reglab/statecodes huggingface dataset:
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 33 - Health Insurance Portability and Accountability › Subchapter III - Group Insurance › § 31–3303.13a. Treatment of certain multiple employer welfare arrangements

§ 31–3303.13a. Treatment of certain multiple employer welfare arrangements.
The Commissioner may issue rules to create a grandfathered status with respect to any of the requirements of this chapter for multiple employer welfare arrangements that existed and operated in the District as of December 15, 2017, and comply with federal law and regulations applicable to multiple employer welfare arrangements as of December 15, 2017.
(Apr. 13, 1999, D.C. Law 12-209, § 313a; as added Mar. 22, 2019, D.C. Law 22-266, § 2(e), 66 DCR 1423.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 33 - Health Insurance Portability and Accountability › Subchapter III - Group Insurance › § 31–3303.13b. License requirement for non-District multiple employer welfare arrangements

§ 31–3303.13b. License requirement for non-District multiple employer welfare arrangements.
No multiple employer welfare arrangement located outside of the District may conduct any business in the District, including marketing, offering, or issuing a health benefit plan to any individual or employer, unless licensed as an insurer, a hospital and medical services corporation, a fraternal benefit society, or a health maintenance organization.
(Apr. 13, 1999, D.C. Law 12-209, § 313b; as added Mar. 22, 2019, D.C. Law 22-266, § 2(e), 66 DCR 1423.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 33 - Health Insurance Portability and Accountability › Subchapter III - Group Insurance › § 31–3303.13c. Licensing requirement for certain multiple employer welfare arrangements

§ 31–3303.13c. Licensing requirement for certain multiple employer welfare arrangements.
(a) A multiple employer welfare arrangement that is not fully insured, as described in subsection (c) of this section, shall not operate in the District or market, offer, or issue a health benefit plan to any individual or employer in the District without first meeting the requirements for, and becoming licensed as, an insurer, a hospital and medical services corporation, a fraternal benefit society, or a health maintenance organization.
(b) The existence of contracts of reinsurance shall not be considered in determining whether a multiple employer welfare arrangement is fully insured.
(c) For the purposes of this section, a multiple employer welfare arrangement is not fully insured unless the covered benefits it provides are:
(1) Insured on a direct basis by an insurance company licensed to transact the business of insurance in District; or
(2) Arranged for or provided on a direct basis by
(A) A hospital and medical services corporation;
(B) A fraternal benefit society;
(C) A health maintenance organization licensed in the District; or
(D) Any combination of these entities.
(Apr. 13, 1999, D.C. Law 12-209, § 313c; as added Mar. 22, 2019, D.C. Law 22-266, § 2(e), 66 DCR 1423.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 33 - Health Insurance Portability and Accountability › Subchapter III - Group Insurance › § 31–3303.13d. Short-term, limited-duration health insurance

§ 31–3303.13d. Short-term, limited-duration health insurance.
(a) An insurer shall not provide short-term, limited-duration health insurance policies, certificates of coverage, or contracts unless the insurer obtains a certificate of authority from the Commissioner to offer health insurance.
(b) An insurer offering for sale a short-term, limited-duration health insurance policy, certificate of coverage, or contract shall apply the same underwriting standards to all applicants for such coverage regardless of whether the applicant has previously been covered by a short-term, limited-duration health insurance policy, certificate of coverage, or contract.
(c) A short-term, limited-duration health insurance policy, certificate of coverage, or contract shall not exclude from coverage as a pre-existing condition any medical or behavioral health condition for which an applicant sought treatment in the prior 12 months or for which an applicant is currently in an active course of treatment. An insurer shall not use underwriting related to such a condition to deny enrollment in short-term, limited-duration coverage to an applicant.
(d) A short-term, limited-duration insurance policy, certificate of coverage, or contract shall terminate not more than 3 months after its effective date.
(e) A short-term, limited-duration health insurance policy, certificate of coverage, or contract shall not be extended or renewed. The insurer shall not issue, directly or indirectly through an affiliate, a new short-term, limited-duration health insurance policy, certificate of coverage, or contract to an individual who had such a policy, certificate of coverage, or contract from the insurer within the preceding 9 months.
(f) An insurer shall ensure that each policy, certificate of coverage, or contract for short-term, limited-duration health insurance and all application materials for enrollment in that coverage displays prominently, in at least 14-point type, a statement that the coverage does not constitute minimum essential coverage for the purposes of satisfying the individual responsibility requirement of § 47-5102, and any other disclosures the Commissioner may require through rulemaking, including the types of benefits and consumer protections that are and are not included in the coverage.
(g) A company offering for sale a short-term, limited-duration health insurance policy, certificate of coverage, or contract shall provide to the Commissioner any information the Commissioner requires by rulemaking.
(Apr. 13, 1999, D.C. Law 12-209, § 313d; as added Mar. 22, 2019, D.C. Law 22-266, § 2(e), 66 DCR 1423.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 33 - Health Insurance Portability and Accountability › Subchapter III - Group Insurance › § 31–3303.14. Applicability

