2023 District of Columbia Code › Title 1 - Government Organization › Chapter 3 - Specified Governmental Authority › Subchapter IV - Special Programs › Part C - Medical Benefits Protection › § 1–307.41. Insurer obligations

§ 1–307.41. Insurer obligations.
(a) No insurer may deny coverage or withhold payments under its plan for any enrollee, subscriber, policyholder, or certificateholder on the basis that such enrollee, subscriber, policyholder, or certificateholder is eligible for Medicaid pursuant to a Medicaid state plan adopted by the District of Columbia or any other jurisdiction pursuant to § 1902 of the Social Security Act (79 Stat. 344; 42 U.S.C. § 1396a).
(b) No insurer may deny enrollment of a child under the health plan of the child’s parent on the grounds that:
(1) The child was born out of wedlock;
(2) The child is not claimed as a dependent on the parent’s federal income tax return; or
(3) The child does not reside with the parent or in the insurer’s service area.
(c) Where a child has health coverage through an insurer of a noncustodial parent, the insurer shall:
(1) Provide such information to the custodial parent as may be necessary to obtain benefits through such coverage, including the information required under § 46-251.05(a).
(2) Permit the custodial parent (or the provider, with the custodial parent’s approval) to submit claims for covered services without the approval of the noncustodial parent; and
(3) Make payments on claims submitted in accordance with paragraph (2) of this subsection directly to the custodial parent, the provider, or the District of Columbia Medicaid agency.
(d) Where a parent is required by a court or administrative order to provide health coverage for a child, and the parent is eligible for family health coverage, the insurer shall:
(1) Permit the parent to enroll, under the family coverage, a child who is otherwise eligible for the coverage without regard to any enrollment season restrictions;
(2) Enroll the child under family coverage upon application by the child’s other parent, or by the District of Columbia agency administering either the Medicaid program or the child support enforcement program pursuant to Title IV-D of the Social Security Act (88 Stat. 2351; 42 U.S.C. §§ 652 through 669), if the employed parent is enrolled but fails to make application to obtain coverage of the child;
(2A) Enroll the child and the employed parent under family coverage upon application by the child’s other parent, or by the District of Columbia agency administering either the Medicaid program or the child support enforcement program pursuant to Part D of Title IV of the Social Security Act, approved January 4, 1975 (88 Stat. 2351; 42 U.S.C. § 651 et seq.), if the employed parent is not enrolled and the health insurance plan requires the employed parent’s enrollment for the child to be eligible; and
(3) Not disenroll (or eliminate coverage of) the child unless the insurer is provided satisfactory written evidence that:
(A) The court or administrative order is no longer in effect; or
(B) The child is or will be enrolled in comparable health coverage through another insurer which will take effect not later than the effective date of disenrollment.
(e) As a condition of doing business in the District:
(1) An insurer shall not impose requirements on a District of Columbia agency that has been assigned the rights of an individual eligible for medical assistance under the District State Medicaid Plan and covered for health benefits from the insurer that are different from requirements applicable to an agent or assignee of any other individual so covered.
(2) An insurer shall:
(A) Accept the District’s right of recovery and the assignment to the District of any right of an individual or other entity to payment from the insurer for an item or service for which payment has been made under the District State Medicaid Plan;
(B) Respond to any inquiry by the District, or its agent, regarding a claim for payment for a health care item or service that the District submits within 3 years after the date that the health-care item or service was provided;
(C) Not deny a claim submitted by the District because of the date of submission of the claim, the type or format of the claim form, or for failure to present proper documentation at the point-of-sale that is the basis of the claim; provided, that the District:
(i) Submits the claim within the 3-year period beginning on the date of which the item or service was furnished; and
(ii) Commences an action to enforce its right with respect to the claim within 6 years of submitting the claim; and
(D) Upon the request of the Mayor, in a manner prescribed by the Mayor, provide coverage, eligibility, and paid claims data to the District, or its agent, to determine the period that individuals who received, or were eligible for, health care assistance were, or could have been, covered by an insurer and the nature of the coverage that is being, or was, provided by the health insurer. The data to be provided shall include:
(i) Each individual’s:
(I) Name;
(II) Address; and
(III) Plan identification number; and
(ii) Any other information prescribed by the Mayor.
(f) For the purposes of this section, the term “insurer” includes a self-insured plan, a group health plan, as defined in section 607(1) of the Employee Retirement Income Security Act of 1974, approved April 7, 1986 (100 Stat. 231; 29 U.S.C. § 1167(1)), a service benefit plan, a managed care organization, a pharmacy benefit manager, or other party that is, by statute, contract, or agreement, legally responsible for payment of a claim for all or part of a health-care item or service.
(Mar. 14, 1995, D.C. Law 10-202, § 2, 41 DCR 7704; Mar. 30, 2004, D.C. Law 15-130, § 201(a), 51 DCR 1615; Mar. 25, 2009, D.C. Law 17-353, § 304, 56 DCR 1117; Sept. 24, 2010, D.C. Law 18-223, § 5102, 57 DCR 6242.)
Prior Codifications
1981 Ed., § 1-359.1.
Section References
This section is referenced in § 46-205 and § 46-251.10.
