§ 31–3105. Exemptions.

(a) Methods of determining levels of payment or reimbursement for services, or for the type of facility charge eligible for payment or reimbursement under this chapter, and shall be consistent with those for physical illnesses in general and shall take into consideration usual, customary, and reasonable charges for those services. Except as otherwise provided in § 31-3104, deductible or copayment plans, and limits on total amounts payable to an individual in a calendar year or lifetime payment limits, may be applied; provided, that the inpatient and outpatient benefits set forth in § 31-3104 shall be provided for health plans issued in the individual market and small group market with a lifetime payment limit of not less than $80,000 or 1/3 of the lifetime maximum for physical illness, whichever is greater; provided further, that for health plans issued in the large group market, the inpatient and outpatient benefits set forth in § 31-3104 shall be applied with the same lifetime and annual limits for medical, surgical, and mental benefits.

(b) If the cost of complying with the mental health benefits provisions of subsection (a) of this section for large group markets result in at least a 1% increase in the cost of the plan, the group health plan (or health benefit plan or certificate offered in connection with a group health plan) shall be exempt from complying with those mental health benefits parity provisions.

(c) If a group health plan is exempt from complying with the mental health benefits parity provisions under subsection (b) of this section, it shall comply with the individual and small group market requirements.

(d) Nothing in this section shall be construed as requiring health maintenance organizations to provide a greater level of covered benefits than the level required of health insurers.

(e) Repealed.

(Feb. 28, 1987, D.C. Law 6-195, § 6, 34 DCR 491; Mar. 16, 1993, D.C. Law 9-192, § 2(c), 39 DCR 9007; Oct. 21, 2000, D.C. Law 13-178, § 2(c), 47 DCR 6844; Mar. 8, 2007, D.C. Law 16-232, § 203, 54 DCR 368; Mar. 8, 2007, D.C. Law 16-242, § 2(e), 54 DCR 601.)

Prior Codifications

1981 Ed., § 35-2305.

Effect of Amendments

D.C. Law 13-178 rewrote this section.

D.C. Law 16-232, repealed subsec. (e), which formerly read:

“(e) The mental parity provisions in this section shall not apply to benefits for services furnished after September 29, 2001, unless these provisions are re-enacted.”

D.C. Law 16-242, in subsec. (b), substituted “health benefit plan or certificate” for “health insurance”; and, in subsec. (d), substituted “health insurers” for “insurers”.

Emergency Legislation

For temporary amendment of section, see §§ 2(c) and (d) of the Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage Emergency Amendment Act of 1998 (D.C. Act 12-274, February 19, 1998, 45 DCR 1526).

For temporary repeal of section, see § 2(c) of the Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage Second Emergency Amendment Act of 1998 (D.C. Act 12-546, December 24, 1998, 45 DCR 497).

For temporary addition of § 35-2305.1 1981 Ed., see § 2(d) of the Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage Second Emergency Amendment Act of 1998 (D.C. Act 12-546, December 18, 1998, 46 DCR 497).

Temporary Legislation

For temporary (225 day) repeal of section, see § 2(c) of Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage Temporary Amendment Act of 1998 (D.C. Law 12-108, May 8, 1998, law notification 46 DCR 3259).

For temporary (225 day) addition, see § 2(d) of Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage Temporary Amendment Act of 1998 (D.C. Law 12-108, May 8, 1998, law notification 46 DCR ).

Section 2(d) of D.C. Law 12-108 was amended by D.C. Law 12-264, § 38, April 20, 1999, 46 DCR 2118.

Editor's Notes

Because of the prior expiration of certain provisions of this section required by subsection (e) of this section, section 203(a) of D.C. Law 16-232 provided that “subsections (a) through (d) are hereby revived.”