Code of the District of Columbia

§ 31–3171.09. Health benefit plan certification.

(a) To be certified as a qualified health plan, a health benefit plan shall, at a minimum:

(1) Provide the essential health benefits package described in section 1302(a) of the Federal Act; except, that the plan is not required to provide essential benefits that duplicate the minimum benefits of qualified dental plans, as provided in subsection (e) of this section, if:

(A) The Authority has determined that at least one qualified dental plan is available to supplement the plan’s coverage; and

(B) The health carrier makes prominent disclosure at the time it offers the plan, in a form approved by the Authority, that the plan does not provide the full range of essential pediatric dental benefits and that qualified dental plans providing those benefits and other dental benefits not covered by the plan are offered through the exchanges;

(2) Obtain prior approval of premium rates and contract language from the Commissioner;

(3) Provide at least a bronze level of coverage, as determined by § 31-3171.04(a)(11), unless the plan is certified as a qualified catastrophic plan, meets the requirements of section 1302(e) of the Federal Act, and will only be offered to individuals eligible for catastrophic coverage;

(4) Ensure that the cost-sharing requirements of the plan do not exceed the limits established under section 1302(c)(1) of the Federal Act, and if the plan is offered through the SHOP Exchange, the plan’s deductible does not exceed the limits established under section 1302(c)(2) of the Federal Act;

(5) Be offered by a health carrier that:

(A) Is licensed and in good standing to offer health insurance coverage in the District;

(B)(i) Offers at least one qualified health plan at the bronze level, at least one qualified health plan at the silver level, and at least one qualified health plan at the gold level through each component of the Authority in which the health carrier participates;

(ii) For the purposes of this subparagraph, the term “component” refers to the SHOP Exchange and the exchange for individual coverage within the American Health Benefit Exchange;

(C) Charges the same premium rate for each qualified health plan without regard to whether the plan is offered through the exchanges and without regard to whether the plan is offered directly from the health carrier or through an insurance producer;

(D) Does not charge any cancellation fees or penalties in violation of § 31-3171.04(c);

(E) Complies with the regulations established by the Secretary under section 1311(d) of the Federal Act and any other requirements as the Authority may establish;

(E) Quality improvement;

(F) Uniform enrollment forms and descriptions of coverage; and

(G) Information on quality measures for health benefit plan performance; and

(H) Offers plans subject to the meaningful difference standard, as defined in section 4(ii) of Chapter 1 of the Affordable Exchanges Guidance, dated March 1, 2013, by the Centers for Consumer Information and Insurance Oversight at the Centers for Medicare and Medicaid Services in the U.S. Department of Health and Human Services, or as may be defined by the executive board for the Authority;

(6) Meet the requirements of certification pursuant to the authority provided in this chapter and by the Secretary under section 1311(c) of the Federal Act, and rules promulgated pursuant to this chapter or the Federal Act, which include:

(A) Minimum standards in the areas of marketing practices;

(B) Network adequacy;

(C) Essential community providers in underserved areas;

(D) Accreditation;

(E) Quality improvement;

(F) Uniform enrollment forms and descriptions of coverage; and

(G) Information on quality measures for health benefit plan performance;

(7) Be determined by the Authority that making the plan available through the exchanges is in the interest of qualified individuals and qualified employers;

(8) Comply with section 512 of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, approved October 3, 2008 (Pub. L. No. 110-343; 122 Stat. 3881), as applied to the Federal Act, including covering behavioral health inpatient and outpatient services for mental health and substance use disorders without day or visit limitations;

(9) Provide a drug formulary that includes, at a minimum, the greater of either the number of drugs listed in each category and class found in the District's base-benchmark plan formulary, or the minimum number of drugs, by category and class, as established by the Center for Consumer Information and Insurance Oversight in the Centers for Medicare and Medicaid Services at the U.S. Department of Health and Human Services; and

(10) Provide benefits identical to the essential health benefits benchmark plan, as defined in federal regulations promulgated pursuant to section 1302(a) of the Federal Act, as defined by the District without benefit substitution.

(b) The Authority shall not withhold certification from a health benefit plan:

(1) On the basis that the plan is a fee-for-service plan;

(2) Through the imposition of premium price controls by the Authority;

(3) On the basis that the health benefit plan provides treatments necessary to prevent patients’ deaths in circumstances the Authority determines are inappropriate or too costly; or

(4) On the basis of the number of qualified health plans being offered.

(c) The Authority shall require each health carrier seeking certification of a plan as a qualified health plan to:

(1) Submit a justification for any premium increase before implementation of that increase, and prominently post the information on its publically accessible website;

(2)(A) Make available to the public, in the format described in subparagraph (B) of this paragraph, and submit to the Authority, the Secretary, and the Commissioner, accurate and timely disclosure of the following:

(i) Claims payment policies and practices;

(ii) Periodic financial disclosures;

(iii) Data on enrollment;

(iv) Data on disenrollment;

(v) Data on the number of claims that are denied;

(vi) Data on rating practices;

(vii) Information on cost-sharing and payments with respect to any out-of-network coverage;

(viii) Information on enrollee and participant rights under title I of the Federal Act; and

(ix) Other information as determined appropriate by the Secretary.

