Health Benefit Exchange.

D.C. Code div. V, tit. 31, ch. 31D

in effect

D.C. Code § 31-3171.01 Definitions.

31-3171.01. Definitions. (1) “American Health Benefit Exchange” means an entity established pursuant to § 31-3171.04, and section 1311(b) of the Federal Act. (2) “Authority” means the District of Columbia Health Benefit Exchange Authority established by § 31-3171.02. (2A) "Basic health program" means a program established pursuant to section 1331 of the Federal Act (42 U.S.C. § 18051). (3) “Commissioner” means the Commissioner of the Department of Insurance, Securities and Banking, as established by § 31-102. (3A) “Direct gross receipts” means all policy and membership fees and net premium receipts or consideration received in a calendar year on all health insurance carrier risks originating in or from the District of Columbia. (4) “Federal Act” means the Patient Protection and Affordable Care Act, approved March 23, 2010 (124 Stat. 119; 42 U.S.C. § 18001, note), as amended by the Health Care and Education Reconciliation Act of 2010 approved March 30, 2010 (124 Stat. 1029; 42 U.S.C. § 1305, note), and any amendments, regulations, or guidance issued pursuant to the Federal Act. (5) (A) “Health benefit plan” means a policy, contract, certificate, or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. (B) The term “health benefit plan” does not include: (i) Coverage only for accident or disability income insurance, or any combination thereof; (ii) Liability insurance, including general liability insurance and automobile liability insurance; (iii) Coverage issued as a supplement to liability insurance; (iv) Workers' compensation or similar insurance; (v) Automobile medical payment insurance; (vi) Credit-only insurance; (vii) Coverage for on-site medical clinics; or (viii) Other similar insurance coverage, specified in federal regulations issued pursuant to the Health Insurance Portability and Accountability Act of 1996, approved August 21, 1996 (110 Stat. 1936; 42 U.S.C. § 201, note) (“HIPAA”), under which benefits for health care services are secondary or incidental to other insurance benefits. (C) The term “health benefit plan” does not include the following benefits if they are provided under a separate policy, certificate of insurance, or contract of insurance, or are otherwise not an integral part of the plan: (i) Limited scope dental or vision benefits; (ii) Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; or (iii) Other similar, limited benefits specified in federal regulations issued pursuant to HIPAA. (D) The term “health benefit plan” does not include the following benefits if the benefits are provided under a separate policy, certificate of insurance, or contract of insurance, and there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and the benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor: (i) Coverage only for a specified disease or illness; or (ii) Hospital indemnity or other fixed indemnity insurance. (E) The term “health benefit plan” does not include the following if offered as a separate policy, certificate of insurance, or contract of insurance: (i) A Medicare supplemental policy as defined in section 1882(g)(1) of the Social Security Act (42 U.S.C. § 1395ss(g)(1)); (ii) Coverage supplemental to the coverage provided under 10 U.S.C. § 1071 et seq.; or (iii) Similar supplemental coverage provided to coverage under a group health plan. (6) “Health carrier” means an entity subject to the insurance laws and regulations of the District that contracts, or offers to contract, to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including: (A) An accident and sickness insurance company; (B) A health maintenance organization; (C) A hospital and medical services corporation; or (D) Any other entity providing a health benefit plan. (7) “Health professional” shall have the same meaning as provided in § 3-1201.01(8). (8) “Internal Revenue Code of 1986” means the Internal Revenue Code of 1986, approved August 16, 1954 (100 Stat. 2095; 26 U.S.C. § 1 et seq.). (8A) “Metal level” means the bronze, silver, gold, and platinum levels of coverage as defined in section 1302(d)(1) of the Federal Act. (8B) “Navigator” refers to the entities described in section 1311(i) of the Federal Act. (8C) “Net premium receipts or consideration received” means gross premiums or consideration received less the sum of premiums received for reinsurance assumed and premiums or consideration returned on policies or contracts canceled or not taken. (9) “PHSA” means the Public Health Service Act, approved July 1, 1944 (58 Stat. 682; 42 U.S.C. § 201 et seq.). (10) “Qualified dental plan” means a limited-scope dental plan that has been certified in accordance with § 31-3171.09. (11) “Qualified employer” means a small employer that elects to make its full-time employees eligible for one or more qualified health plans offered through the Small Business Health Options Program Exchange (“SHOP Exchange”), and, at the option of the employer, some or all of its part-time employees; provided, that the employer: (A) Has its principal place of business in the District and elects to provide coverage through the SHOP Exchange to all of its eligible employees, wherever employed; or (B) Elects to provide coverage through the SHOP Exchange to all of its eligible employees who are principally employed in the District. (12) “Qualified health plan” means a health benefit plan that has a certification validating that the plan meets the criteria for certification described in section 1311(c) of the Federal Act and § 31-3171.09. (13) “Qualified individual” means an individual, including a minor, who: (A) Is seeking to enroll in a qualified health plan offered to individuals through the Authority; (B) Resides in the District; (C) At the time of enrollment, is not incarcerated, other than incarceration pending the disposition of charges; and (D) Is, and is reasonably expected to be, for the entire period for which enrollment is sought, a citizen or national of the United States or an alien lawfully present in the United States. (14) “Secretary” means the Secretary of the United States Department of Health and Human Services. (15) “SHOP Exchange” means a Small Business Health Options Program Exchange established pursuant to § 31-3171.04, and section 1311(b) of the Federal Act. (16) (A) “Small employer” means a single employer that employed an average of not more than 50 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 (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. (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 employer is reasonably expected to employ in the current calendar year. (v) An employer that makes enrollment in qualified health plans available to its employees through the SHOP Exchange and would cease to be a small employer by reason of an increase in the number of its employees shall continue to be treated as a small employer for purposes of this chapter as long as it continuously makes enrollment through the SHOP Exchange available to its employees. (17) “Social Security Act” means the Social Security Act, approved August 14, 1935 (49 Stat. 620; 42 U.S.C. § 301 et seq.), as amended. (18) “Standardized plan” means a plan with defined benefits and cost sharing as determined by the executive board for the Authority. (March 2, 2012, D.C. Law 19-94, § 2, 59 DCR 213; July 16, 2014, D.C. Law 20-123, § 2(a), 61 DCR 5379; June 23, 2015, D.C. Law 21-13, § 2(a), 62 DCR 5946; Dec. 6, 2025, D.C. Law 26-55, § 5082(a), 72 DCR 9825.)