§ 31–3303.14. Applicability.
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.
(Apr. 13, 1999, D.C. Law 12-209, § 314, 45 DCR 8433.)
Prior Codifications
1981 Ed., § 35-1044.
Emergency Legislation
See notes to § 31-3301.01.
Temporary Legislation
See Historical and Statutory Notes following § 31-3301.01.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 33A - Health Insurance Ratemaking › § 31–3311.03. Loss ratio disclosure

§ 31–3311.03. Loss ratio disclosure.
Policies, certificates, and marketing materials shall prominently display medical loss ratio disclosure, as defined by rule.
(Apr. 8, 2011, D.C. Law 18-360, § 104, 58 DCR 896.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 33A - Health Insurance Ratemaking › § 31–3311.03a. Essential health benefits

§ 31–3311.03a. Essential health benefits.
(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 the District pursuant to section 1302 of the Affordable Care Act.
(b) If the essential health benefits benchmark plan for the individual and small group market does not include all of the benefit categories specified by section 1302 of the Affordable Care Act, or a need exists to add additional benefits, the Commissioner, with the approval of the Executive Board of the Health Benefit Exchange Authority, may, by rule, supplement the benchmark plan benefits as needed so long as the benchmark plan meets the minimum requirements of section 1302 of the Affordable Care Act.
(c)(1) A health plan offering the required essential health benefits for the individual and small group markets, other than a health plan offered through the federal basic health program or Medicaid, may not be offered in the District unless the Commissioner determines that it is substantially equal to the benchmark plan.
(2) When making this determination, the Commissioner shall:
(A) Ensure that the plan covers the essential health benefits categories specified in section 1302 of the Affordable Care Act; and
(B) Consider whether the health plan has a benefit design that would create a risk of biased selection based on health status and whether the health plan contains meaningful scope and level of benefits in each of the 10 essential health benefit categories specified by section 1302 of Affordable Care Act.
(d)(1) Except as provided in paragraph (2) of this subsection, notwithstanding any other provision of benefits mandated by District law, the benchmark plan adopted by the Commissioner shall be the benefits required in all health benefit plans offered in the individual and small group markets.
(2) Grandfathered health plans, as defined in section 1251 of the Affordable Care Act, shall be exempt from complying with the requirements of the benchmark plan.
(April 8, 2011, D.C. Law 18-360, § 104a; as added May 2, 2015, D.C. Law 20-265, § 104(b), 62 DCR 1529.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 33A - Health Insurance Ratemaking › § 31–3311.03b. Underwriting ratemaking criteria

§ 31–3311.03b. Underwriting ratemaking criteria.
(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 curve; and
(3) The rating for tobacco uses.
(b) The Commissioner’s authority to implement subsection (a) of this section shall be accomplished in a manner that is not inconsistent with, or would prevent the application of, the Affordable Care Act and its implementing regulations. In exercising the authority under subsection (a) of this section, the Commissioner may provide consumer protections and benefits that exceed those provided in the Affordable Care Act.
(c) Health insurers are required to merge their experience in the individual and group markets for purposes of setting health insurance rates.
(April 8, 2011, D.C. Law 18-360, § 104b; as added May 2, 2015, D.C. Law 20-265, § 104(b), 62 DCR 1529.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 33A - Health Insurance Ratemaking › § 31–3311.04. Annual rate filing requirement

