Health Insurance Benefit Coverage Law Summaries

The District of Columbia's mandated health care law is located in the District of Columbia Code Annotated at Title 35.

WHAT THE EMPLOYER MUST DO

The District of Columbia does not require employers to provide health insurance for their employees. However, if an employer does provide insurance, it must be aware of specific coverage required to be included in health insurance policies and contracts. This coverage is summarized below.

Mental health coverage. --All group health insurance policies providing coverage on an expenses-incurred basis, and group service or indemnity-type contracts issued by a nonprofit health service plan must provide coverage for the medical and psychological treatment of mental illness. This provision applies only to policies or contracts issued in the District to cover individuals who are residents of, or employed in, the District (Sec. 35-2302).

Group health insurance policies or contracts that are the result of collective bargaining between a legally certified union and the employer are required to include coverage for inpatient and outpatient treatment of mental illness (Sec. 35-2302).

All individual subscriber contracts and policies must also offer at least minimum-level coverage (see below) for the medical and psychological treatment of mental illness (Sec. 35-2302). Health maintenance organizations likewise are required to offer such coverage (Sec. 35-2310).

Coverage and benefits for mental illness must be provided to employees of the District and their dependents who are insured through the District of Columbia Employees' Health Benefits Program. Supplemental coverage and benefits that comply with the requirements for mental illness outlined below must also be provided to District employees and their dependents who are insured through the Federal Employees' Health Benefits Program (Sec. 35-2311).

Covered benefits for mental illness in insurance policies and contracts are limited to inpatient, residential, and outpatient services certified as necessary by a physician, psychologist, advanced practice registered nurse, or social worker (Sec. 35-2302).

Before an insured party may qualify to receive benefits for treatment of mental illness, a physician, psychologist, advanced practice registered nurse, or social worker must certify that the individual is suffering from mental illness and prescribe appropriate treatment, which may include referral to other treatment providers. All mental illness treatment or services eligible for health insurance coverage are subject to peer review procedures (Sec. 35-2302).

Coverage for mental illness is limited to treatment of clinically significant mental illnesses identified in the most recent edition of the International Classification of Diseases or of the Diagnostic and Statistical Manual of the American Psychiatric Association. Treatment will be covered for a minimum of 45 days per year for inpatient or residential care in a hospital or nonhospital residential facility, and at a minimum rate of 75 percent for the first 40 outpatient visits per year and at a minimum rate of 60 percent for any outpatient visits thereafter for that year (Sec. 35-2304). These inpatient and outpatient benefits must be provided with a lifetime payment limit of not less than $80,000 or one-third of the lifetime maximum for physical illness, whichever is greater (Sec. 35-2305).

Methods of determining levels of payment or reimbursement for services, or for the type of facility charge eligible for payment or reimbursement for mandated mental illness coverage, must be consistent with those for physical illnesses in general and must take into consideration usual, customary, and reasonable charges for those services (Sec. 35-2305).

Exceptions. --Coverage of mental illness need not be provided, however, in the following: Medicare supplement policies, accident-only policies, dread disease policies, student accident policies, nursing home policies, and home health care policies (Sec. 35-2302).

Dependent care coverage. --All individual and group health insurance policies providing coverage on an expense-incurred basis and individual and group service-or indemnity-type contracts issued by a nonprofit health service plan must provide that health insurance benefits are payable with respect to a newly born child of the insured or subscriber from the moment of birth (Sec. 35-1101).

The coverage for dependent children up to 18 years of age must include (Sec. 35-1102):

(1) coverage for injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects, birth abnormalities, and prematurity; and

(2) coverage for preventive and primary care services, including physical examinations, measurements, sensory screening, neuropsychiatric evaluation, and development screening, which coverage must include unlimited visits for children up to the age of 12 years, and three visits per year for minor children ages 12 years up to 18 years of age. Preventive and primary care services must also include, as recommended by the physician, hereditary and metabolic screening at birth, immunizations, urinalysis, tuberculin tests, and hematocrit, hemoglobin, and other appropriate blood tests, including tests to screen for sickle hemoglobinopathy.

Exceptions. --Specifically excluded from the coverage requirements for dependents outlined above are Medicare Supplement insurance policies, accident only policies, dread disease policies, student accident policies, nursing home policies, and home health care policies (Sec. 35-1105).

Habilitative services. --A health insurer shall (1) provide coverage of habilitative services for children under the age of 21 years and may do so through a managed care system; (2) not be required to provide reimbursement for habilitative services actually delivered through early intervention or school services; and (3) provide notice to its insureds and enrollees about this required coverage. The coverage shall not be more restrictive than coverage provided for any other illness, condition, or disorder for purposes of determining deductibles, benefit year or lifetime durational limits, benefit year or lifetime dollar limits, lifetime episodes or treatment limits, copayment and coinsurance factors, and benefit year maximum for deductibles and copayments and coinsurance factors (Title 31, Subtitle N, Ch. 35A, Sec. 31-3542, as added by B. 711, L. 2005, enacted October 23, 2006).

Substance abuse coverage. --All group health insurance policies providing coverage on an expenses-incurred basis, and group service or indemnity-type contracts issued by a nonprofit health service plan must provide coverage for the medical and psychological treatment of drug abuse and alcohol abuse. This provision applies only to policies or contracts issued in the District to cover individuals who are residents of, or employed in, the District (Sec. 35-2302).

Group health insurance policies or contracts that are the result of collective bargaining between a legally certified union and the employer are required to include coverage for inpatient and outpatient treatment of drug and alcohol abuse (Sec. 35-2302).

