), 54 DCR 601.)
Editor's Notes
Section 3 of D.C. Law 16-242 provided: “Section 2 shall apply to all individual and group health benefit plans issued or renewed on the first day of the month beginning on or after 90 days after the effective date of this act.”
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31A - Health Benefits Plans Prompt Payment › § 31–3133. Retroactive denial of reimbursement

§ 31–3133. Retroactive denial of reimbursement.
(a) A health insurer may only retroactively deny reimbursement to a health care provider:
(1) For services subject to coordination of benefits with another health insurer during the 18-month period after the date that the health insurer paid the health care provider; or
(2) Except as provided in paragraph (1) of this subsection, during the 6-month period after the date that the health insurer paid the health care provider.
(b)(1) A health insurer that retroactively denies reimbursement to a health care provider under subsection (a)(1) of this section shall provide the health care provider with a written statement specifying the basis for the retroactive denial. If the retroactive denial of reimbursement results from coordination of benefits, the written statement shall provide the name and address of the entity acknowledging responsibility for payment of the denied claim.
(2) This subsection shall not apply if a health insurer retroactively denies reimbursement to a health care provider because:
(A) The information submitted to the health insurer was fraudulent;
(B) The information submitted to the health insurer was improperly coded and the health insurer has provided to the health care provider sufficient information regarding the coding guidelines used by the health insurer at least 30 days prior to the date the services subject to the retroactive denial were rendered; or
(C) The claim submitted to the health insurer was a duplicate claim.
(3) Information submitted to the health insurer may be considered to be improperly coded under paragraph (1) of this subsection if the information submitted to the health insurer by the health care provider:
(A) Uses codes that do not conform with the coding guidelines used by the health insurer applicable as of the date that services were rendered; or
(B) Does not otherwise conform with the contractual obligations of the health care provider to the health insurer applicable as of the date that services were rendered.
(c) If a health insurer retroactively denies reimbursement for services as a result of coordination of benefits, the health care provider shall have 180 days after the date of denial, unless the health insurer permits a longer time period, to submit a claim for reimbursement for the service to the health insurer responsible for payment.
(d) A health insurer that retroactively denies reimbursement to a health care provider under this section shall provide the health care provider with a written statement specifying the basis for the retroactive denial.
(e) This section shall not apply to an adjustment to reimbursement made as part of an annual contracted reconciliation of a risk-sharing arrangement.
(July 23, 2002, D.C. Law 14-176, § 4, 49 DCR 5086.)
Section References
This section is referenced in § 31-3138.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31A - Health Benefits Plans Prompt Payment › § 31–3134. Provider panels

§ 31–3134. Provider panels.
(a) Except for Medicaid and Medicare provider panels, if a provider panel contract between a provider and a health insurer, or other entity that provides hospital, physician, or other health care services to a health insurer, require a provider, as a condition of participating in one of the health insurer’s or other entity’s provider panels, to participate in any other provider panel owned or operated by the health insurer or other entity, the contract shall contain a provision permitting the provider to refuse participation in one or more of the other provider panels at the time the contract is executed or renewed. The status of a physician as a member of, or as being eligible for, other existing or new provider panels shall not be adversely affected by the exercise of the right to refuse participation.
(b) If a provider elects to terminate participation on a provider panel of a health insurer or entity that provides hospital, physicians, or health services to a health insurer, the provider shall:
(1) Notify the health insurer at least 90 days before termination; and
(2) For at least 90 days after the date of notice of termination, continue to furnish health care services to an enrollee of a health insurer for whom the provider was responsible for the delivery of health care services prior to the notice of termination.
(July 23, 2002, D.C. Law 14-176, § 5, 49 DCR 5086.)
Section References
This section is referenced in § 31-3138.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31A - Health Benefits Plans Prompt Payment › § 31–3135. Claims payment report