D.C. Code § 31-3171.02 Establishment and purpose.

31-3171.02. Establishment and purpose. (a) There is established, as an independent authority of the District government, the District of Columbia Health Benefit Exchange Authority. The Authority shall be an instrumentality, created to effectuate the purposes stated in this chapter, that shall have a legal existence separate from the District government. (b) The purposes of the Authority shall be to: (1) Enable individuals and small employers to find affordable and easier-to-understand health insurance; (2) Facilitate the purchase and sale of qualified health plans; (3) Assist small employers in facilitating the enrollment of their employees in qualified health plans; (4) Reduce the number of uninsured; (5) Provide a transparent marketplace for health benefit plans; (6) Educate consumers; and (7) Assist individuals and groups to access programs, premium assistance tax credits, and cost-sharing reductions. (Mar. 2, 2012, D.C. Law 19-94, § 3, 59 DCR 213.)

D.C. Code § 31-3171.03 District of Columbia Health Benefit Exchange Authority Fund.

31-3171.03. District of Columbia Health Benefit Exchange Authority Fund. (a) There is established as a nonlapsing fund the District of Columbia Health Benefit Exchange Authority Fund (“Fund”), which shall be administered by the Authority in accordance with generally accepted accounting principles and which shall be used solely for the purposes set forth in this chapter and the costs of administering this chapter. (b) The Fund shall consist of: (1) Any user fees, licensing fees, or other assessments collected by the Authority; (2) Income from investments made on behalf of the Fund; (3) Interest on money in the Fund; (4) Money collected by the executive board as a result of a legal or other action; (5) Donations; (6) Grants; (7) All general revenue funds appropriated by a line item in the budget submitted pursuant to § 1-204.46, and authorized by Congress for the purposes of the Authority; and (8) Any other money from any other source accepted for the benefit of the Fund. (c) All revenues, income from investments, proceeds, and other monies, from whatever source derived, that are collected or received by the Authority shall be deposited into the Fund. All funds deposited into the Fund, and any interest earned on those funds, shall not revert to the unrestricted fund balance of the General Fund of the District of Columbia at the end of a fiscal year, or at any other time, but shall be continually available for the uses and purposes set forth in this chapter without regard to fiscal year limitation, subject to authorization by Congress. (d) The Chief Financial Officer shall invest the money of the Fund in the same manner as other District money may be invested. (e) (1) The Authority is authorized to charge, through rulemaking: (A) User fees; (B) Licensing fees; and (C) Other assessments on health carriers selling qualified dental plans or qualified health plans in the District, including qualified health plans and qualified dental plans sold outside the exchanges. (2) User fees, licensing fees, or other assessments authorized shall not exceed reasonable projections regarding the amount necessary to support the operations of the Authority. (3) The assessment on health carriers pursuant to subsection (f) of this section shall be a tax and licensing and regulatory fee for purposes of 45 CFR §§ 158.221(c) and 158.161(b). (f) (1) The Authority shall annually assess, through a Notice of Assessment, each health carrier doing business in the District with direct gross receipts of $50,000 or greater in the preceding calendar year an amount based on a percentage of its direct gross receipts for the preceding calendar year. These assessments shall be deposited in the Fund. (2) The Authority shall adjust the assessment rate in each assessable year. The amount assessed shall not exceed reasonable projections regarding the amount necessary to support the operations of the Authority. (3) Each health carrier shall pay to the Authority the amount stated in the Notice of Assessment within 30 business days after the date of the Notice of Assessment. (4) Failure to pay the assessment in accordance with paragraph (3) of this subsection shall subject the health carrier to § 31-1204. (Mar. 2, 2012, D.C. Law 19-94, § 4, 59 DCR 213; Feb. 26, 2015, D.C. Law 20-155, § 5083, 61 DCR 9990; June 23, 2015, D.C. Law 21-13, § 2(b), 62 DCR 5946.)

