2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 34 - Health Maintenance Organizations › § 31–3401. Definitions

§ 31–3401. Definitions.
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 to the enrollees of the health maintenance organization by external providers, and the contracting provider pays the external providers pursuant to a contract between the contracting provider and the health maintenance organization.
(2) “Agent” means a person who solicits, negotiates, effects, procures, delivers, renews, or continues a contract for health maintenance organization membership, other than for himself, or a person who advertises or otherwise holds himself out to the public as such. Health maintenance organization agents shall not include salaried employees and officers of the HMO or its parents, subsidiaries or other corporations under common control with the HMO, whose principal duties do not include the negotiation or solicitation of enrollee contracts.
(3) “Basic health care services” means preventive care, emergency care, inpatient and outpatient hospital and physician care, diagnostic laboratory and diagnostic and therapeutic radiological services, and services mandated under Chapter 29 of this title, Chapter 31 of this title, and Chapter 38 of this title.
(4) “Capitated basis” means fixed per member per month payment or percentage of dues payment wherein the provider or an affiliation of providers assumes the full risk for the cost of contracted services without regard to the type, value, or frequency of services provided. For the purposes of this definition, the term “capitated basis” includes the cost associated with operating staff or group model facilities.
(5) “Carrier” means a health maintenance organization, a licensed insurer, Group Hospitalization and Medical Services, Inc., or other entity responsible for payment of benefits or provision of services under a group or individual contract.
(6) “Commissioner” means the Commissioner of the Department of Insurance, Securities, and Banking.
(7) “Contracting provider” means a physician or other health care provider who enters into an administrative service provider contract with a health maintenance organization.
(8) “Copayment” means either a dollar or percentage amount an enrollee must pay in order to receive a specific covered service which is not fully prepaid.
(9) “Covered services” means health care services included in the health maintenance organization’s evidence of coverage in accordance with the terms of the health maintenance organization’s group or individual contract.
(10) “Deductible” means the amount an enrollee is responsible to pay out-of-pocket before the health maintenance organization begins to pay the costs associated with treatment.
(11) “Director” means the Director of the Department of Health, established by Reorganization Plan No. 4 of 1996.
(12) “District” means the District of Columbia.
(13) “Enrollee” means an individual who is covered by a health maintenance organization.
(14) “Enrollment fees” means the payment charged by the health maintenance organization which shall be paid by an enrollee or by a group on behalf of enrollees for coverage in the health maintenance organization.
(15) “Evidence of coverage” means a statement of the essential features and covered services of the health maintenance organization which is given to the enrollee by the health maintenance organization or by the group contract holder.
(16) “Extension of benefits” means the continuation of coverage under a particular benefit provided under a contract following termination with respect to an enrollee who is hospitalized on the date of termination.
(17) “External provider” means a health care provider, including a physician or hospital, that is not a contracting provider, or an employee, shareholder, or partner of a contracting provider.
(18) Repealed.
(19) “Group contract” means a contract issued and delivered in the District for health care services which by its terms limits eligibility to members of a specified group. The group contract may include coverage for dependents.
(20) “Group contract holder” means the person to which the group contract has been issued.
(21) “Health maintenance organization” or “HMO” means any person that undertakes to provide or arrange for the delivery of basic health care services to enrollees on a prepaid basis, except for enrollee responsibility for copayments and deductibles.
(22) “Health maintenance organization producers” means any person who solicits, negotiates, effects, procures, delivers, renews, or continues a policy or contract for HMO membership or who takes or transmits a membership fee or premium for such a policy or contract, other than for himself, or a person who advertises or otherwise holds himself out to the public as such.
(23) “Hold harmless” means an expressed or implied arrangement between a provider and a health maintenance organization by which the provider, or any representative of the provider, agrees not to collect or attempt to collect from any enrollee any money owed to the provider by the health maintenance organization or by a contracting provider, except for copayments and deductibles owed by the enrollee, or any payment or charges for health care services not covered under the evidence of coverage.
(24) “Individual contract” means a contract delivered in the District for health care services issued to and covering an individual enrollee. The individual contract may include dependents of the enrollee.
(25) “Insolvent” or “insolvency” means that the organization has been declared bankrupt and placed under an order of liquidation by a court of competent jurisdiction.
(26) “Mayor” means the Mayor of the District of Columbia.
(27) “Net worth” means the excess of total admitted assets over total liabilities, but the liabilities shall not include fully subordinated debt.
(28) “Participating provider” means a provider who, under an express or implied contract with a health maintenance organization or with its contractor or subcontractor, has agreed to provide covered services to enrollees with an expectation of receiving payment, other than copayment or deductible, directly or indirectly from the health maintenance organization.
(29) “Person” means any natural or artificial person, including, but not limited to, individuals, partnerships, associations, trusts, or corporations.
(30) “Point of service plan” means a delivery system that permits an enrollee of a health maintenance organization to receive services outside the provider panel of the health maintenance organization under the terms and conditions of the enrollee’s contract with the health maintenance organization.