§ 31–3311.04. Annual rate filing requirement.
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 demonstrate, in accordance with actuarial principles and standards, using reasonable assumptions, that the appropriate medical loss ratio standards can be expected to be met over the entire period for which rates are computed and that insurer is in compliance with the ratemaking principles of this chapter. If the data submitted does not confirm that the insurer has satisfied the requirements of this chapter, the Commissioner shall notify the insurer in writing of the deficiency within 30 business days of the date that the data is submitted. The insurer shall have 30 days after the date of the Commissioner’s notice to file amended rates that comply with this chapter. If the insurer fails to file amended rates within the 30-day period, the Commissioner shall order that the insurer’s filed rates for the nonconforming policies and certificates be reduced to an amount that would bring the rates into compliance with this chapter. Upon request of the insurer and before any order or notice issued pursuant to this section becomes final, the Commissioner shall hold a hearing upon not less than 10 business days’ written notice to the insurer specifying the matters to be considered at the hearing. The insurer’s failure to file amended rates within the specified time or the issuance of the Commissioner’s order amending the rates shall not preclude the insurer from filing an amendment of its rates at a later time.
(Apr. 8, 2011, D.C. Law 18-360, § 105, 58 DCR 896.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 33A - Health Insurance Ratemaking › § 31–3311.05. Commissioner’s authority to rescind approved rates

§ 31–3311.05. Commissioner’s authority to rescind approved rates.
(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 approved by the Commissioner, but subsequently disapproved under this chapter, shall be considered disapproved on a prospective basis only from the date of the notice of disapproval, unless the insurer made a material misrepresentation in its contract form or rate filings, in which case the rates shall be deemed disapproved on a retroactive basis.
(b) If, at any time subsequent to the approval of rates, the Commissioner finds that a filing does not meet the requirements of this chapter, the Commissioner shall issue an order to the insurer specifying why the filing fails to meet the requirements of this chapter, and, stating when, within a reasonable period thereafter, the filing shall be no longer effective. The order shall not affect any subscriber contract, group certificate, or other contract made or issued prior to the expiration of the period set forth in the order. The Commissioner may, prior to issuing the order and if requested by the insurer, hold a hearing upon not less than 10 business days’ written notice to the insurer specifying the matters to be considered at the hearing.
(c) For violations of this chapter, the Commissioner may order any relief which is appropriate, including disapproving a rate and awarding interest.
(Apr. 8, 2011, D.C. Law 18-360, § 106, 58 DCR 896; Sept. 26, 2012, D.C. Law 19-171, § 85(b), 59 DCR 6190.)
Effect of Amendments
The 2012 amendment by D.C. Law 19-171 substituted “this title” for “this act” [translated as “this chapter”] in (b).
References in Text
This act, referred to in subsec. (b), is D.C. Law 18-360, the Reasonable Health Insurance Ratemaking and Health Care Reform Act of 2010.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 33A - Health Insurance Ratemaking › § 31–3311.06. Post-claims underwriting and prior approval for rescission, cancellation, or limitation

§ 31–3311.06. Post-claims underwriting and prior approval for rescission, cancellation, or limitation.
(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 intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage. The plan or coverage shall not be cancelled without prior notice to the Commissioner as required by subsection (b) of this section and prior notice to the consumer and an opportunity to appeal as required by the Patient Protection and Affordable Care Act, approved March 23, 2010 (124 Stat. 109; scattered sections of the United States Code).
(b) A health carrier shall provide at least 30 days advance written notice to each plan enrollee, or for individual health insurance coverage, primary subscriber, who would be affected by the proposed rescission of coverage before coverage under the plan may be rescinded in accordance with subsection (a) of this section regardless of, in the case of group or only to an individual within the group. The notice shall explain the reason for the rescission, procedures of appealing, and how to contact the Health Care Ombudsman and the Department of Insurance, Securities, and Banking for further information.
(c) Prior to rescinding the enrollee’s plan or coverage, the insurer shall provide to the Commissioner documentation to support the rescission and the Commissioner shall have 5 business days following receipt of the proposed rescission and supporting documentation to review the documentation to determine if the insurer is complying with the requirements of subsection (a) of this section. The insurer may rescind the plan or coverage after the end of the 5-day period of review unless the Commissioner objects or disapproves the proposed rescission within the 5-day period.
(Apr. 8, 2011, D.C. Law 18-360, § 107, 58 DCR 896.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 33A - Health Insurance Ratemaking › § 31–3311.07. Public records

§ 31–3311.07. Public records.
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 website.
(Apr. 8, 2011, D.C. Law 18-360, § 108, 58 DCR 896.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 33A - Health Insurance Ratemaking › § 31–3311.08. Annual report and recommendations

