For the purposes of this chapter, the term:
(1) "Commissioner" means Commissioner of the Department of Insurance and Securities Regulation.
(2) "District" means the District of Columbia.
(3) "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.
(4) "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.
(5) "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.
(6) "Health benefit plan" means any 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" 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.
(7) "Individual health plan" means a plan offering health insurance coverage offered to individuals other than in connection with a group health plan.
(8) "Mastectomy" means the surgical removal of all or substantially all of a breast as a result of breast cancer.
(Apr. 3, 2001, D.C. Law 13-254, § 2, 48 DCR 723.)
HISTORICAL AND STATUTORY NOTES
Legislative History of Laws
Law 13-254, the "Woman's Health and Cancer Rights Federal Law Conformity Act of 2000," was introduced in Council and assigned Bill No. 13-592, which was referred to the Committee on Human Services. The Bill was adopted on first and second readings on November 8, 2000, and December 5, 2000, respectively. Signed by the Mayor on December 22, 2000, it was assigned Act No. 13-541 and transmitted to both Houses of Congress for its review. D.C. Law 13-254 became effective on April 3, 2001.
(a) An individual or group health plan which is a health benefit plan, and a health insurer providing health insurance coverage, that provides medical and surgical benefits with respect to a mastectomy shall, in a manner determined in consultation with the attending physician and the patient, provide the following coverage in the case of a participant or beneficiary who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy:
(1) All stages of reconstruction of the breast on which the mastectomy has been performed;
(2) Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
(3) Prostheses and physical complications at all stages of mastectomy, including lymphedemas.
(b) Coverage for the procedures in subsection (a) of this section may be subject to annual deductibles and coinsurance provisions as may be considered appropriate and as are consistent with those established for other benefits under the health benefit plan or coverage.
(Apr. 3, 2001, D.C. Law 13-254, § 3, 48 DCR 723.)
HISTORICAL AND STATUTORY NOTES
Legislative History of Laws
For D.C. Law 13-254, see notes following § 31-3831.
(a) Written notice of the availability of coverage, as set forth in § 31- 3832, shall be delivered to the participant and beneficiary under the health plan upon enrollment and annually thereafter. Notice of the benefits shall be prominently positioned in any literature or correspondence made available or distributed by the health benefit plan or health insurer and shall be transmitted to the participant or beneficiary upon the earlier of:
(1) Any yearly informational packet sent to the participant or beneficiary, as part of the packet;
(2) In the next mailing made by the health benefit plan or health insurer to the participant or beneficiary; or
(3) Not later than 60 days after April 3, 2001.
(b) An individual or group health plan which is a health benefit plan, and a health insurer that has already provided notice in order to comply with the Women's Health and Cancer Rights Act of 1998, approved October 21, 1998 (112 Stat. 2681; 29 USC § 1185b, 42 USC § 300 gg-6, and 42 USC § 300gg-52), need not provide additional notice under this chapter; provided, that it files with the Commissioner a written statement, with a copy of the notice attached, certifying that it is in compliance.
(Apr. 3, 2001, D.C. Law 13-254, § 4, 48 DCR 723.)
HISTORICAL AND STATUTORY NOTES
Legislative History of Laws
For D.C. Law 13-254, see notes following § 31-3831.
An individual or group health plan, and a health insurer offering health care coverage that provides coverage for prescription drugs, shall provide benefits which cover any hormone replacement therapy that is prescribed or ordered for treating symptoms and conditions of menopause.
(Apr. 3, 2001, D.C. Law 13-254, § 5, 48 DCR 723.)
HISTORICAL AND STATUTORY NOTES
Legislative History of Laws
For D.C. Law 13-254, see notes following § 31-3831.
An individual or group health plan which is a health benefit plan, and a health insurer offering health care coverage, shall not:
(1) Deny a patient eligibility, or continued eligibility, to enroll or renew coverage under terms of the health benefit plan, solely for the purpose of avoiding the requirements of this chapter; or
(2) Penalize or otherwise reduce or limit the reimbursement of an attending provider, or provide incentives (monetary or otherwise) to an attending provider, to induce such provider to provide care to an individual participant or beneficiary in a manner inconsistent with this chapter.
(Apr. 3, 2001, D.C. Law 13-254, § 6, 48 DCR 723.)
HISTORICAL AND STATUTORY NOTES
Legislative History of Laws
For D.C. Law 13-254, see notes following § 31-3831.
The Commissioner shall promulgate regulations necessary to implement the provisions of this chapter within 180 days after April 3, 2001.
(Apr. 3, 2001, D.C. Law 13-254, § 7, 48 DCR 723.)
HISTORICAL AND STATUTORY NOTES
Legislative History of Laws
For D.C. Law 13-254, see notes following § 31-3831.
The provisions of this chapter shall apply to group health benefit plans for years beginning on or after April 3, 2001.
(Apr. 3, 2001, D.C. Law 13-254, § 8, 48 DCR 723.)
HISTORICAL AND STATUTORY NOTES
Legislative History of Laws
For D.C. Law 13-254, see notes following § 31-3831.