D.C. Code § 31-3171.04 Authority duties and powers.

31-3171.04. Authority duties and powers. (a) The Authority shall: (1) Establish the American Health Benefit Exchange to assist qualified individuals in the District with enrollment in qualified health plans; (1A) Establish and operate a basic health program, established pursuant to section 1331 of the Federal Act (42 U.S.C. § 18051); (2) Establish a SHOP Exchange through which qualified employers may access coverage for their employees and shall enable any qualified employer to specify a level of coverage so that any of its employees may enroll in any qualified health plan offered through the SHOP Exchange at the specified level of coverage; (3) Certify plans as qualified health plans as set forth in § 31-3171.09 and make such plans available to qualified individuals and qualified employers, as required by the Federal Act, with effective dates on January 1, 2014; provided, that the Authority shall not make available any health benefit plan that is not a qualified health plan. (4) Have independent personnel authority to hire, retain, and terminate personnel as appropriate to perform the functions of the Authority consistent with Chapter 6 of Title 1 [§ l-601.01 et seq.], including establishing compensation and reimbursement consistent with the District’s wage grade and non-wage grade schedules; (5) Have procurement authority independent of the Office of Contracting and Procurement, and shall not be subject to Chapter 3A of Title 2 [§ 2-352.01 et seq.]; except, that § 2-352.02(a), (b), (c), and (e) shall apply. (6) Publish the average costs of licensing, regulatory fees, and any other payments required by the Authority, and the administrative costs of the Authority, on a website that is publically accessible, to educate consumers on these costs. This information shall include information on monies lost to waste, fraud, and abuse; (7) Implement procedures for certification, recertification, and decertification, consistent with guidelines developed by the Secretary under section 1311(c) of the Federal Act and of this chapter, of health benefit plans as qualified health plans; (8) Provide for the operation of a toll-free telephone hotline to respond to requests for assistance, utilizing staff who are trained to provide assistance in a culturally and linguistically appropriate manner; (9) Provide for enrollment periods, as provided under section 1311(c)(6) of the Federal Act; (10) Maintain a publically accessible website, through which enrollees and prospective enrollees of qualified health plans and dental plans may obtain standardized comparative information, including on health plan quality and performance, for such plans; (11) Assign a rating to each qualified health plan offered through the exchanges in accordance with the criteria developed by the Secretary under section 1311(c)(3) of the Federal Act, and determine each qualified health plan’s level of coverage in accordance with regulations issued by the Secretary under section 1302(d)(2)(A) of the Federal Act; (12) Use a standardized format for presenting health benefit options in the exchanges, including the use of the uniform outline of coverage established under section 2715 of the PHSA; (13) Conduct eligibility determinations, in accordance with section 1413 of the Federal Act for the Medicaid program under title XIX of the Social Security Act, the Children’s Health Insurance Program under title XXI of the Social Security Act, or any other applicable District program pursuant to the policies and procedures established by the Department of Health Care Finance; (14) Establish and make available, through a website that is publicly available, a calculator to determine the actual cost of coverage after application of any premium tax credit under section 36B of the Internal Revenue Code of 1986 and any cost-sharing reduction under section 1402 of the Federal Act, and, if feasible, which is designed to provide consumers with information on out-of-pocket costs for in-network and out-of-network services, taking into account any cost-sharing reductions; (15) Grant a certification, subject to section 1411 of the Federal Act, attesting that, for purposes of the individual responsibility penalty under section 5000A of the Internal Revenue Code of 1986, an individual is exempt from the individual responsibility requirement or from the penalty imposed by that section because: (A) There is no affordable qualified health plan available through the exchanges, or the individual’s employer, covering the individual; or (B) The individual meets the requirements for another exemption from the individual responsibility requirement or penalty; (16) Transfer to the Secretary of the United States Department of the Treasury the following: (A) A list of the individuals who are issued a certification under paragraph (15) of this subsection, including the name and taxpayer identification number of each individual; (B) The name and taxpayer identification number of each individual who was an employee of an employer who was determined to be eligible for the premium tax credit under section 36B of the Internal Revenue Code of 1986 because the employer: (i) Did not provide minimum essential coverage; or (ii) Provided the minimum essential coverage, but it was determined under section 36B(c)(2)(C) of the Internal Revenue Code of 1986 to either be