§ 31–3311.08. Annual report and recommendations.
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 the District law differs.
(Apr. 8, 2011, D.C. Law 18-360, § 109, 58 DCR 896.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 33A - Health Insurance Ratemaking › § 31–3311.09. Rules

§ 31–3311.09. 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, § 110, 58 DCR 896.)
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 33A - Health Insurance Ratemaking › § 31–3311.10. Application

§ 31–3311.10. Application.
(a) 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.
(b) Small group market requirements under this chapter shall apply to a health benefit plan offered by a multiple employer welfare arrangement, including an association or any other entity, if the plan covers an employee of a small employer, as that term is defined in§ 31-3301.01(42), in the District.
(c) Individual market requirements under this chapter shall apply to a health benefit plan offered by a multiple employer welfare arrangement, including an association or any other entity, if the plan covers an individual in the District who is not an employee or dependent of a participating employer.
(Apr. 8, 2011, D.C. Law 18-360, § 111, 58 DCR 896; Mar. 22, 2019, D.C. Law 22-266, § 3(a), 66 DCR 1423.)
Emergency Legislation
For temporary (90 days) amendment of this section, see § 3(a) of Health Insurance Marketplace Improvement Emergency Amendment Act of 2018 (D.C. Act 22-526, Dec. 10, 2018, 65 DCR 13424).
Temporary Legislation
For temporary (225 days) amendment of this section, see § 3(a) of Health Insurance Marketplace Improvement Temporary Amendment Act of 2018 (D.C. Law 22-251, Mar. 15, 2019, 66 DCR 975).
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 33A - Health Insurance Ratemaking › § 31–3311.11. Definitions

§ 31–3311.11. Definitions.
For the purposes of this chapter, the term:
(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), as the law and its implementing regulations were in effect on December 15, 2017.
(2) “Commissioner” means the Commissioner of the Department of Insurance, Securities, and Banking established by Chapter 1 of this title [§ 31-101
et seq.
].
(April 8, 2011. D.C. Law 18-360, § 112; as added May 2, 2015, D.C. Law 20-265, § 104(c), 62 DCR 1529; Mar. 22, 2019, D.C. Law 22-266, § 3(b), 66 DCR 1423.)
Emergency Legislation
For temporary (90 days) amendment of this section, see § 3(b) of Health Insurance Marketplace Improvement Emergency Amendment Act of 2018 (D.C. Act 22-526, Dec. 10, 2018, 65 DCR 13424).
Temporary Legislation
For temporary (225 days) amendment of this section, see § 3(b) of Health Insurance Marketplace Improvement Temporary Amendment Act of 2018 (D.C. Law 22-251, Mar. 15, 2019, 66 DCR 975).
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 34 - Health Maintenance Organizations › § 31–3404. Powers of health maintenance organizations

§ 31–3404. Powers of health maintenance organizations.
(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 equipment as may reasonably be required for its principal office or for such purposes as may be necessary in the transaction of the business of the organization;
(2) Transactions between affiliated entities, including loans and the transfer of responsibility under all contracts (provider, enrollee, etc.) between affiliates or between the health maintenance organization and its parent;
(3) The furnishing of health care services through providers, provider associations, or agents for providers which are under contract with or employed by the health maintenance organization;
(4) The contracting with any person for the performance on its behalf of certain functions, such as marketing, enrollment, and administration;
(5) The contracting with an insurance company, including Group Hospitalization and Medical Service, Inc., licensed in the District for the provision of insurance, indemnity, or reimbursement against the cost of covered services provided by the health maintenance organization or with optometry services, podiatry services, dental services, pharmaceutical service plans, and other entities authorized to do business in the District for the provision of supplemental health services;
(6) The joint marketing of products with an insurance company authorized to do business in the District as long as the company that is offering each product is clearly identified; and
(7) Entering into administrative service provider contracts with contracting providers whereby covered services are rendered to enrollees by external providers who have entered into contracts with the contracting provider.
(b) A health maintenance organization shall file notice, with adequate supporting information, with the Commissioner prior to the exercise of any power granted in subsection (a)(1), (2), or (4) of this section which may affect the financial soundness of the health maintenance organization. The Commissioner shall disapprove such exercise of power only if the Commissioner determines it would substantially and adversely affect the financial soundness of the health maintenance organization and endanger its ability to meet its obligations. If the Commissioner does not disapprove within 30 days of the filing of the notice, the exercise of power shall be deemed approved.
(c) The Commissioner may issue rules and regulations exempting those activities having a de minimis effect from the filing requirement of this subsection.
(Apr. 9, 1997, D.C. Law 11-235, § 5, 44 DCR 818; Mar. 24, 1998, D.C. Law 12-81, § 46(b), 45 DCR 745.)
Prior Codifications
1981 Ed., § 35-4504.
Section References
This section is referenced in § 31-3411.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 34 - Health Maintenance Organizations › § 31–3405. Fiduciary responsibilities