§ 31–3135. Claims payment report.
A health insurer shall include with its annual report filed with the Commissioner a claims payment report to include the:
(1) Number of claims received in the previous calendar year;
(2) Number of claims denied in the previous calendar year;
(3) Number of claims paid:
(A) In the previous calendar year;
(B) In 30 days;
(C) In 60 days;
(D) In 120 days; and
(E) In more than 120 days; and
(4) Average number of days to pay a claim submitted in the previous calendar year.
(July 23, 2002, D.C. Law 14-176, § 6, 49 DCR 5086.)
Section References
This section is referenced in § 31-3138.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31A - Health Benefits Plans Prompt Payment › § 31–3136. Penalties

§ 31–3136. Penalties.
An action by a health insurer that establishes a pattern or practice of repeated violation of this chapter, as determined by the Commissioner, shall constitute a violation as provided in Chapter 22A of this title.
(July 23, 2002, D.C. Law 14-176, § 7, 49 DCR 5086.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31A - Health Benefits Plans Prompt Payment › § 31–3138. Applicability

§ 31–3138. Applicability.
(a) This chapter shall apply to any individual and group health benefits plan issued or renewed in the District of Columbia. Health insurers shall comply with this chapter on the earlier of October 16, 2002, or the effective date of the claims payment standards in section 1173 of the Social Security Act, approved August 14, 1935 (110 Stat. 2024; 42 U.S.C. § 1320d-2).
(b) Section 31-3132 shall apply to claims received on or after October 16, 2002.
(c) Section 31-3133 shall apply to retroactive denials made on or after October 16, 2002.
(d) Section 31-3134 shall apply to any contract issued or renewed on or after October 16, 2002.
(e) Section 31-3135 shall apply to claims data collected beginning with the first full calendar year following July 23, 2002. A health insurer shall include this data in the annual report filed with the Commissioner beginning on March 15, 2004.
(July 23, 2002, D.C. Law 14-176, § 9, 49 DCR 5086.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31B - Health Benefit Plans Withdrawal from Market › § 31–3151. Definitions

§ 31–3151. Definitions.
For the purposes of this chapter, the term:
(1) “Application” means a carrier’s application pursuant to this chapter for approval to voluntarily withdraw from the District of Columbia health insurance market.
(2) “Carrier” means any person or organization subject to the authority of the Commissioner that provides one or more health benefit plans in the District of Columbia, and includes an insurer, a hospital and medical services corporation, a fraternal benefit society, a health maintenance organization, or multiple employer welfare arrangement.
(3) “Commissioner” means the Commissioner of the Department of Insurance, Securities, and Banking.
(4) “Health benefit plan” means any accident and health insurance policy or certificate, hospital and medical services corporation contract, health maintenance organization subscriber contract, a plan provided by a multiple employer welfare arrangement, or a plan provided by another benefit arrangement. The term “health benefit plan” does not mean accident only, credit, or disability insurance; coverage of Medicare services or federal employee health plans, pursuant to contracts with the United States government; Medicare supplement or long-term care insurance; dental only or vision only insurance; specified disease insurance; hospital confinement indemnity coverage; limited benefit health coverage; coverage issued as a supplement to liability insurance; insurance arising out of a workers’ compensation or similar law; automobile medical payment insurance; medical expense and loss of income benefits; or insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.
(5) “HIPAA” means the Health Insurance Portability and Accountability Act of 1996, approved August 21, 1996 (110 Stat. 1936; scattered sections of the United States Code).
(6) “Medicare” means the health insurance program established pursuant to the Health Insurance for the Aged Act, approved July 30, 1965 (79 Stat. 290; 42 U.S.C. § 401 et seq.).
(7) “Withdraw” means the full cessation of underwriting insurance policies, including the nonrenewal of existing insurance policies, relative to any line of business or any subgroup thereof, including individual accounts.
(Apr. 12, 2005, D.C. Law 15-328, § 2, 52 DCR 1459.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31B - Health Benefit Plans Withdrawal from Market › § 31–3152. Procedures for voluntary withdrawal by carriers