All individual subscriber contracts and policies must also offer at least minimum-level coverage (see below) for the medical and psychological treatment of drug and alcohol abuse (Sec. 35-2302). Health maintenance organizations are likewise required to offer such coverage (Sec. 35-2310).

Coverage and benefits for drug and alcohol abuse must be provided to employees of the District and their dependents who are insured through the District of Columbia Employees' Health Benefits Program. Supplemental coverage and benefits that comply with the requirements for drug and alcohol abuse coverage outlined below must also be provided to District employees and their dependents who are insured through the Federal Employees' Health Benefits Program (Sec. 35-2311).

Covered benefits for drug and alcohol abuse in insurance policies and contracts are limited to inpatient, residential, and outpatient services certified as necessary by a physician, psychologist, advanced practice registered nurse, or social worker (Sec. 35-2302).

Before an insured party may qualify to receive benefits for treatment of drug or alcohol abuse, a physician, psychologist, advanced practice registered nurse, or social worker must certify that the individual is suffering from drug or alcohol abuse and prescribe appropriate treatment, which may include referral to other treatment providers. All drug and alcohol abuse treatment or services eligible for health insurance coverage are subject to peer review procedures (Sec. 35-2302).

Covered drug and alcohol abuse benefits are limited to coverage of treatment of clinically significant substance use disorders identified in the most recent edition of the International Classification of Diseases or of the Diagnostic and Statistical Manual of the American Psychiatric Association (Sec. 35-2303).

The process whereby a person who is intoxicated by or dependent on drugs or alcohol or both is assisted through the period of time necessary to eliminate the intoxicating agent from the body, while keeping the physiological risk to the patient at a minimum, is a covered benefit. Such treatment must be covered for a minimum of 12 days annually (Sec. 35-2303).

Additional treatment as a covered benefit for drug or alcohol abuse must be provided by a hospital, a nonhospital residential facility, an outpatient treatment facility, a physician, a psychologist, an advanced practice registered nurse, or a social worker, and must include inpatient services, outpatient services, or any combination of these, certified as necessary by a physician, psychologist, advanced practice registered nurse, or social worker. Such treatment must be covered for a minimum of 28 days per year for inpatient or residential care in a hospital or nonhospital residential facility, and for a minimum of 30 outpatient visits per year (Sec. 35-2303).

Treatment regimens that include psychiatric, psychological, and other prescribed interventions are also a covered benefit (Sec. 35-2303).

Methods of determining levels of payment or reimbursement for services, or for the type of facility charge eligible for payment or reimbursement for mandated drug and alcohol abuse coverage, must be consistent with those for physical illnesses in general and must take into consideration usual, customary, and reasonable charges for those services (Sec. 35-2305).

Exceptions. --Coverage of drug and alcohol abuse need not be provided in the following: Medicare supplement policies, accident-only policies, dread disease policies, student accident policies, nursing home policies, and home health care policies (Sec. 35-2302).

Preexisting conditions. --A health insurer offering group health insurance coverage may, with respect to a participant or beneficiary, impose a preexisting limitation only if (1) such exclusion relates to a condition (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within the six-month period ending on the enrollment date; (2) such exclusion extends for a period of not more than 12 months (or 18 months in the case of a late enrollee) after the enrollment date; and (3) the period of any such preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage, if any, applicable to the participant or beneficiary as of the enrollment date (Sec. 35-1037, as added by D.C. Act 12-496, L. 1998).

A group health plan and a health insurer offering health insurance coverage may not impose any preexisting condition exclusion (1) in the case of an individual who, as of the last day of the 30-day period beginning with the date of birth, is covered under creditable coverage; (2) in the case of a child who is adopted or placed for adoption before attaining 18 years of age and who, as of the last day of the 30-day period beginning on the date of the adoption or placement for adoption, is covered under creditable coverage; or (3) relating to pregnancy as a preexisting condition. Items (1) and (2) just above will no longer apply to an individual after the end of the first 63-day period during all of which the individual was not covered under any creditable coverage (Sec. 35-1037, as added by D.C. Act 12-496, L. 1998).

Mammograms. --Any group health benefit plan, including Medicaid, shall provide health insurance benefits to cover a baseline mammogram for women and an annual screening mammogram for women. Such benefits must not be subject to an annual or coinsurance deductible (Sec. 31-2902, as amended by D.C. Law 15-291).

Cervical cancer screenings. --Any group health benefit plan, including Medicaid, shall provide health insurance benefits to cover annual cervical cytologic screening for women and cervical cytologic screening for women upon certification by an attending physician that the test is medically necessary. Such benefits must not be subject to an annual or coinsurance deductible (Sec. 31-2902, as amended by D.C. Law 15-291).

Colorectal cancer screenings. --Group health insurance policies must provide coverage for colorectal cancer screening for policyholders residing in the District (Sec. 2, D.C. Law 14-100, effective April 13, 2002).

Emergency services. --All health insurers, hospitals or medical services corporations, and HMOs must reimburse for emergency services that are due to a medical emergency. Reimbursement for such services may not be denied solely because the member failed to obtain preauthorization (Sec. 35-4802, as added by D.C. Act 12-356, L. 1998).

Genetic information/testing. --The Human Rights Act of 1977 generally prohibits health benefit plans and health insurers from using genetic information as a condition of eligibility or in setting premium rates. Also, health benefit plans and health insurers may not request or require genetic testing (Sec. 2-1402.31, as amended by B. 52 (Act No. 648, Law No. 263), L. 2003, effective April 5, 2005).

WHO TO CONTACT

Contact the Insurance Administration at 441 4th St., NW, 8th Floor North, Washington, DC 20001. Telephone: (202) 727-8000; Fax: (202) 727-7940).

This is a summary of Health Insurance Benefit Coverage Laws in the District of Columbia.