§ 31–3405. Fiduciary responsibilities.
(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 health maintenance organization shall maintain in force a fidelity bond or fidelity insurance on such employees and officers, directors, and partners in an amount not less than $250,000 and not more than $5,000,000.
(Apr. 9, 1997, D.C. Law 11-235, § 6, 44 DCR 818.)
Prior Codifications
1981 Ed., § 35-4505.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 34 - Health Maintenance Organizations › § 31–3408. Annual report. [Repealed]

§ 31–3408. Annual report. [Repealed]
Repealed.
(Apr. 9, 1997, D.C. Law 11-235, § 9, 44 DCR 818; Apr. 27, 1999, D.C. Law 12-274, § 501(a)(3), 46 DCR 1294; Mar. 27, 2003, D.C. Law 14-252, § 2(d), 50 DCR 225.)
Prior Codifications
1981 Ed., § 35-4508.
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.).
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 34 - Health Maintenance Organizations › § 31–3408.01. Compliance with other laws

§ 31–3408.01. Compliance with other laws.
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 Ratemaking Reform Act of 2010 [Chapters 30A, 31C, and 33A of this title].
(Apr. 9, 1997, D.C. Law 11-235, § 9a; as added Mar. 27, 2003, D.C. Law 14-252, § 2(d), 50 DCR 225; Apr. 8, 2011, D.C. Law 18-360, § 502(a), 58 DCR 896.)
Effect of Amendments
D.C. Law 18-360 deleted “and” from the end of par. (4), substituted “; and” for a period the end of par. (5), and added par. (6).
Editor's Notes
Application of Law 14-252: Section 3 of D.C. Law 14-252 provided: “This act shall not apply until the Commissioner gives written notice that all necessary rules and administrative procedures are in place to effect the provisions of this act.”
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 34 - Health Maintenance Organizations › § 31–3409. Information to enrollees

§ 31–3409. Information to enrollees.
(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 that will affect them directly.
(c) An enrollee must be notified in writing by a health maintenance organization of the termination of the primary care provider who provided health care services to that enrollee. A health maintenance organization shall provide assistance to the enrollee in transferring to another participating primary care provider.
(d) A health maintenance organization shall provide to enrollees information on how services may be obtained, where additional information on access to services can be obtained, and a number where the enrollee can contact the HMO at no cost to the enrollee.
(Apr. 9, 1997, D.C. Law 11-235, § 10, 44 DCR 818.)
Prior Codifications
1981 Ed., § 35-4509.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 34 - Health Maintenance Organizations › § 31–3410. Grievance procedures [Repealed]

§ 31–3410. Grievance procedures [Repealed]
Repealed.
(Apr. 9, 1997, D.C. Law 11-235, § 11, 44 DCR 818; Apr. 27, 1999, D.C. Law 12-274, § 501(a)(4), 46 DCR 1294.)
Prior Codifications
1981 Ed., § 35-4510.
Section References
This section is referenced in § 31-3419.
Editor's Notes
Application of 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. .
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 34 - Health Maintenance Organizations › § 31–3411. Investments

§ 31–3411. Investments.
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.
(Apr. 9, 1997, D.C. Law 11-235, § 12, 44 DCR 818.)
Prior Codifications
1981 Ed., § 35-4511.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 34 - Health Maintenance Organizations › § 31–3415. Filing requirements for rating information