Effect of Amendments
D.C. Law 15-130, in subsec. (c)(1), deleted “for the child” following “may be necessary”, and inserted “, including the information required under § 46-251.05(a)”; and, in subsec. (d), deleted “and” from the end of par. (2), and added par. (2A).
D.C. Law 17-353, in subsec. (f), substituted “member insurer” for “hospital and medical service plan”.
D.C. Law 18-223 rewrote subsecs. (e) and (f), which had read as follows:
“(e) An insurer may not impose requirements on a District of Columbia agency, which has been assigned the rights of an individual eligible for medical assistance under Medicaid and covered for health benefits from the insurer, that are different from requirements applicable to an agent or assignee of any other individual so covered.
“(f) For purposes of this section, the term “insurer” includes a group health plan, as defined in section 607(1) of the Employee Retirement Income Security Act of 1974 (100 Stat. 231; 29 U.S.C. § 1167(1)), a public or private organization which is a qualifying health maintenance organization under federal regulations, or a member insurer as defined in § 31-5401(8).”
Emergency Legislation
For temporary (90 day) amendment of section, see § 201(a) of Medical Support Establishment and Enforcement Emergency Amendment Act of 2002 (D.C. Act 14-485, October 3, 2002, 49 DCR 9631).
For temporary (90 day) amendment of section, see § 201(a) of Medical Support Establishment and Enforcement Congressional Review Emergency Amendment Act of 2002 (D.C. Act 14-600, January 7, 2003, 50 DCR 664).
For temporary (90 day) amendment of section, see § 201(a) of Medical Support Establishment and Enforcement Emergency Amendment Act of 2003 (D.C. Act 15-208, October 24, 2003, 50 DCR 9856).
For temporary (90 day) amendment of section, see § 201(a) of Medical Support Establishment and Enforcement Congressional Review Emergency Amendment Act of 2004 (D.C. Act 15-330, January 28, 2004, 51 DCR 1603).
For temporary (90 day) amendment of section, see § 1002 of Fiscal Year 2010 Balanced Budget Support Emergency Act of 2010 (D.C. Act 18-450, June 28, 2010, 57 DCR 5635).
For temporary (90 day) amendment of section, see § 1002 of Fiscal Year 2010 Balanced Budget Support Congressional Review Emergency Act of 2010 (D.C. Act 18-531, August 6, 2010, 57 DCR 8109).
For temporary (90 day) amendment of section, see § 5102 of Fiscal Year 2011 Budget Support Emergency Act of 2010 (D.C. Act 18-463, July 2, 2010, 57 DCR 6542).
Temporary Legislation
For temporary (225 day) amendment of section, see § 201(a) of Medical Support Establishment and Enforcement Temporary Amendment Act of 2002 (D.C. Law 14-238, March 25, 2003, law notification 50 DCR 2751).
For temporary (225 day) amendment of section, see § 201(a) of Medical Support Establishment and Enforcement Temporary Amendment Act of 2003 (D.C. Law 15-84, March 10, 2004, law notification 51 DCR 3376).
Section 1002 of D.C. Law 18-222 rewrote subsecs. (e) and (f) to read as follows:
“(e) As a condition of doing business in the District:
“(1) An insurer shall not impose requirements on a District of Columbia agency that has been assigned the rights of an individual eligible for medical assistance under the District State Medicaid Plan and covered for health benefits from the insurer that are different from requirements applicable to an agent or assignee of any other individual so covered; and
“(2) An insurer shall:
“(A) Accept the District’s right of recovery and the assignment to the District of any right of an individual or other entity to payment from the insurer for an item or service for which payment has been made under the District State Medicaid Plan;
“(B) Respond to any inquiry by the District, or its agent, regarding a claim for payment for a health care item or service that the District submits within 3 years after the date that the health care item or service was provided; and
“(C) Not deny a claim submitted by the District because of the date of submission of the claim, the type or format of the claim form, or for failure to present proper documentation at the point-of-sale that is the basis of the claim; provided, that:
“(i) The District submits the claim within the 3-year period beginning on the date of which the item or service was furnished; and
“(ii) The District commences an action to enforce its right with respect to the claim within 6 years of submitting the claim; and
“(D) Upon the request of the Mayor, in a manner prescribed by the Mayor, provide coverage, eligibility, and paid claims data to the District, or its agent, to determine the period that individuals who received, or were eligible for, health care assistance were, or could have been, covered by an insurer and the nature of the coverage that is being, or was, provided by the health insurer. The data to be provided shall include:
“(i) Each individual’s:
“(I) Name;
“(II) Address; and
“(III) Plan identification number; and
“(ii) Any other information prescribed by the Mayor.”.
“(f) For the purposes of this section, the term “insurer” includes a self-insured plan, a group health plan, as defined in section 607(1) of the Employee Retirement Income Security Act of 1974, approved April 7, 1986 (100 Stat. 231; 29 U.S.C. 1167(1)), a service benefit plan, a managed care organization, a pharmacy benefit manager, or other party that is, by statute, contract, or agreement, legally responsible for payment of a claim for all or part of a health care item or service.”.
Section 2002(b) of D.C. Law 18-222 provided that the act shall expire after 225 days of its having taken effect.
Short Title
Short title: Section 5101 of D.C. Law 18-223 provided that subtitle K of title V of the act may be cited as the “Medicaid Benefits Protection Amendment Act of 2010”.