unaffordable to the employee or did not provide the required minimum actuarial value; and (C) The name and taxpayer identification number of: (i) Each individual who notifies the Authority under section 1411(b)(4) of the Federal Act that he or she has changed employers; and (ii) Each individual who ceases coverage under a qualified health plan during a plan year and the effective date of the cessation; (17) Provide to each employer the name of each employee of the employer described in paragraph (16)(B) of this subsection who ceases coverage under a qualified health plan during a plan year and the effective date of the cessation; (18) Perform the duties required of the Authority by the Secretary, or the Secretary of the United States Department of the Treasury, related to determining eligibility for: (A) Premium tax credits; (B) Reduced cost-sharing; or (C) Individual responsibility requirement exemptions; (19) Select entities qualified to serve as Navigators in accordance with section 1311(i) of the Federal Act, and standards developed by the Secretary, and award grants to enable Navigators to: (A) Conduct public education activities to raise awareness of the availability of qualified health plans and qualified dental plans; (B) Distribute fair and impartial information concerning enrollment in qualified health plans and qualified dental plans, and the availability of premium tax credits under section 36B of the Internal Revenue Code of 1986 and cost-sharing reductions under section 1402 of the Federal Act; (C) Facilitate enrollment in qualified health plans and qualified dental plans; (D) Provide referrals to an office of health insurance consumer assistance or health insurance ombudsman, including the Office of Health Care Ombudsman and Bill of Rights, or any other appropriate District agency, for any enrollee with a grievance or question regarding his or her health benefit plan, coverage, or a determination under that plan or coverage; and (E) Provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the exchanges; (20) Review the rate of premium growth within and outside the exchanges and consider the information in developing recommendations on whether to continue limiting qualified employer status to small employers; (21) Consult with stakeholders relevant to carrying out the activities required under this chapter, including: (A) Educated health care consumers who are enrollees in qualified health plans or qualified dental plans; (B) Individuals and entities with experience in facilitating enrollment in qualified health plans or dental plans; (C) Representatives of small businesses and self-employed individuals; (D) The Department of Health Care Finance; (E) Individuals who have experience enrolling difficult-to-reach populations in public insurance programs; (F) Public health experts; (G) Health care providers; and (H) Office of Health Care Ombudsman and Bill of Rights; (22) Meet the following financial integrity requirements: (A) Keep an accurate accounting of all activities, receipts, and expenditures and annually submit to the Secretary, Mayor, Council, and the Commissioner a report of the accountings; (B) Fully cooperate with any investigation conducted by the Secretary pursuant to the Secretary’s authority under the Federal Act; (C) Allow the Secretary, in coordination with the Inspector General of the United States Department of Health and Human Services, to: (i) Investigate the affairs of the Authority; (ii) Examine the properties and records of the Authority; and (iii) Require periodic reports in relation to the activities undertaken by the Authority; and (D) In carrying out its activities under this chapter, not use any funds intended for the administrative and operational expenses of the Authority for: (i) Staff retreats; (ii) Promotional giveaways; (iii) Excessive executive compensation; or (iv) Promotion of federal or District legislative and regulatory modifications not contemplated under the Federal Act; and (23) Administer the hardship and affordability exemptions under Chapter 51 of Title 47. (b) In addition to certifying qualified health plans, the Authority shall allow a health carrier to offer a plan that provides limited scope dental benefits meeting the requirements of section 9832(c)(2)(A) of the Internal Revenue Code of 1986 through the exchanges, either separately or in conjunction with a qualified health plan, if the plan provides pediatric dental benefits meeting the requirements of section 1302(b)(1)(J) of the Federal Act. (c) Neither the Authority nor a health carrier offering qualified health plans through the exchanges may charge an individual a fee or penalty for termination of coverage if the individual enrolls in another type of minimum essential coverage because the individual has become newly eligible for that coverage or because the individual’s employer-sponsored coverage has become unaffordable under the standards of section 36B(c)(2)(C) of the Internal Revenue Code of 1986. (d) The operations of the Authority are subject to the provisions of this chapter whether the operations are performed directly by the Authority or through an entity under a contract with the Authority. (Mar. 2, 2012, D.C. Law 19-94, § 5, 59 DCR 213; Mar. 14, 2014, D.C. Law 20-94, § 3(a), 61 DCR 963; Oct. 30, 2018, D.C. Law 22-168, § 5003(a), 65 DCR 9388; Dec. 6, 2025, D.C. Law 26-55, § 5082(b), 72 DCR 9825.)