§ 31–3152. Procedures for voluntary withdrawal by carriers.
(a) A carrier shall give the Commissioner written notice, prior to notifying the members of the health benefit plan, of its intent to discontinue the offering of all health benefit plans in the District of Columbia and shall submit to the Commissioner an application with the following information:
(1) The name of the carrier;
(2) The name, address, telephone number, and facsimile number of the carrier’s representative responsible for the activities pertaining to withdrawing from the District of Columbia health insurance market;
(3) A specific description of the reasons the carrier is withdrawing its health benefit plans from the District of Columbia health insurance market;
(4) A statement of the number of in-force policies affected by the withdrawal;
(5) A copy of the nonrenewal notice, which complies with HIPAA, that the carrier will send to its enrollees and dependents once its application is approved; and
(6) Any other information or documentation that the Commissioner considers relevant and appropriate in connection with the carrier ceasing to offer a health benefit plan in the District of Columbia.
(b) The carrier shall obtain prior approval of its application from the Commissioner before it commences to voluntarily withdraw from the District of Columbia health insurance market.
(c) The Commissioner shall complete his or her review of the application submitted by the carrier to withdraw from the District of Columbia health insurance market within 60 days after receipt of all requested documentation.
(d) To ensure that health care services will be available and accessible to all group and nongroup policyholders of a withdrawing carrier, the Commissioner may allocate the group and nongroup contracts among other carriers in a similar manner as provided in § 31-3414.
(e) The Commissioner may condition his or her approval of the carrier’s application upon the terms and conditions as are necessary for the protection of the carrier’s policyholders, its creditors, or the public interest.
(Apr. 12, 2005, D.C. Law 15-328, § 3, 52 DCR 1459.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31B - Health Benefit Plans Withdrawal from Market › § 31–3153. Judicial review; mandamus

§ 31–3153. Judicial review; mandamus.
(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 filing of an appeal pursuant to this section shall not stay the application of any rule, regulation, order, or other action of the Commissioner to the appealing party unless the court, after giving the appealing party notice and an opportunity to be heard, determines that failure to grant the stay would be detrimental to the interest of policyholders, shareholders, creditors, or the public.
(c) Any carrier aggrieved by any failure of the Commissioner to act or make a determination required by this chapter may petition the Superior Court of the District of Columbia for a writ in the nature of a mandamus or a peremptory mandamus directing the Commissioner to act or make the determination forthwith.
(Apr. 12, 2005, D.C. Law 15-328, § 4, 52 DCR 1459.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31B - Health Benefit Plans Withdrawal from Market › § 31–3154. Regulations

§ 31–3154. Regulations.
The Commissioner may promulgate rules and regulations necessary to implement the provisions of this chapter, including provisions for the disposal of books of business.
(Apr. 12, 2005, D.C. Law 15-328, § 5, 52 DCR 1459.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31C - Health Benefit Plans Equity › § 31–3161. Prohibition on gender-based discrimination in rate making

