Code of the District of Columbia

§ 31–3501. Definitions.

For the purposes of this chapter, the term:

(1) “Commissioner” means the Commissioner of the Department of Insurance, Securities, and Banking.

(1A) “Community health reinvestment” means expenditures that promote and safeguard the public health or that benefit current or future subscribers, including premium rate reductions.

(1B) “Contractholder” means a person entering into a subscriber contract with a corporation.

(2) “Corporation” means a nonstock, nonprofit corporation which is subject to regulation and licensing under this chapter and which offers subscriber contracts as part of a hospital service plan, a medical service plan, or both.

(3) “Domestic corporation” means a corporation organized under the laws of the District, or formed or organized under an act of Congress.

(3A) “Healthy DC and Health Care Expansion Fund” means the Healthy DC and Health Care Expansion Fund established by § 31-3514.02.

(4) “Hospital service plan” means a plan for providing hospital and related services by hospitals and others which entitles a subscriber to certain hospital and related services, or to benefits and indemnification for such services.

(4A)(A)(i) Except as provided in sub-subparagraph (ii) of this subparagraph, “large employer” means, in connection with a group health plan with respect to a calendar year and a plan year, a single employer that employed an average of at least 51 employees on business days during the preceding calendar year and at least 2 employees on the first day of the plan year.

(ii) Beginning in calendar year 2016 and for each succeeding year, “large employer” means, in connection with a group health plan with respect to a calendar year and a plan year, a single employer that employed an average of at least 101 employees on business days during the preceding calendar year and at least 2 employees on the first day of the plan year.

(B) For the purposes of this paragraph:

(i) All persons treated as a single employer under section 414(b), (c), (m), or (o) of the Internal Revenue Code of 1986, October 22, 1986 (100 Stat. 2085; 26 U.S.C. § 414(b), (c), (m), or (o)), shall be treated as a single employer;

(ii) An employer and any predecessor employer shall be treated as a single employer;

(iii) All employees shall be counted, including part-time employees and employees who are not eligible for health benefit coverage through the employer; and

(iv) If an employer was not in existence throughout the preceding calendar year, the determination of whether that employer is a large employer shall be based on the average number of employees that the employer is reasonably expected to employ in the current calendar year.

(5) “Mayor” means the Mayor of the District of Columbia or the Mayor’s designated agent.

(6) “Medical service plan” means a plan for providing medical services and related services by physicians and others which entitles a subscriber to certain medical and related services, or to benefits and indemnification for such services.

(7) “Plan” means a hospital service plan, a medical service plan, or a combination of the two.

(7A) “Public-private partnership” means a mutually acceptable written agreement between the Mayor and a hospital and medical services corporation that is certified by the Commissioner upon the execution and delivery of the agreement by the parties and which agreement:

(A) Shall include the following provisions:

(i) A $5 million annual payment to the Healthy DC Fund (or appropriate successor fund) by the hospital and medical services corporation to be used for subsidies that expand health insurance coverage for low-income District residents;

(ii) A targeted city-wide health care initiative aimed at improving nutrition and increasing physical fitness among the District’s senior citizens, or another comparable health promotion program;

(iii) A term not to exceed 5 years, subject to extension upon the mutual written agreement of the parties;

(iv)(I)(aa) The maintenance and support of the existing District open enrollment program as it operated prior to the enactment of the Medical Insurance Empowerment Amendment Act of 2008, effective March 25, 2009 (D.C. Law 17-369; 56 DCR 1346) (“open enrollment program”), which program has an estimated average premium of $357 per member per month, and the enhancement of the open enrollment program by offering a new health maintenance organization product that includes comprehensive benefits with an average initial premium currently estimated at about $300 per member per month, which average may vary based upon age and family status, and subject to other reasonable adjustments, but with no adjustments for gender or pre-existing conditions.