§ 31–3415. Filing requirements for rating information.
(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 accordance with actuarial principles for various categories of enrollees, provided that the enrollment fees applicable to an enrollee shall not be individually determined based on the status of an enrollee’s health. However, the fees shall not be excessive, inadequate, or unfairly discriminatory. A statement by a qualified actuary or other qualified person acceptable to the Commissioner as to the appropriateness of the use of the methodology, based on reasonable assumptions, shall accompany the filing along with adequate supporting information. A health maintenance organization filing a schedule of enrollment fees or methodology for determining enrollment fees pursuant to this section shall also comply with the Reasonable Health Insurance Ratemaking Reform Act of 2010 [Chapters 30A, 31C, and 33A of this title].
(c) The Commissioner shall approve the schedule of enrollment fees dues or methodology for determining enrollment fees if the requirements of subsection (b) of this section are met. If the Commissioner disapproves the filing, the Commissioner shall notify the health maintenance organization. In the notice, the Commissioner shall specify the reasons for disapproval. A hearing shall be held within 30 days after a request in writing by the person filing. If the Commissioner does not take action on the schedule or methodology within 30 days of the filing, it shall be deemed approved.
(Apr. 9, 1997, D.C. Law 11-235, § 16, 44 DCR 818; Apr. 8, 2011, D.C. Law 18-360, § 502(b), 58 DCR 896.)
Prior Codifications
1981 Ed., § 35-4515.
Section References
This section is referenced in § 31-3419.
Effect of Amendments
D.C. Law 18-360, in subsec. (b), added the fourth sentence.
Emergency Legislation
For temporary (90 day) amendment of section, see § 2 of Reasonable Health Insurance Premium Increase Emergency Amendment Act of 2010 (D.C. Act 18-328, March 18, 2010, 57 DCR 2546).
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 34 - Health Maintenance Organizations › § 31–3417. Powers of insurance corporations

§ 31–3417. Powers of insurance corporations.
(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 such insurance companies, or subsidiaries or affiliates thereof, may jointly organize and operate a health maintenance organization. The business of insurance is deemed to include the providing of health care by a health maintenance organization owned or operated by an insurer or subsidiary thereof.
(b) Notwithstanding any other provision of insurance laws, an insurer may contract with a health maintenance organization to provide insurance or similar protection against the cost of care provided through health maintenance organizations and to provide coverage in the event of the failure of a health maintenance organization to meet its obligations.
(c) The enrollees of a health maintenance organization constitute a permissible group under such laws. Among other things, under such contracts the insurer may make benefit payments to health maintenance organizations for health care services rendered by providers.
(Apr. 9, 1997, D.C. Law 11-235, § 18, 44 DCR 818; Mar. 24, 1998, D.C. Law 12-81, § 46(d), 45 DCR 745.)
Prior Codifications
1981 Ed., § 35-4517.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 34 - Health Maintenance Organizations › § 31–3418. Examinations. [Repealed]

§ 31–3418. Examinations. [Repealed]
Repealed.
(Apr. 9, 1997, D.C. Law 11-235, § 19, 44 DCR 818; Oct. 23, 1997, D.C. Law 12-32, § 12(c), 44 DCR 4819; Mar. 27, 2003, D.C. Law 14-252, § 2(g), 50 DCR 225.)
Prior Codifications
1981 Ed., § 35-4518.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 34 - Health Maintenance Organizations › § 31–3420. Rehabilitation, liquidation, or conservation of health maintenance organizations

§ 31–3420. Rehabilitation, liquidation, or conservation of health maintenance organizations.
(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 the rehabilitation, liquidation, or conservation of insurance companies. The Commissioner may apply for an order directing the Commissioner to rehabilitate, liquidate, or conserve a health maintenance organization upon any one or more grounds set forth in §§ 31-1310 and 31-1315, or when in the Commissioner’s opinion the continued operation of a health maintenance organization would be hazardous either to the enrollees or to the people of the District. Enrollees shall have the same priority in the event of liquidation or rehabilitation as the law provides to policyholders of an insurer.
(b) For the purposes of determining the priority of distribution of general assets, claims of enrollees and enrollees’ beneficiaries shall have the same priority as established by § 31-1315, for policyholders and beneficiaries of insured of insurance companies. If an enrollee is liable to any provider for services provided pursuant to and covered by the health care plan, that liability shall have the status of an enrollee claim for distribution of general assets.
(c) Any provider who is obligated by law or agreement to hold enrollees harmless from liability for services pursuant to and covered by a health care plan shall have a priority of distribution of the general assets immediately following that of enrollees and enrollee’s beneficiaries as described herein, and immediately preceding the priority of distribution assigned to general creditors.
(Apr. 9, 1997, D.C. Law 11-235, § 21, 44 DCR 818; Mar. 8, 2007, D.C. Law 16-232, § 204(b), 54 DCR 368.)
Prior Codifications
1981 Ed., § 35-4520.
Effect of Amendments
D.C. Law 16-232, in subsec. (c), substituted “law” for “statute” and inserted “assigned to general creditors”.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 34 - Health Maintenance Organizations › § 31–3421. Summary orders and supervision

