Code of the District of Columbia

§ 31–3302.01. Guaranteed availability of individual health insurance coverage to certain individuals with prior group coverage.

(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.)

Prior Codifications

1981 Ed., § 35-1022.

Section References

This section is referenced in § 31-3301.01.

Emergency Legislation

See notes to § 31-3301.01.

Temporary Legislation

See Historical and Statutory Notes following § 31-3301.01.