(a) This subchapter applies only to those health insurers that offer individual health insurance coverage in the District of Columbia. Nothing in this subchapter shall require health insurers participating only in the group health insurance market to offer individual health insurance coverage.
(b) A health insurer may not offer any individual health benefit plans in the District of Columbia unless the health insurer offers, and actively markets, the policies required by this section.
(c) Unless a health insurer makes an election under subsection (d)(2) of this section, the health insurer may not:
(1) Decline to offer coverage to, or deny enrollment of, an eligible individual; or
(2) Impose any preexisting condition provision on an eligible individual.
(d)(1) A health insurer that makes an election under paragraph (2) of this subsection may choose to offer at least 2 different policy forms, both of which are designed for, made generally available to, actively marketed to, and enroll both eligible individuals and other individuals. Policy forms that have different cost-sharing arrangements or different riders shall be considered to be different policy forms.
(2) No later than July 1, 1997, a health insurer that intends to offer 2 policy forms shall submit in writing to the Commissioner both:
(A) An election whether to offer (i) a high level and low level policy form, each of which includes benefits substantially similar to other individual health insurance coverage offered by the health insurer in the District of Columbia, or (ii) policy forms with the largest and next to largest premium volume of all policy forms offered by the health insurer in the District of Columbia; and
(B) An election as to which methodology the health insurer will use to determine the weighted average valuation as defined in § 31-3301.01(45).
(3) An election made under this section shall be binding for a 2-year period. After the initial 2-year period, and for each subsequent 2-year period, a health insurer shall again make the elections required by this section.
(4) An election shall be made on a form and in a manner required by the Commissioner.
(5) The actuarial value of benefits provided under individual health insurance coverage shall be calculated based on a standardized population and a set of standardized utilization and cost factors.
(6) A health insurer shall submit any information the Commissioner may require to support and justify the health insurer's calculations of actuarial values.
(7) A health insurer shall issue the individual health benefit plan elected under this section to any eligible individual.
(8) A health insurer shall not impose any pre-existing condition provision on an eligible individual.
(Apr. 13, 1999, D.C. Law 12-209, § 201, 45 DCR 8433.)
HISTORICAL AND STATUTORY NOTES
Prior Codifications
1981 Ed., § 35-1022.
Temporary Addition of Section
See Historical and Statutory Notes following § 31-3301.01.
Emergency Act Amendments
See notes to § 31-3301.01.
Legislative History of Laws
For legislative history of D.C. Law 12-209, see Historical and Statutory Notes following § 31-3301.01.
(a) A health insurer that offers health insurance coverage in the individual market may:
(1) Limit the individuals who may be enrolled under such coverage to those who live, reside, or work within the service area for such network plan; and
(2) Within the service area of such plan, deny such coverage to such individuals if the health insurer has demonstrated to the Commissioner that:
(A) It will not have the capacity to deliver services adequately to additional individual enrollees because of its obligations to existing group contract holders, enrollees, and enrollees covered under individual contracts; and
(B) It is applying this section uniformly to individuals without regard to any health status-related factor of such individuals and without regard to whether the individuals are eligible individuals.
(b) A health insurer, upon denying health insurance coverage in the District of Columbia in accordance with subsection (a)(2) of this section, may not offer coverage in the individual market within such service area for a period of 180 days after such coverage is denied.
(Apr. 13, 1999, D.C. Law 12-209, § 202, 45 DCR 8433.)
HISTORICAL AND STATUTORY NOTES
Prior Codifications
1981 Ed., § 35-1023.
Temporary Addition of Section
See Historical and Statutory Notes following § 31-3301.01.
Emergency Act Amendments
See notes to § 31-3301.01.
Legislative History of Laws
For legislative history of D.C. Law 12-209, see Historical and Statutory Notes following § 31-3301.01.
(a) A health insurer may deny health insurance coverage in the individual market to an eligible individual if the health insurer has demonstrated to the satisfaction of the Commissioner that:
(1) It does not have the financial reserves necessary to underwrite additional coverage; and
(2) It is applying this section uniformly to all individuals in the individual market in the District of Columbia consistent with the laws of the District of Columbia and without regard to any health status-related factor of such individuals and without regard to whether the individuals are eligible individuals.