§ 31–3161. Prohibition on gender-based discrimination in rate making.
(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 decision, determined through a method that is in any way based upon the gender or sex of a person covered under the health benefit plan.
(c) Each individual health benefit plan offered, sold, issued, or renewed in the District shall provide hospitalization benefits for childbirth to the same extent as benefits provided in the policy for any covered illness. In addition to the provisions of this subsection and subsection (c) of this section, if a mother is required to remain hospitalized after childbirth for medical reasons and the mother requests that the newborn remain in the hospital, the individual health benefit plan shall pay the cost of additional hospitalization for the newborn for up to 4 days.
(d) Each individual health benefit plan offered, sold, issued, or renewed in the District shall provide coverage for the cost of inpatient hospitalization services for a mother and newborn child for a minimum of:
(1) Forty-eight hours of inpatient hospitalization care after an uncomplicated vaginal delivery; and
(2) Ninety-six hours of inpatient hospitalization care after an uncomplicated cesarean section.
(e) A mother may request a shorter length of stay than that provided in subsection (c) of this section if the mother decides, in consultation with the mother’s attending provider, that less time is needed for recovery.
(f)(1) For a mother and newborn child who have a shorter hospital stay than that provided under subsection (c) of this section, the individual health benefit plan shall provide coverage for:
(A) One home visit scheduled to occur within 24 hours after hospital discharge; and
(B) An additional home visit if prescribed by the mother’s attending provider.
(2) For a mother and newborn child who remain in the hospital for at least the length of time provided under subsection (c) of this section, the individual health benefit plan shall provide coverage for a home visit if prescribed by the mother’s attending provider.
(3) A home visit under paragraph (1) or (2) of this subsection shall:
(A) Be provided in accordance with generally accepted standards of nursing practice for home care of a mother and newborn child;
(B) Be provided by a registered nurse with at least one year of experience in maternal and child health nursing or community health nursing with an emphasis on maternal and child health; and
(C) Include any services required by the mother’s attending provider.
(Apr. 8, 2011, D.C. Law 18-360, § 302, 58 DCR 896.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31C - Health Benefit Plans Equity › § 31–3162. Rules

§ 31–3162. Rules.
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.
(Apr. 8, 2011, D.C. Law 18-360, § 303, 58 DCR 896.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31C - Health Benefit Plans Equity › § 31–3163. Application

§ 31–3163. Application.
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.
(Apr. 8, 2011, D.C. Law 18-360, § 304, 58 DCR 896.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31D - Health Benefit Exchange › § 31–3171.02. Establishment and purpose

§ 31–3171.02. Establishment and purpose.
(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 separate from the District government.
(b) The purposes of the Authority shall be to:
(1) Enable individuals and small employers to find affordable and easier-to-understand health insurance;
(2) Facilitate the purchase and sale of qualified health plans;
(3) Assist small employers in facilitating the enrollment of their employees in qualified health plans;
(4) Reduce the number of uninsured;
(5) Provide a transparent marketplace for health benefit plans;
(6) Educate consumers; and
(7) Assist individuals and groups to access programs, premium assistance tax credits, and cost-sharing reductions.
(Mar. 2, 2012, D.C. Law 19-94, § 3, 59 DCR 213.)
Section References
This section is referenced in § 31-3171.01.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31D - Health Benefit Exchange › § 31–3171.07. Advisory board

§ 31–3171.07. Advisory board.
(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 recommendations of, and consult with, the advisory boards on:
(1) Insurance standards;
(2) Covered benefits;
(3) Premiums;
(4) Plan certification;
(5) Internet technology system development; and
(6) Any other policy or operational issues, within the executive board’s discretion.
(d) The executive board shall:
(1) Select the members of the advisory boards;
(2) Establish the terms of the members;
(3) Ensure that at least one member of the standing advisory board demonstrates expertise as a health insurance broker or agent;
(4) Appoint the chair of the standing advisory board;
(5) Determine the residency requirement of any additional advisory board created; and
(6) Appoint the chair of any additional advisory boards created.
(e)(1) An advisory board member may continue to serve until the appointment of his or her successor.
(2) Vacancies shall be filled by appointment by the executive board for the unexpired term of the appointee’s predecessor.
(f) Each person appointed to an advisory board shall have demonstrated and acknowledged expertise on issues related to at least one of the following groups:
(1) Health professionals;
(2) Health insurance consumers;
(3) Disease and demographic-specific advocacy groups;
(4) Commercial sector health plans;
(5) Public sector health plans;
(6) Health insurance brokers;
(7) Health care consumer interest advocacy;
(8) Health care foundations;
(9) Exchange consumers; or
(10) Such other interests considered necessary.
(Mar. 2, 2012, D.C. Law 19-94, § 8, 59 DCR 213.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31D - Health Benefit Exchange › § 31–3171.08. Executive director and Authority staff