(B) The information required in subparagraph (A) of this paragraph shall be provided in plain language, as that term is defined in section 1311(e)(3)(B) of the Federal Act;

(3) Permit individuals to learn, in a timely manner upon the request of the individual, the amount of cost-sharing, including deductibles, copayments, and coinsurance, under the individual’s plan or coverage that the individual would be responsible for paying with respect to the furnishing of a specific item or service by a participating provider and make this information available to the individual through a website that is publically accessible, and through other means for individuals without access to the Internet; and

(4) Promptly notify affected individuals of price and benefit changes, or other changes in circumstances that could materially impact enrollment or coverage.

(d) The Authority shall not exempt any health carrier seeking certification as a qualified health plan, regardless of the type or size of the health carrier, from District licensure or solvency requirements, and shall apply the criteria of this section in a manner that assures a level playing field between or among health carriers participating in the exchanges.

(e)(1) The provisions of this chapter that are applicable to qualified health plans shall also apply, to the extent relevant, to qualified dental plans except as modified in accordance with the provisions of paragraphs (2), (3) and (4) of this subsection or by regulations adopted by the Authority.

(2) The health carrier shall be licensed to offer dental coverage, but need not be licensed to offer other health benefits.

(3) The plan shall be limited to dental and oral health benefits, without substantially duplicating the benefits typically offered by health benefit plans without dental coverage and shall include, at a minimum, the essential pediatric dental benefits prescribed by the Secretary pursuant to section 1302(b)(1)(J) of the Federal Act, and such other dental benefits as the Authority or the Secretary may specify by regulation.

(4) Health carriers may jointly offer a comprehensive plan through the exchanges in which the dental benefits are provided by a health carrier through a qualified dental plan and the other benefits are provided by a health carrier through a qualified health plan; provided, that the plans are priced separately and are also made available for purchase separately at the same price.

(f) The Authority shall take the information required by subsection (c)(1) of this section, along with the information and the recommendations provided to the Authority by the Commissioner under section 2794(b) of the PHSA, into consideration when determining whether to allow the health carrier to make plans available through the exchanges.

(g) A qualified health plan may provide additional services that are not in the essential health benefits package required in subsection (a)(1) of this section, if the services are eligible for claims submission and reimbursement.

(h) For the purposes of the essential health benefits benchmark plan, as defined in federal regulations promulgated pursuant to section 1302(a) of the Federal Act, the term “habilitative services” includes health care services that help a person keep, learn, or improve skills and functioning for daily living, including applied behavioral analysis for the treatment of autism spectrum disorder.


(Mar. 2, 2012, D.C. Law 19-94, § 10, 59 DCR 213; July 16, 2014, D.C. Law 20-123, § 2(b), 61 DCR 5379.)

Section References

This section is referenced in § 31-3171.01 and § 31-3171.04.

Effect of Amendments

The 2014 amendment by D.C. Law 20-123 added “at least one qualified health plan at the bronze level,” in (a)(5)(B)(i); deleted “and” at the end of (a)(5)(D); added (a)(5)(F), (a)(5)(G), and (a)(5)(H); made minor stylistic changes in (a)(6) and (a)(7); added (a)(8), (a)(9), and (a)(10); made minor stylistic changes in (b)(2) and (b)(3); and added (b)(4), (g), and (h).

Emergency Legislation

For temporary (90 days) amendment of this section, see § 2(b) of the Better Prices, Better Quality, Better Choices for Health Coverage Emergency Act of 2013 (D.C. Act 20-87, June 19, 2013, 60 DCR 9542, 20 DCSTAT 1446).

For temporary (90 days) addition of D.C. Law 19-94, § 10a, see §§ 2(c) and 3 of the Better Prices, Better Quality, Better Choices for Health Coverage Congressional Review Emergency Amendment Act of 2013 (D.C. Act 20-170, September 26, 2013, 60 DCR 14742).

For temporary (90 days) amendment of section, see § 2(b) of the Better Prices, Better Quality, Better Choices for Health Coverage Emergency Amendment Act of 2014, (D.C. Act 20-335, May 22, 2014, 61 DCR 5375).

Temporary Legislation

For temporary (225 days) addition of D.C. Law 19-94, § 10a, concerning distribution of individual and small group health benefit plans, see § 2(c) of the Better Prices, Better Quality, Better Choices for Health Coverage Temporary Amendment Act of 2013 (D.C. Law 20-22, October 3, 2013, 60 DCR 10880).

For temporary (225 days) addition of D.C. Law 19-94, § 10b, concerning sale, solicitation, and negotiation by insurance producers, see §2(c) of the Better Prices, Better Quality, Better Choices for Health Coverage Temporary Amendment Act of 2013 (D.C. Law 20-22, October 3, 2013, 60 DCR 10880).

For temporary (225 days) amendment of this section, see § 2(b) of the Better Prices, Better Quality, Better Choices for Health Coverage Temporary Amendment Act of 2013 (D.C. Law 20-22, October 3, 2013, 60 DCR 10880).