(b) A health insurer, upon denying individual health insurance coverage in the District of Columbia in accordance with subsection (a) of this section, may not offer such coverage in the individual market within the District of Columbia for a period of 180 days after the date such coverage is denied or until the health insurer has demonstrated to the satisfaction of the Commissioner that the health insurer has sufficient financial reserves to underwrite additional coverage, whichever is later.
(Apr. 13, 1999, D.C. Law 12-209, § 203, 45 DCR 8433.)
HISTORICAL AND STATUTORY NOTES
Prior Codifications
1981 Ed., § 35-1024.
Temporary Addition of Section
See Historical and Statutory Notes following § 31-3301.01.
Emergency Act Amendments
See notes to § 31-3301.01.
Legislative History of Laws
For legislative history of D.C. Law 12-209, see Historical and Statutory Notes following § 31-3301.01.
(a) The provisions of this chapter shall not be construed to require that a health insurer offering health insurance coverage only in connection with group health plans or through one or more bona fide associations, or both, offer such health insurance coverage in the individual market.
(b) A health insurer offering health insurance coverage in connection with group health plans under this subchapter shall not be deemed to be a health insurer offering individual health insurance coverage solely because such issuer offers a conversion policy.
(c) A health insurer offering individual health insurance coverage solely because such insurer offers any insurance coverage for children as a participant in a pilot program relating to insurance coverage for children shall not be deemed to be a health insurer offering individual health insurance coverage.
(Apr. 13, 1999, D.C. Law 12-209, § 204, 45 DCR 8433.)
HISTORICAL AND STATUTORY NOTES
Prior Codifications
1981 Ed., § 35-1025.
Temporary Addition of Section
See Historical and Statutory Notes following § 31-3301.01.
Emergency Act Amendments
See notes to § 31-3301.01.
Legislative History of Laws
For legislative history of D.C. Law 12-209, see Historical and Statutory Notes following § 31-3301.01.
(a) Except as provided in this section, a health insurer that provides individual health insurance coverage shall renew or continue in force such coverage at the option of the individual.
(b) A health insurer may nonrenew or discontinue health insurance coverage of an individual in the individual market based on one or more of the following:
(1) The individual has failed to pay premiums or contributions in accordance with the terms of the health insurance coverage or the issuer has not received timely premium payments;
(2) The individual has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the coverage;
(3) The insurer is ceasing to offer coverage in the individual market in accordance with this chapter;
(4) In the case of a health insurer that offers health insurance coverage in the individual market through a network plan, the individual no longer resides, lives, or works in the service area, or in an area for which the health insurer is authorized to do business, but only if such coverage is terminated under this section uniformly without regard to any health status-related factor of covered individuals; or
(5) In the case of health insurance coverage that is made available in the individual market only through one or more bona fide associations, the membership of the individual in the association (on the basis of which the coverage is provided) ceases, but only if such coverage is terminated under this section uniformly without regard to any health status-related factor of covered individuals.
(c) Requirements for uniform termination of coverage. --
(1) Discontinuance of a particular type of health insurance coverage.
In any case in which a health insurer decides to discontinue offering a particular type of health insurance coverage offered in the individual market, coverage of such type may be discontinued by the health insurer only if:
(i) The health insurer provides notice to each covered individual provided coverage of this type in such market of such discontinuation at least 90 days prior to the date of the discontinuation of such coverage;
(ii) The health insurer offers to each individual in the individual market provided coverage of this type the option to purchase any other individual health insurance coverage currently being marketed by the health insurer for individuals in such market; and
(iii) In exercising the option to discontinue coverage of this type, and in offering the option of coverage under this subsection, the health insurer acts uniformly without regard to any health status-related factor of enrolled individuals or individuals who may become eligible for such coverage.
(2) Discontinuance of all coverage.
(A) Subject to paragraph (1)(iii) of this subsection, in any case in which a health insurer elects to discontinue offering all health insurance coverage in the individual market in the District of Columbia, health insurance coverage may be discontinued by the health insurer only if:
(i) The health insurer provides notice to the Commissioner and to each individual of such discontinuation at least 180 days prior to the date of the expiration of such coverage, and
(ii) All health insurance issued or delivered for issuance in the District of Columbia in such market is discontinued and coverage under such health insurance coverage in such market is not renewed.
(B) In the case of discontinuation under paragraph (1) of this subsection in the individual market, the health insurer may not provide for the issuance of any health insurance coverage in the individual market in the District of Columbia during the 5-year period beginning on the date of the discontinuation of the last health insurance coverage not so renewed.