D.C. Code § 31-3171.05 Executive board establishment and membership.

31-3171.05. Executive board establishment and membership. (a) There is established an executive board to govern the Authority consisting of: (1) Seven voting members, who shall be residents of the District of Columbia, appointed by the Mayor, with the advice and consent of the Council pursuant to § 1-523.01(f). (2) Four nonvoting, ex-officio members, or their designees, who shall be the: (A) Director of the Department of Health Care Finance; (B) Commissioner of the Department of Insurance, Securities and Banking; (C) Director of the Department of Health; and (D) Director of the Department of Human Services. (b) (1) Members of the executive board, other than an ex-officio member, shall be appointed for a term of 4 years, except that for the initial appointments: (A) Two shall be for a term of 2 years; (B) One shall be for a term of 3 years; (C) Two shall be for a term of 4 years; and (D) Two shall be for a term of 5 years. (2) (A) A member of the executive board may continue to serve until his or her successor has been approved by the Council and appointed by the Mayor. (B) Vacancies shall be filled by Mayoral appointment for the unexpired term in the same manner of the original appointment. (C) A member of the executive board, upon findings by the Mayor, may be removed for incompetence, misconduct, or failure to perform the duties of the position. (c) (1) Each person appointed to the executive board as a voting member shall have demonstrated and acknowledged expertise in at least 2 of the following areas: (A) Individual or small employer health care coverage; (B) Health benefits plan administration; (C) Health care finance; (D) Administering a public or private health care delivery system; (E) Purchasing health plan coverage; (F) Prior experience in commercial insurance management; (G) Actuarial analysis; (H) Health care economics; (I) Human services administration; (J) Health care consumer interest advocacy; (K) Public health programs; or (L) Enrolling individuals into health benefit plans. (2) The Mayor shall consider the expertise of each of the members of the executive board and attempt to make appointments so that the executive board’s composition reflects a diversity of expertise. (3) At least one voting member of the executive board shall have demonstrated knowledge in health care consumer interest advocacy. (d) Each member of the executive board shall have the responsibility and duty to meet the requirements of this chapter, the Federal Act, and all applicable District and federal laws and regulations, to serve the public interest of the individuals and small businesses seeking health care coverage through the exchanges, and to ensure the operational effectiveness and fiscal solvency of the Authority. (e) The executive board shall elect a chairperson on an annual basis. (f) Executive board members shall receive no compensation for their services but shall receive actual and necessary expenses incurred in the performance of their official duties. (g) The Mayor shall nominate a majority of the executive board members within 90 days of March 2, 2012. (Mar. 2, 2012, D.C. Law 19-94, § 6, 59 DCR 213.)

D.C. Code § 31-3171.06 Powers and duties of executive board.

31-3171.06. Powers and duties of executive board. (a) Subject to any limitations under this chapter, or other applicable law, the executive board shall have all the powers necessary to carry out the functions authorized by the Federal Act and consistent with the purposes of the Authority. (b) The enumeration of specific powers in this chapter is not intended to restrict the executive board’s power to take any lawful action that it determines is necessary to carry out the functions authorized by the Federal Act and is consistent with the purposes of the Authority. (c) In addition to the powers set forth elsewhere in this chapter, the executive board may: (1) Adopt and alter an official seal; (2) Sue, be sued, plead, and be impleaded; (3) Adopt bylaws, rules, and policies; (4) Maintain an office in the District at a place designated by the executive board; (5) Enter into any agreements or contracts and execute the instruments necessary to manage its affairs and to carry out the purposes of this chapter; (6) Apply for and receive grants, contracts, or other public or private funding; and (7) Do all things necessary in conformity with the law to exercise the powers granted by this chapter. (d) (1) To carry out the purposes of this chapter or perform any of its functions under this chapter, the executive board may contract or enter into memoranda of understanding with eligible entities, including the: (A) Department of Health Care Finance; (B) Department of Human Services; (C) Department of Insurance, Securities and Banking; (D) Insurance producers and third-party administrators registered in the District; and (E) Any other entities that have experience in individual and small group public and private health insurance plans or in facilitating enrollment in those plans. (2) The executive board shall ensure that any entity under a contract with the Authority complies with the provisions of this chapter when performing services on behalf of the Authority that are subject to this chapter. (e) (1) The executive board may enter into information-sharing agreements with federal agencies, District agencies, agencies of one or more states, and other state health insurance exchanges to carry out the provisions of this chapter. (2) An information-sharing agreement entered into under paragraph (1) of this subsection shall: (A) Include adequate protections with respect to the confidentiality of information; and (B) Comply with all District and federal laws and regulations. (f) The executive board shall adopt written policies and procedures, which shall be made publicly accessible on the Authority’s website and published in the District of Columbia Register, governing all procurements of the Authority. (g) The executive board may limit the number of plans offered in the exchanges using selective criteria or contracting; provided, that individuals and employers have an adequate number and selection of choices. (h) The executive board may merge the exchanges for individual coverage within the American Health Benefits Exchange and the SHOP Exchange if a merger is considered by the Authority to be in the best interest of the District. (Mar. 2, 2012, D.C. Law 19-94, § 7, 59 DCR 213; Mar. 14, 2014, D.C. Law 20-94, § 3(b), 61 DCR 963.)

D.C. Code § 31-3171.07 Advisory board.