(bb) The annual premium rate of the existing open enrollment program shall not exceed 125% of the comparable medically underwritten product and shall be determined once every 12 months. The benefit package shall include, at a minimum, primary care services, specialist services, temporomandibular joint problems chiropractic services, mental health and addiction treatment, organ transplantation, treatment for morbid obesity, open heart surgery, and pharmaceutical benefits.

(cc) The medical loss ratio to be utilized in rate filings and determinations shall not exceed 150%;

(II) Under the open enrollment program pursuant to sub-sub-subparagraph (I) of this sub-subparagraph:

(aa) Current members shall be permitted to maintain the option to continue their current open enrollment program coverage or opt for the new health maintenance organization product;

(bb) New open enrollment members shall only be offered the new health maintenance organization product; and

(cc) Total enrollment under subparagraph (A)(iv)(I) of this paragraph shall be capped at 2,500;

(v) Participation in the open enrollment program (including the health maintenance organization product) may be limited to District residents, which shall be subject to periodic confirmation; and

(vi)(I) A corporation shall prominently advertise the availability of the new open enrollment health maintenance organization product continuously on the Internet and at least quarterly in a newspaper of general circulation throughout the District.

(II) The content and format of the advertising shall be filed with the Commissioner no less than 30 days before its appearance in a newspaper or on the Internet;

(B) May include the following provisions:

(i) Authority for the Commissioner to grant a hospital and medical services corporation reasonable relief from the requirements of the agreement, such as if federal or state health care reforms make the requirements unnecessary or redundant or if the corporation does not meet a financial performance or similar test as specified in the agreement; provided, that any relief granted shall not affect the certification of the agreement by the Commissioner or the status of the agreement as a public-private partnership for all purposes under this chapter; and

(ii) Reasonable expiration and termination provisions; and

(C) Shall be effective upon the certification of the Commissioner.

(7B) “RS Fund” means the rate stabilization fund established by § 31-3514(j).

(7C)(A)(i) Except as provided in sub-subparagraph (ii) of this subparagraph, “small employer” means a single employer that employed an average of not more than 50 employees during the preceding calendar year.

(ii) Beginning in calendar year 2016 and for each succeeding year, “small employer” means a single employer that employed an average of not more than 100 employees during the preceding calendar year.

(B) For the purposes of this paragraph:

(i) All persons treated as a single employer under section 414(b), (c), (m), or (o) of the Internal Revenue Code of 1986, October 22, 1986 (100 Stat. 2085; 26 U.S.C. § 414(b), (c), (m), or (o)), shall be treated as a single employer;

(ii) An employer and any predecessor employer shall be treated as a single employer;

(iii) All employees shall be counted, including part-time employees and employees who are not eligible for health benefit coverage through the employer; and

(iv) If an employer was not in existence throughout the preceding calendar year, the determination of whether that employer is a small employer shall be based on the average number of employees that the employer is reasonably expected to employ in the current calendar year.”

(8) “Subscriber” means any person entitled to benefits under the terms and conditions of a subscriber contract.

(9) “Subscriber contract” means a written group or individual contract which is issued to a contractholder by a corporation which provides for subscriber participation in a hospital service plan, a medical service plan, or a combination of the two.

(10) “Subsidiary” means an affiliate controlled by a corporation directly or indirectly through 1 or more intermediaries.

(11) “Surplus” means the amount by which all admitted assets of the corporation exceed its liabilities, inclusive of the reserves required pursuant to § 31-3509.

(4A)(A)(i) Except as provided in sub-subparagraph (ii) of this subparagraph, “large employer” means, in connection with a group health plan with respect to a calendar year and a plan year, a single employer that employed an average of at least 51 employees on business days during the preceding calendar year and at least 2 employees on the first day of the plan year.

(ii) Beginning in calendar year 2016 and for each succeeding year, “large employer” means, in connection with a group health plan with respect to a calendar year and a plan year, a single employer that employed an average of at least 101 employees on business days during the preceding calendar year and at least 2 employees on the first day of the plan year.