(d) At the time of coverage renewal, a health insurer may modify the health insurance coverage for a policy form offered to individuals in the individual market so long as such modification is consistent with the laws of the District of Columbia and effective on a uniform basis among all individuals with that policy form.
(e) In applying this section in the case of health insurance coverage that is made available by health insurers in the individual market to individuals only through one or more associations, a reference to an "individual" is deemed to include a reference to such an association of which the individual is a member.
(Apr. 13, 1999, D.C. Law 12-209, § 205, 45 DCR 8433.)
HISTORICAL AND STATUTORY NOTES
Prior Codifications
1981 Ed., § 35-1026.
Temporary Addition of Section
See Historical and Statutory Notes following § 31-3301.01.
Emergency Act Amendments
See notes to § 31-3301.01.
Legislative History of Laws
For legislative history of D.C. Law 12-209, see Historical and Statutory Notes following § 31-3301.01.
The provisions of § 31-3303.07(j) shall apply to health insurance coverage offered by a health insurer in the individual market in the same manner as they apply to health insurance coverage offered by a health insurer in connection with a group health plan in the small or large group market.
(Apr. 13, 1999, D.C. Law 12-209, § 206, 45 DCR 8433.)
HISTORICAL AND STATUTORY NOTES
Prior Codifications
1981 Ed., § 35-1027.
Temporary Addition of Section
See Historical and Statutory Notes following § 31-3301.01.
Emergency Act Amendments
See notes to § 31-3301.01.
Legislative History of Laws
For legislative history of D.C. Law 12-209, see Historical and Statutory Notes following § 31-3301.01.
(a) The Commissioner may adopt regulations to enable him or her to establish and administer such standards relating to the provisions of this chapter as may be necessary to (i) implement the requirements of this chapter, and (ii) assure that the District of Columbia's regulation of health insurers is not preempted pursuant to the Health Insurance Portability and Accountability Act of 1996, approved August 21, 1996 (P.L. 104-191; 110 Stat.1936).
(b) The Commissioner may revise or amend such regulations and may increase the scope of the regulations to the extent necessary to maintain federal approval of the District of Columbia's program for regulation of health insurers pursuant to the requirements established by the United States Department of Health and Human Services.
(c) The Commissioner shall annually advise the Committee on Consumer and Regulatory Affairs, or such other Council committee or committees having subject matter jurisdiction over health insurance, of revisions and amendments made pursuant to subsection (b) of this section.
(Apr. 13, 1999, D.C. Law 12-209, § 207, 45 DCR 8433.)
HISTORICAL AND STATUTORY NOTES
Prior Codifications
1981 Ed., § 35-1028.
Temporary Addition of Section
See Historical and Statutory Notes following § 31-3301.01.
Emergency Act Amendments
See notes to § 31-3301.01.
Legislative History of Laws
For legislative history of D.C. Law 12-209, see Historical and Statutory Notes following § 31-3301.01.
Unless otherwise specifically provided in this chapter, the provisions of this subchapter shall apply to individual health benefit plans issued or renewed on or after January 1, 1998.
(Apr. 13, 1999, D.C. Law 12-209, § 208, 45 DCR 8433.)
HISTORICAL AND STATUTORY NOTES
Prior Codifications
1981 Ed., § 35-1029.
Temporary Addition of Section
See Historical and Statutory Notes following § 31-3301.01.
Emergency Act Amendments
See notes to § 31-3301.01.
Legislative History of Laws
For legislative history of D.C. Law 12-209, see Historical and Statutory Notes following § 31-3301.01.
Nothing in this subchapter shall be construed to:
(1) Restrict the amount of the premium rates that an issuer may charge an individual for health insurance coverage provided in the individual market; or
(2) Prevent a health insurer offering health insurance coverage in the individual market from establishing premium discounts or rebates or modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention.
(Apr. 13, 1999, D.C. Law 12-209, § 209, 45 DCR 8433.)
HISTORICAL AND STATUTORY NOTES
Prior Codifications
1981 Ed., § 35-1030.
Temporary Addition of Section
See Historical and Statutory Notes following § 31-3301.01.
Emergency Act Amendments
See notes to § 31-3301.01.
Legislative History of Laws
For legislative history of D.C. Law 12-209, see Historical and Statutory Notes following § 31-3301.01.