31-3171.07. Advisory board. (a) In addition to the executive board, there shall be a standing advisory board consisting of 9 members, who shall be residents of the District. (b) The executive board may create additional advisory boards as it considers appropriate. (c) The executive board shall solicit the recommendations of, and consult with, the advisory boards on: (1) Insurance standards; (2) Covered benefits; (3) Premiums; (4) Plan certification; (5) Internet technology system development; and (6) Any other policy or operational issues, within the executive board’s discretion. (d) The executive board shall: (1) Select the members of the advisory boards; (2) Establish the terms of the members; (3) Ensure that at least one member of the standing advisory board demonstrates expertise as a health insurance broker or agent; (4) Appoint the chair of the standing advisory board; (5) Determine the residency requirement of any additional advisory board created; and (6) Appoint the chair of any additional advisory boards created. (e) (1) An advisory board member may continue to serve until the appointment of his or her successor. (2) Vacancies shall be filled by appointment by the executive board for the unexpired term of the appointee’s predecessor. (f) Each person appointed to an advisory board shall have demonstrated and acknowledged expertise on issues related to at least one of the following groups: (1) Health professionals; (2) Health insurance consumers; (3) Disease and demographic-specific advocacy groups; (4) Commercial sector health plans; (5) Public sector health plans; (6) Health insurance brokers; (7) Health care consumer interest advocacy; (8) Health care foundations; (9) Exchange consumers; or (10) Such other interests considered necessary. (Mar. 2, 2012, D.C. Law 19-94, § 8, 59 DCR 213.)

D.C. Code § 31-3171.08 Executive director and Authority staff.

31-3171.08. Executive director and Authority staff. (a) The executive board shall hire an executive director within 60 days of a majority of executive board members being confirmed to organize, administer, and manage the operations of the Authority. (1) The executive director shall not be an employee in the career service and shall serve at the pleasure of the executive board. (2) The executive director shall become a resident of the District within 180 days of the date of hire. (b) The executive board shall determine the appropriate compensation for the executive director; provided, that the executive director’s compensation shall not exceed the maximum allowable salary in the District of Columbia Excepted Service salary schedule. (c) Under the direction of the executive board, the executive director shall; (1) Be the chief administrative officer of the Authority; (2) Direct, administer, and manage the operations of the Authority; and (3) Perform all duties necessary to comply with and carry out the provisions of this chapter, other District laws and regulations, and the Federal Act. (d) (1) The executive director may employ and retain staff for the Authority. (2) The executive director may retain as independent contractors or employees, and set compensation for: (A) Attorneys; (B) Financial consultants; and (C) Other professionals or consultants necessary to carry out the planning, development, and operations of the Authority and the provisions of this chapter. (3) Employee compensation shall not exceed the maximum allowable salary in the District of Columbia Excepted Service salary schedule. (e) Except as otherwise provided in this chapter, an employee or independent contractor of the Authority shall not be subject to any law, regulation or Mayor’s Order governing District government compensation, including furloughs, pay cuts, or any other general fund cost-saving measure. (Mar. 2, 2012, D.C. Law 19-94, § 9, 59 DCR 213.)

D.C. Code § 31-3171.09 Health benefit plan certification.

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; (F) Provides accurate attestations as required in the initial certification process; (G) Offers one or more standardized plans that meet the criteria developed by the executive board for the Authority, at each metal level in which the carrier is participating, in addition to other plans the carrier may offer; 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.)

D.C. Code § 31-3171.09a Distribution of individual and small group health benefit plans.

31-3171.09a. Distribution of individual and small group health benefit plans. (a) A carrier that offers individual or small group health benefit plans shall offer such plans solely through the American Health Benefit Exchange, as established pursuant to § 31–3171.04(a), subject to the following transition provisions: (1) Individual health benefit plans with plan years beginning on or after January 1, 2014, shall be offered solely through the American Health Benefit Exchange; (2) On or after January 1, 2014, small group health benefit plans offered to any small business that was not insured as of December 31, 2013, shall be offered and issued solely through the American Health Benefit Exchange; (3) Small group health benefit plans offered to or renewed by any small business that was insured as of December 31, 2013, may be issued or renewed during calendar year 2014 through existing distribution channels with the same carrier or a new carrier, except that such plans shall meet the qualifications for certification of a qualified health plan as provided in § 31-3171.09; and (4) Unless the Council acts by October 1, 2014 to change the date that all small group health plans shall be offered, issued, or renewed through the American Health Benefit Exchange, on or after January 1, 2015, all small group health benefit plans shall be offered and issued or renewed solely through the American Health Benefit Exchange. (b) The requirements of this section shall not apply to grandfathered health plans as defined in section 1251 of the Federal Act. (Mar. 2, 2012, D.C. Law 19-94, § 10a; as added July 16, 2014, D.C. Law 20-123, § 2(c), 61 DCR 5379.)

D.C. Code § 31-3171.09b Sale, solicitation, and negotiation by insurance producers.

31-3171.09b. Sale, solicitation, and negotiation by insurance producers. (a) An insurance producer that is licensed in the District and authorized by the Commissioner to sell, solicit, or negotiate health insurance pursuant to Chapter 11A of Title 31 [§ 31-1131.02 et seq.], may sell any qualified health plan offered in the American Health Benefit Exchange, after satisfactorily completing training developed and provided by the Authority. (b) An insurance producer shall be compensated directly by a health carrier for the sale of a qualified health plan offered in the American Health Benefit Exchange. (Mar. 2, 2012, D.C. Law 19-94, § 10b; as added July 16, 2014, D.C. Law 20-123, § 2(c), 61 DCR 5379.)