(B) For the purposes of this paragraph:

(i) All persons treated as a single employer under section 414(b), (c), (m), or (o) of the Internal Revenue Code of 1986, October 22, 1986 (100 Stat. 2085; 26 U.S.C. § 414(b), (c), (m), or (o)), shall be treated as a single employer;

(ii) An employer and any predecessor employer shall be treated as a single employer;

(iii) All employees shall be counted, including part-time employees and employees who are not eligible for health benefit coverage through the employer; and

(iv) If an employer was not in existence throughout the preceding calendar year, the determination of whether that employer is a large employer shall be based on the average number of employees that the employer is reasonably expected to employ in the current calendar year.


(Apr. 9, 1997, D.C. Law 11-245, § 2, 44 DCR 1158; Mar. 2, 2007, D.C. Law 16-192, § 5012(a), 53 DCR 6899; Mar. 25, 2009, D.C. Law 17-369, § 2(a), 56 DCR 1346; Feb. 4, 2010, D.C. Law 18-104, § 2(a), 56 DCR 9182; Sept. 24, 2010, D.C. Law 18-223, § 5023(a), 57 DCR 6242; May 2, 2015, D.C. Law 20-265, § 105(a), 62 DCR 1529.)

Prior Codifications

1981 Ed., § 35-4701.

Effect of Amendments

D.C. Law 16-192 added pars. (3A) and (7A).

D.C. Law 17-369 redesignated former par. (1) as par. (1B); and added pars. (1) and (1A).

D.C. Law 18-104 redesignated former par. (7A) as par. (7B); and added par. (7A).

D.C. Law 18-223, in par. (3A), substituted “Healthy DC and Health Care Expansion Fund” for “Healthy DC Fund” both times it appears.

The 2015 amendment by D.C. Law 20-265 added (4A) and (7C).

Emergency Legislation

For temporary (90 day) amendment of section, see § 5012(a) of Fiscal Year 2007 Budget Support Emergency Act of 2006 (D.C. Act 16-477, August 8, 2006, 53 DCR 7068).

For temporary (90 day) amendment of section, see § 5012(a) of Fiscal Year 2007 Budget Support Congressional Review Emergency Act of 2006 (D.C. Act 16-499, October 23, 2006, 53 DCR 8845).

For temporary (90 day) amendment of section, see § 5012(a) of Fiscal Year 2007 Budget Support Congressional Review Emergency Act of 2007 (D.C. Act 17-1, January 16, 2007, 54 DCR 1165).

For temporary (90 day) amendment of section, see § 2(a) of Hospital and Medical Services Corporation Regulatory Emergency Amendment Act of 2009 (D.C. Act 18-277, January 11, 2010, 57 DCR 935).

For temporary (90 day) amendment of section, see § 3(a) of Medicaid Resource Maximization Emergency Amendment Act of 2010 (D.C. Act 18-390, May 7, 2010, 57 DCR 4339).

For temporary (90 day) amendment of section, see § 201(a) of DC High Risk Pool Program Establishment Emergency Act of 2010 (D.C. Act 18-522, August 3, 2010, 57 DCR 8001).

For temporary (90 day) amendment of section, see § 5023(a) of Fiscal Year 2011 Budget Support Emergency Act of 2010 (D.C. Act 18-463, July 2, 2010, 57 DCR 6542).

Temporary Legislation

Section 2(a) of D.C. Law 18-134 designated par. (7A) as par. (7B); and added par. (7A) to read as follows:

“’(7A) Public-private partnership’ means a mutually acceptable written agreement between the Mayor and a hospital and medical services corporation that is certified by the Commissioner upon the execution and delivery of the agreement by the parties and which agreement:

“(A) Shall include the following provisions:

“(i) A $5 million annual payment to the Healthy DC Fund (or appropriate successor fund) by the hospital and medical services corporation to be used for subsidies that expand health insurance coverage for low-income District residents;