(31) “Primary care provider” means a participating provider who the enrollee has selected or who has otherwise been assigned responsibility for the coordination of covered services to the enrollee.
(32) “Provider” means any hospital or health professional licensed or authorized by reciprocity or endorsement to practice a health occupation by the District pursuant to Chapter 12 of Title 3, or any state.
(33) “Provider panel” means a group of providers that have entered into a written provider service contract with an HMO to provide services under the HMO’s health benefit plan.
(34) “Replacement coverage” means the benefits provided by a succeeding carrier after termination of a member’s enrollment with the preceding carrier.
(35) “Uncovered expenditures” means the cost to the health maintenance organization for covered services that are the obligation of the health maintenance organization for which an enrollee may also be liable in the event of the health maintenance organization’s insolvency and for which no alternative arrangements have been made that are acceptable to the Commissioner.
(Apr. 9, 1997, D.C. Law 11-235, § 2, 44 DCR 818; Mar. 24, 1998, D.C. Law 12-81, § 46(a), 45 DCR 745; Apr. 27, 1999, D.C. Law 12-274, § 501(a)(1), 46 DCR 1294; June 11, 2004, D.C. Law 15-166, § 4(t), 51 DCR 2817.)
Prior Codifications
1981 Ed., § 35-4501.
Effect of Amendments
D.C. Law 15-166, in par. (6), substituted “Commissioner of the Department of Insurance, Securities, and Banking” for “Commissioner of Insurance and Securities”.
Emergency Legislation
For temporary (90 day) amendment of section, see § 4(t) of Consolidation of Financial Services Emergency Amendment Act of 2004 (D.C. Act 15-381, February 27, 2004, 51 DCR 2653).
For temporary (90 day) additions, see §§ 101 to 106 of DC High Risk Pool Program Establishment Emergency Act of 2010 (D.C. Act 18-522, August 3, 2010, 57 DCR 8001).
Temporary Legislation
Section 101 to 106 of D.C. Law 18-271 added sections to read as follows:
“Sec. 101. Establishment of the DC High Risk Pool Program.
“(a) There is established the DC High Risk Pool Program (‘Program’), which shall provide affordable health insurance benefits to eligible individuals.
“(b) The Program shall be:
“(1) Administered by the Department of Health Care Finance, established by the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.01 et seq.);
“(2) Funded through federal funds made available through the temporary high risk pool program, established by the Patient Protection and Affordable Care Act, approved March 23, 2010 (124 Stat. 119; 42 U.S.C. § 18001) (‘federal act’), and administered by the U.S. Department of Health and Human Services;
“(3) Subject to the availability of funding; and
“(4) Expire on December 31, 2013; provided, that federal requirements or contractual obligations between the District and the U.S. Department of Health and Human Services do not necessitate a different date.
“(c) Nothing in this section shall be construed to create or constitute an entitlement to health insurance or to health or medical benefits.
“Sec. 102. Program eligibility.
“An individual shall be eligible for the Program if the individual:
“(1) Is a District resident;
“(2) Is a United States citizen, or lawfully in the country;
“(3) Has not had creditable health coverage for the 6 months prior to applying for the Program;
“(4) Has one or more pre-existing conditions that have resulted in the inability to obtain commercial insurance coverage on the individual market; and
“(5) Is not eligible for public health-insurance benefits.
“Sec. 103. Program benefits.
“The Program shall provide comprehensive coverage for services that meet the requirements of the temporary high risk pool program, established by the federal act.
“Sec. 104. Affordability of coverage.
“Under the Program:
“(1) The premium levels charged to enrollees shall be no greater than 100% of the standard risk rate for each age group, with a variability no greater than 4-to-1 between any 2 age groups;
“(2) The out-of-pocket limit of coverage for cost-sharing for the required benefits shall not be greater than the applicable amount described in section 223(c)(2) of the Internal Revenue Code of 1986, approved December 8, 2003 (117 Stat. 2469; 26 U.S.C. § 223(c)(2)), for the year involved; and
“(3) There shall not be any annual or lifetime dollar limits on any service, including prescription drugs.
“Sec. 105. Program implementation.
“To meet the deadline set by the U.S. Department of Health and Human Services, the Mayor is authorized to enter into a contract with a qualified insurer or hospital and medical services corporation licensed in the District.
“Sec. 106. Rules.
“The Mayor, pursuant to Title I of the District of Columbia Administrative Procedure Act, approved October 21, 1968 (82 Stat. 1204; D.C. Official Code § 2-501 et seq.), shall issue rules to implement the provisions of this title.”
Section 302(b) of D.C. Law 18-271 provided that the act shall expire after 225 days of its having taken effect.
Editor's Notes
Application of D.C. Law 12-274: Section 501(b) of D.C. Law 12-274 provided that this section shall apply upon the promulgation of regulations pursuant to § 32-574.1§ 44-304.01, (2001 Ed.).