D.C. Code § 31-3171.10 Conflicts of interest.

31-3171.10. Conflicts of interest. (a) (1) A member of the executive board or of the staff of the Authority shall not be employed by, a consultant to, a member of the board of directors of, affiliated with, or otherwise a representative of, a health carrier or other insurer, an agent or broker, a health professional, or a health care facility or health clinic while serving on the board or on the staff of the Authority. (2) A member of the executive board or of the staff of the Authority shall not be a member, a board member, or an employee of a trade association of health carriers, health facilities, health clinics, or health professionals while serving on the board or on the staff of the Authority. (3) A member of the executive board or of the staff of the Authority shall not be a health professional unless he or she receives no compensation for rendering services as a health professional and does not have an ownership interest in a professional health care practice. (b) No member of the executive board or of the staff of the Authority shall, for one year after the end of the member’s service on the board or employment by the Authority, accept employment with any health carrier that offers a qualified health benefit plan through the exchanges. (c) No member of the executive board shall make, participate in making, or in any way attempt to use his or her official position to influence the making of any decision that he or she knows or has reason to know will have a reasonably foreseeable material financial effect, distinguishable from its effect on the public generally, on him or her or a member of his or her immediate family, or on either of the following: (1) Any source of income, other than gifts and other than loans by a commercial lending institution in the regular course of business on terms available to the public without regard to official status, aggregating $250 or more in value provided to, received by, or promised to the member within 12 months prior to the time when the decision is made. (2) Any business entity in which the member is a director, officer, partner, trustee, or employee, or holds any position of management. (Mar. 2, 2012, D.C. Law 19-94, § 11, 59 DCR 213.)

D.C. Code § 31-3171.11 Open meetings.

31-3171.11. Open meetings. The executive and advisory boards shall be subject to subchapter IV of Chapter 5 of Title 2 [§ 2-571 et seq.]; except, that the executive board may hold closed sessions when considering matters related to litigation, personnel, contracting, or rates. (Mar. 2, 2012, D.C. Law 19-94, § 12, 59 DCR 213.)

D.C. Code § 31-3171.12 Limitation of liability.

31-3171.12. Limitation of liability. There shall not be any liability, in a private capacity, on the part of the executive or advisory board members, or any officer, or employee of the executive or advisory board, for or on account of any act performed or obligation entered into in an official capacity when done in good faith, without intent to defraud, and in connection with the administration, management, or conduct of this chapter or affairs related to this chapter. (Mar. 2, 2012, D.C. Law 19-94, § 13, 59 DCR 213.)

D.C. Code § 31-3171.13 Relation to other laws.

31-3171.13. Relation to other laws. (a) Nothing in this chapter, and no action taken by the Authority pursuant to this chapter, shall be construed to preempt or supersede the authority of the Commissioner to regulate the business of insurance within the District. Except as expressly provided to the contrary in this chapter, all health carriers offering qualified health plans and qualified dental plans in the District shall comply fully with all applicable health insurance laws of the District and regulations adopted and orders issued by the Commissioner. (b) Nothing in this chapter, and no action taken by the Authority pursuant to this chapter, shall be construed to preempt or supersede the authority of the Department of Health Care Finance, as the single state agency, to establish policy and enforce the rules and regulations governing Titles XIX and XXI of the Social Security Act and other health-care programs under its jurisdiction. (Mar. 2, 2012, D.C. Law 19-94, § 14, 59 DCR 213.)

D.C. Code § 31-3171.14 Powers of the Mayor.

31-3171.14. Powers of the Mayor. Notwithstanding any other provision of this chapter, all powers and authority vested by this chapter in the Authority shall remain with the Mayor until: (1) A majority of members of the executive board have been confirmed by the Council; and (2) The executive board has hired an executive director. (Mar. 2, 2012, D.C. Law 19-94, § 15, 59 DCR 213.)

D.C. Code § 31-3171.15 Dissolution of the Authority.

31-3171.15. Dissolution of the Authority. Upon dissolution, liquidation, or other termination of the Authority: (1) All rights and properties of the Authority shall pass to and be vested in the District, subject to the rights of lien holders and other creditors; (2) Any net earnings of the Authority, beyond that necessary for retirement of any indebtedness or to implement a public purpose or program of the District authorized under this chapter, shall not inure to the benefit of any person other than the District; (3) The expenditure of any net earnings shall be restricted to costs related to the direct delivery of health care to residents of the District. (Mar. 2, 2012, D.C. Law 19-94, § 16, 59 DCR 213.)

D.C. Code § 31-3171.16 Implementation and reports.