§ 31–3171.08. Executive director and Authority staff.
(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 shall serve at the pleasure of the executive board.
(2) The executive director shall become a resident of the District within 180 days of the date of hire.
(b) The executive board shall determine the appropriate compensation for the executive director; provided, that the executive director’s compensation shall not exceed the maximum allowable salary in the District of Columbia Excepted Service salary schedule.
(c) Under the direction of the executive board, the executive director shall;
(1) Be the chief administrative officer of the Authority;
(2) Direct, administer, and manage the operations of the Authority; and
(3) Perform all duties necessary to comply with and carry out the provisions of this chapter, other District laws and regulations, and the Federal Act.
(d)(1) The executive director may employ and retain staff for the Authority.
(2) The executive director may retain as independent contractors or employees, and set compensation for:
(A) Attorneys;
(B) Financial consultants; and
(C) Other professionals or consultants necessary to carry out the planning, development, and operations of the Authority and the provisions of this chapter.
(3) Employee compensation shall not exceed the maximum allowable salary in the District of Columbia Excepted Service salary schedule.
(e) Except as otherwise provided in this chapter, an employee or independent contractor of the Authority shall not be subject to any law, regulation or Mayor’s Order governing District government compensation, including furloughs, pay cuts, or any other general fund cost-saving measure.
(Mar. 2, 2012, D.C. Law 19-94, § 9, 59 DCR 213.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 31D - Health Benefit Exchange › § 31–3171.09a. Distribution of individual and small group health benefit plans

§ 31–3171.09a. Distribution of individual and small group health benefit plans.
(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 with plan years beginning on or after January 1, 2014, shall be offered solely through the American Health Benefit Exchange;
(2) On or after January 1, 2014, small group health benefit plans offered to any small business that was not insured as of December 31, 2013, shall be offered and issued solely through the American Health Benefit Exchange;
(3) Small group health benefit plans offered to or renewed by any small business that was insured as of December 31, 2013, may be issued or renewed during calendar year 2014 through existing distribution channels with the same carrier or a new carrier, except that such plans shall meet the qualifications for certification of a qualified health plan as provided in § 31-3171.09; and
(4) Unless the Council acts by October 1, 2014 to change the date that all small group health plans shall be offered, issued, or renewed through the American Health Benefit Exchange, on or after January 1, 2015, all small group health benefit plans shall be offered and issued or renewed solely through the American Health Benefit Exchange.
(b) The requirements of this section shall not apply to grandfathered health plans as defined in section 1251 of the Federal Act.
(Mar. 2, 2012, D.C. Law 19-94, § 10a; as added July 16, 2014, D.C. Law 20-123, § 2(c), 61 DCR 5379.)
Emergency Legislation
For temporary (90 days) addition of this section, see § 2(c) of the Better Prices, Better Quality, Better Choices for Health Coverage Emergency Amendment Act of 2013 (D.C. Act 20-87, June 19, 2013, 60 DCR 9542, 20 DCSTAT 1446).
For temporary (90 days) addition of this section, see §§ 2(c) and 3 of the Better Prices, Better Quality, Better Choices for Health Coverage Congressional Review Emergency Amendment Act of 2013 (D.C. Act 20-170, September 26, 2013, 60 DCR 14742).
For temporary (90 days) addition of this section, see § 2(c) of the Better Prices, Better Quality, Better Choices for Health Coverage Emergency Amendment Act of 2014 (D.C. Act 20-335, May 22, 2014, 61 DCR 5375).
Temporary Legislation
For temporary (225 days) addition of this section, see § 2(c) of the Better Prices, Better Quality, Better Choices for Health Coverage Temporary Amendment Act of 2013 (D.C. Law 20-22, October 3, 2013, 60 DCR 10880).