§ 31–3421. Summary orders and supervision.
(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 Commissioner may, after notice and hearing, order the health maintenance organization to take such action reasonably necessary to rectify the condition or violation, including, but not limited to, 1 or more of the following:
(1) Reduce the total amount of present and potential liability for benefits by reinsurance or other method acceptable to the Commissioner;
(2) Reduce the volume of new business being accepted;
(3) Reduce expenses by specified methods;
(4) Suspend or limit the writing of new business for a period of time;
(5) Increase the health maintenance organization’s capital and surplus by contribution; or
(6) Take such other steps as the Commissioner may deem appropriate under the circumstances.
(b) For the purposes of this section, a violation by a health maintenance organization of any law of the District to which the health maintenance organization is subject shall be deemed a violation of this chapter.
(c) The Commissioner is authorized, by rules and regulations, to set uniform standards and criteria for early warning that the continued operation of any health maintenance organization might be hazardous to its enrollees, creditors, or the general public and to set standards for evaluating the financial condition of any health maintenance organization, which standards shall be consistent with the purpose expressed in subsection (a) of this section.
(d) The remedies and measures available to the Commissioner under this section shall be in addition to, and not in lieu of, the remedies and measures available to the Commissioner under the provisions of Chapter 13 of this title.
(Apr. 9, 1997, D.C. Law 11-235, § 22, 44 DCR 818.)
Prior Codifications
1981 Ed., § 35-4521.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 34 - Health Maintenance Organizations › § 31–3422. Regulations

§ 31–3422. Regulations.
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 pursuant to emergency procurement provisions set forth in § 2-354.05.
(Apr. 9, 1997, D.C. Law 11-235, § 23, 44 DCR 818; Sept. 26, 2012, D.C. Law 19-171, § 215, 59 DCR 6190.)
Prior Codifications
1981 Ed., § 35-4522.
Effect of Amendments
The 2012 amendment by D.C. Law 19-171 substituted “set forth in § 2-354.05” for “set forth in § 2-303.12.”
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 34 - Health Maintenance Organizations › § 31–3424. Statutory construction and relationship to other laws

§ 31–3424. Statutory construction and relationship to other laws.
(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 not apply to an insurer or hospital or medical service corporation licensed and regulated pursuant to the insurance laws of the District except with respect to its health maintenance organization activities authorized and regulated pursuant to this chapter.
(b) Solicitation of enrollees by a health maintenance organization granted a certificate of authority, or its representatives, shall not be construed to violate any provision of law relating to solicitation or advertising by health professionals.
(c) Any health maintenance organization authorized under this chapter shall not be deemed to be practicing medicine and shall be exempt from the provisions set forth by the Board of Medicine relating to the practice of medicine.
(Apr. 9, 1997, D.C. Law 11-235, § 26, 44 DCR 818.)
Prior Codifications
1981 Ed., § 35-4524.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 34 - Health Maintenance Organizations › § 31–3425. Filings and reports as public documents

§ 31–3425. Filings and reports as public documents.
All applications, filings, and reports required under this chapter shall be treated as public documents, except those which are trade secrets or privileged or confidential quality assurance, commercial, and financial information, other than any annual financial statement that may be required under § 31-3408 [repealed].
(Apr. 9, 1997, D.C. Law 11-235, § 27, 44 DCR 818.)
Prior Codifications
1981 Ed., § 35-4525.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 34 - Health Maintenance Organizations › § 31–3428. Coordination of benefits. [Repealed]

§ 31–3428. Coordination of benefits. [Repealed]
Repealed.
(Apr. 9, 1997, D.C. Law 11-235, § 30, 44 DCR 818; Mar. 27, 2003, D.C. Law 14-252, § 2(j), 50 DCR 225.)
Prior Codifications
1981 Ed., § 35-4528.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 34 - Health Maintenance Organizations › § 31–3429. Point of service plan