31-3171.16. Implementation and reports. (a) The executive board shall: (1) Study, in consultation with the advisory boards established under this chapter and with other stakeholders: (A) The feasibility and desirability of the Authority engaging in: (i) Selective contracting, either through competitive bidding or a negotiation process similar to that used by large employers, to reduce health care costs and improve quality-of-care by certifying only those health benefit plans that meet certain requirements, such as: (I) Promoting patient-centered medical homes; (II) Adopting electronic health records; (III) Meeting minimum outcome standards; (IV) Implementing payment reforms to reduce medical errors and preventable hospitalizations; (V) Reducing disparities; (VI) Ensuring adequate reimbursements; (VII) Enrolling high-risk members and underserved populations; (VIII) Managing chronic conditions and promoting healthy consumer lifestyles; (IX) Value-based insurance design; (X) Adhering to transparency guidelines; and (XI) Uniform price and quality reporting; (ii) Multistate contracting; and (iii) Entering into a regional exchange; (B) The rules under which health benefit plans should be offered inside and outside the exchanges in order to mitigate adverse selection and encourage enrollment in the exchanges, including: (i) Whether any benefits should be required of qualified health plans beyond those mandated by the Federal Act, and whether any such additional benefits should be required of health benefit plans offered outside the exchanges; (ii) Whether health carriers offering health benefit plans outside the exchanges should be required to offer either all the same health benefit plans inside the exchanges or, alternatively, at least one health benefit plan inside the exchanges; (iii) Whether managed care organizations with Health Choice contracts should be required to offer products inside the exchanges; (iv) Whether health carriers offering health benefit plans inside the exchanges should be required to also participate in the District medical assistance program; and (v) Which provisions applicable to qualified health plans should be made applicable to qualified dental plans; (C) The design and operation of the Authority’s Navigator program and any other appropriate consumer-assistance mechanisms, including: (i) How the Navigator program could utilize, interact with, or complement private-sector resources, including insurance producers; (ii) The infrastructure of the existing private sector health insurance distribution system in the District to determine whether private sector resources may be available and suitable for use by the Authority; (iii) The effect the exchanges may have on private sector employment in the health insurance distribution system in the District; (iv) What functions, in addition to those required by the Federal Act, should be performed by Navigators; (v) What training and expertise should be required of Navigators, and whether different markets and populations require Navigators with different qualifications; (vi) How Navigators should be retained and compensated, and how disparities between Navigator compensation and the compensation of insurance producers outside the exchanges can be minimized or avoided; (vii) How to ensure that Navigators provide information in a manner culturally, linguistically, and otherwise appropriate to the needs of the diverse populations served by the Authority, and that Navigators have the capacity to meet these needs; and (viii) What other means of consumer assistance may be appropriate and feasible, and how they should be designed and implemented; (D) The design and function of the SHOP Exchange beyond the requirements of the Federal Act, to promote quality, affordability, and portability, including: (i) Whether it should be a defined contribution/employee choice model or whether employers should choose the qualified health plan to offer their employees; (ii) Whether the current individual and small group markets should be merged; and (iii) Whether the SHOP Exchange should be made available to employers with 50 to 100 employees prior to 2016, as authorized by the Federal Act; (E) How the Authority will ensure financial integrity in compliance with the Federal Act, including: (i) A recommended plan for the budget of the Authority; (ii) The user fees, licensing fees, or other assessments that should be imposed by the Authority to fund its operations, including what type of user fee cap or other methodology would be appropriate to ensure that the income of the Authority comports with the expenditures of the Authority; and (iii) A recommended plan for how to prevent fraud, waste, and abuse; and (F) How the Authority should conduct its public relations and advertising campaign, including what type of solicitation, if any, of individual consumers or employers, would be desirable and appropriate; and (2) Report its findings under paragraph (1) of this subsection to the Mayor, Council, and public within 180 days of March 2, 2012. (b) (1) The executive board shall prepare a plan that identifies how the Authority will be financially self-sustaining by January 1, 2015. (2) The plan, which shall be certified by an independent actuary as actuarially sound, shall be submitted to the Mayor and Council not later than December 15, 2013. (Mar. 2, 2012, D.C. Law 19-94, § 17, 59 DCR 213.)

D.C. Code § 31-3171.17 Rules.

31-3171.17. Rules. (a) The Authority, pursuant to subchapter I of Chapter 5 of Title 2 [§ 2-501 et seq.], shall issue rules to implement the provisions of this chapter and as authorized by § 47-5109. (b) The Authority shall submit all proposed rules adopted by the Authority to the Council for a 30-day period of review, excluding Saturdays, Sundays, legal holidays, and days of Council recess. If the Council does not approve or disapprove the proposed rules, in whole or in part, by resolution, within this 30-day review period, the proposed rules shall be deemed approved. (c) Regulations promulgated under this section shall not conflict with or prevent the application of regulations promulgated by the Secretary under the Federal Act. (Mar. 2, 2012, D.C. Law 19-94, § 18, 59 DCR 213; Oct. 30, 2018, D.C. Law 22-168, § 5003(b), 65 DCR 9388.)

Source: Council of the District of Columbia (code.dccouncil.gov)URL: https://code.dccouncil.gov/us/dc/council/code/titles/31/chapters/31DFetched: 10/21/2026