“(ii) A targeted city-wide health care initiative aimed at improving nutrition and increasing physical fitness among the District’s senior citizens, or another comparable health promotion program;

“(iii) A term not to exceed 5 years, subject to extension upon the mutual written agreement of the parties;

“(iv)(I)(aa) The maintenance and support of the existing District open enrollment program as it operated prior to the enactment of the Medical Insurance Empowerment Amendment Act of 2008, effective March 25, 2009 (D.C. Law 17-369; 56 DCR 1346) (‘open enrollment program’), which program has an estimated average premium of $357 per member per month, and the enhancement of the open enrollment program by offering a new health maintenance organization product that includes comprehensive benefits with an average initial premium currently estimated at about $300 per member per month, which average may vary based upon age and family status, and subject to other reasonable adjustments, but with no adjustments for gender or pre-existing conditions.

“(bb) The annual premium rate of the existing open enrollment program shall not exceed 125% of the comparable medically underwritten product and shall be determined once every 12 months. The benefit package of the health maintenance organization product shall include, at a minimum, primary care services, specialist services, temporomandibular joint problems chiropractic services, mental health and addiction treatment, organ transplantation, treatment for morbid obesity, open heart surgery, and pharmaceutical benefits.

“(cc) The medical loss ratio of the health maintenance organization product to be utilized in rate filings and determinations shall not exceed 150%;

“(II) Under the open enrollment program pursuant to sub-sub-subparagraph (I) of this sub-subparagraph:

“(aa) Current members shall be permitted to maintain the option to continue their current open enrollment program coverage or opt for the new health maintenance organization product;

“(bb) New open enrollment members shall only be offered the new health maintenance organization product; and

“(cc) Total enrollment under subparagraph A)(iv)(I) of this paragraph shall be capped at 2,500;

“(v) Participation in the open enrollment program (including the health maintenance organization product) may be limited to District residents, which shall be subject to periodic confirmation; and

“(vi)(I) A corporation shall prominently advertise the availability of the new open enrollment health maintenance organization product continuously on the Internet and at least quarterly in a newspaper of general circulation throughout the District.

“(II) The content and format of the advertising shall be filed with the Commissioner no less than 30 days before its appearance in a newspaper or on the Internet;

“(B) May include the following provisions:

“(i) Authority for the Commissioner to grant a hospital and medical services corporation reasonable relief from the requirements of the agreement, such as if federal or state health care reforms make the requirements unnecessary or redundant or if the corporation does not meet a financial performance or similar test as specified in the agreement; provided, that any relief granted shall not affect the certification of the agreement by the Commissioner or the status of the agreement as a public-private partnership for all purposes under this act; and

“(ii) Reasonable expiration and termination provisions; and

“(C) Shall be effective upon the certification of the Commissioner.”.

Section 6(b) of D.C. Law 18-134 provided that the act shall expire after 225 days of its having taken effect.

Section 3(a) of D.C. Law 18-205, in par. (3A), substituted “Healthy DC and Health Care Expansion Fund” for “Healthy DC Fund” both times it appears.

Section 7(b) of D.C. Law 18-205 provided that the act shall expire after 225 days of its having taken effect.

Section 201(a) of D.C. Law 18-271 amended subsec. (7A)(A)(v) to read as follows:

“(v) Participation in the open enrollment program (including the health maintenance organization product) may be limited to District residents who are ineligible for the DC High Risk Pool Program, as defined in the DC High Risk Pool Program Establishment Temporary Act of 2010, passed on 2nd reading on September 21, 2010 (Enrolled version of Bill 18-939). Participant eligibility shall be subject to periodic confirmation; and”.

Section 302(b) of D.C. Law 18-271 provided that the act shall expire after 225 days of its having taken effect.

Short Title

Short title: Section 5011 of D.C. Law 16-192 provided that subtitle B of title V of the act may be cited as the “Hospital and Medical Services Corporation Regulatory Amendment Act of 2006”.