§ 31–3429. Point of service plan.
(a) If an employer, association, or other private group arrangement offers health benefit plan coverage to employees or individuals only through a health maintenance organization, the health maintenance organization with which the employer, association, or other private group arrangement is contracting for the coverage shall offer, or contract with another carrier to offer, a point-of-service option to the employer, association, or other private group arrangement in conjunction with the health maintenance organization as an additional benefit for an employee or individual, at the employee’s or individual’s option to accept or reject.
(b) An employer, association, or other private group arrangement may require an employee or individual that accepts the additional coverage under a point-of-service option under subsection (a) of this section to pay a premium over the amount of the premium for the coverage offered by the health maintenance organization.
(c) A health maintenance organization may impose different cost sharing provisions for the point-of-service option based on whether the service is provided through the provider panel of the health maintenance organization or outside the providers panel of the health maintenance organization.
(d) The requirements of this section shall not apply to any subscriber contract current and in force on April 9, 1997 for the duration of that contract, but these requirements shall apply to any renewal or new subscriber contract issued subsequent to April 9, 1997.
(e) The requirements of this section shall not apply to any subscriber contract issued in the individual market to a person who is not part of a contracted group of subscribers.
(Apr. 9, 1997, D.C. Law 11-235, § 31, 44 DCR 818.)
Prior Codifications
1981 Ed., § 35-4529.
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 34 - Health Maintenance Organizations › § 31–3431. Principal office, books, records, and files of the health maintenance organization to be in the District

§ 31–3431. Principal office, books, records, and files of the health maintenance organization to be in the District.
(a) Any health maintenance organization domiciled in the District or hereafter formed or organized in the District to engage in the health care business as a health maintenance organization shall maintain its principal office within the District, shall keep its books, records, and files in the District, and shall not remove from the District its principal office or its books, records, or files without first obtaining the written permission of the Commissioner; provided, that this section shall not apply to the books, records, and files of any branch office of a health maintenance organization, which books, records, and files relate solely to the business transacted by the branch office agency.
(b) A health maintenance organization domiciled in the District which violates this section shall immediately forfeit its certificate of authority to do business in the District.
(c) An officer, agent, or employee of a health maintenance organization which violates this section shall be guilty of a misdemeanor and, upon conviction, shall pay a fine of not less than $100 for each offense.
(Apr. 9, 1997, D.C. Law 11-235, § 32a; as added Mar. 27, 2003, D.C. Law 14-252, § 2(k), 50 DCR 225.)
Editor's Notes
Application of Law 14-252: Section 3 of D.C. Law 14-252 provided: “This act shall not apply until the Commissioner gives written notice that all necessary rules and administrative procedures are in place to effect the provisions of this act.”
2023 District of Columbia Code › Title 31 - Insurance and Securities › Chapter 34A - Health Organizations RBC › § 31–3451.02. RBC reports

§ 31–3451.02. RBC reports.
(a) A domestic health organization shall, prior to each March 2 (“filing date”), prepare and submit to the Commissioner a report of its RBC levels as of the end of the previous calendar year, in a form and containing such information as is required by the RBC instructions. In addition, a domestic health organization shall file its RBC report:
(1) With the NAIC in accordance with the RBC instructions; and
(2) With the insurance commissioner in any state in which the health organization is authorized to do business, if the insurance commissioner has notified the health organization of its request in writing, in which case the health organization shall file its RBC report not later than the later of:
(A) Fifteen days after the receipt of notice to file its RBC report with that state; or
(B) The filing date.
(b) A health organization's RBC level shall be determined in accordance with the formula set forth in the RBC instructions. The formula shall apply and may be adjusted for the covariance between the following factors in the manner set forth in the RBC instructions:
(1) Asset risk;
(2) Credit risk;
(3) Underwriting risk; and
(4) All other business risks and such other relevant risks as are set forth in the RBC instructions.
(c) If a domestic health organization files an RBC report that, in the judgment of the Commissioner, is inaccurate, the Commissioner shall adjust the RBC report to correct the inaccuracy and shall notify the health organization of the adjustment. The notice shall contain a statement of the reason for the adjustment.
(June 18, 2003, D.C. Law 14-312, § 102, 50 DCR 306; Apr. 15, 2017, D.C. Law 21-278, § 3(b), 64 DCR 963.)
Prior Codifications
2001 Ed., § 31-3851.02.
Section References
This section is referenced in § 31-3451.01.