Chapter 31. Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Coverage.

§ 31–3101. Definitions.

For the purposes of this chapter, the term:

(1) “Alcohol abuse” means any pattern of pathological use of alcohol that causes impairment in social or occupational functioning, or that produces physiological dependency evidenced by physical tolerance or by physical symptoms when it is withdrawn.

(1A) “Advanced practice registered nurse” means a person licensed as a registered nurse and certified as an advanced practice registered nurse pursuant to the District of Columbia Health Occupations Revisions Act of 1985 Amendment Act of 1994 or by the state or territory where the person practices as an advanced practice registered nurse.

(2) “Clinically significant” means sufficient to impair substantially a person’s judgment, behavior, capacity to recognize, or ability to cope with the ordinary demands of life.

(2A) “Commissioner” means the Commissioner of the Department of Insurance, Securities, and Banking.

(3) “Council” means the Council of the District of Columbia.

(4) “Covered benefits” means the health-care services or treatment available to:

(A) An insured party under a health benefits plan or certificate for which the health insurer will pay part or all of the cost;, or

(B) A member of a health maintenance organization as part of the membership contract.

(5) “District” means the District of Columbia.

(6) “Drug abuse” means any pattern of pathological use of a drug that causes impairment in social or occupational functioning, or that produces physiological dependency evidenced by physical tolerance or by physical symptoms when it is withdrawn.

(6A) “Health benefits plan” means any accident and health insurance policy or certificate, hospital and medical services corporation contract, health maintenance organization subscriber contract, plan provided by another benefit arrangement. The term “health benefit plan” does not mean accident only, credit, or disability insurance; coverage of Medicare services or federal employee health plans, pursuant to contracts with the United States government; Medicare supplemental or long-term care insurance; dental only or vision only insurance; specified disease insurance; hospital confinement indemnity coverage; limited benefit health coverage; coverage issued as a supplement to liability insurance, insurance arising out of a workers’ compensation or similar law; automobile medical payment insurance; medical expense and loss of income benefits; or insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.

(6B) “Health insurer” means any person that provides one or more health benefit plans or insurance in the District of Columbia, including an insurer, a hospital and medical services corporation, a fraternal benefit society, a health maintenance organization, a multiple employer welfare arrangement, or any other person providing a plan of health insurance subject to the authority of the Commissioner.

(7) “Health maintenance organization” or “HMO” means any person that undertakes to provide or arrange for the delivery of basic health care services to enrollees on a prepaid basis, except for enrollees responsibility for co-payments and deductibles, and qualifies as a health maintenance organization under Chapter 34 of Title 31.

(8) “Hospital” means a facility licensed as a hospital by the District or by any state or territory of the United States or operated by the District, any state or territory, or the United States.

(8A) “Individual market” means the market for health insurance coverage offered to individuals other than in connection with a group health plan.

(9) “Inpatient services” means therapeutic services that are medically or psychologically necessary and that are provided in a hospital or a nonhospital residential facility to patients admitted to the hospital or nonhospital residential facility.

(10) Repealed.

(10A)(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, approved 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.

(10B) “Large group market” means the health insurance market under which individuals obtain health insurance coverage (directly or through any arrangement) on behalf of themselves and their dependents through a group health plan maintained by a large employer.

(10C) “Managed care system” means a method that a health insurer uses to review and preauthorize a treatment plan that a health care practitioner develops for a covered person using a variety of cost containment methods to control utilization, quality and claims.

(11) “Mayor” means the Mayor of the District of Columbia.

(11A) “Medical or surgical benefits” means benefits with respect to medical or surgical services as defined under the terms of the plan or coverage, but does not include mental health benefits.

(12) “Medically or psychologically necessary” means essential for the treatment of drug abuse, alcohol abuse, or mental illness, as determined by a physician, psychologist, or social worker.

(12A) “Mental health benefits” means benefits with respect to mental health services, as defined under the terms of the plan or coverage, but does not include benefits with respect to treatment of substance abuse or chemical dependency.

(13) “Mental illness” means any psychiatric disease identified in the most recent edition of the International Classification of Diseases or of the American Psychiatric Association Diagnostic and Statistical Manual.

(14) “Nonhospital residential facility” means a facility certified by the District or by any state or territory of the United States as a qualified nonhospital provider of treatment for drug abuse, alcohol abuse, mental illness, or any combination of these, in a residential setting. The term “nonhospital residential facility” includes any facility operated by the District, any state or territory, or the United States to provide these services in a residential setting.

(15) “Outpatient services” means therapeutic services that are medically or psychologically necessary and that are provided to a patient according to an individualized treatment plan that does not require the patient’s admission to a hospital or a nonhospital residential facility. The term “outpatient services” refers to services that may be provided in a hospital, a nonhospital residential facility, an outpatient treatment facility, or the office of a licensed physician, psychologist, or social worker.

(16) “Outpatient treatment facility” means a clinic, counseling center, or other similar location that is certified by the District or by any state or territory as a qualified provider of outpatient services for the treatment of drug abuse, alcohol abuse, or mental illness. The term “outpatient treatment facility” includes any facility operated by the District, any state or territory, or the United States to provide these services on an outpatient basis.

(17) “Peer review” means a system based on written procedures and formally established within the professions of medicine or any of its specialties, psychology, or social work in which a committee of licensed practitioners of the profession reviews another practitioner’s diagnosis and treatment in a specific case and reaches conclusions and recommendations concerning the accuracy of the diagnosis, and the necessity, appropriateness, and effectiveness of the treatment provided and proposed by the practitioner compared to alternative treatments. For the purposes of § 31-3110, the term “peer review” shall also mean the professional utilization procedure or any similar procedure employed by health maintenance organizations.

(18) “Physician” means a person licensed to practice medicine by the District pursuant to the District of Columbia Health Occupations Revision Act of 1985 or by the state or territory where the person practices medicine.

(19) “Psychologist” means a person licensed to practice psychology by the District pursuant to the District of Columbia Health Occupations Revision Act of 1985 or by the state or territory where the person practices psychology.

(19A)(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:

(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 the employer is reasonably expected to employ in the current calendar year.

(19B) “Small group market” means the health insurance market under which individuals obtain health insurance coverage (directly or through any arrangement) on behalf of themselves and their dependents through a group health plan maintained by a small employer.

(20) “Social worker” means a person licensed as an independent clinical social worker by the District pursuant to § 3-1208.04, or who is licensed to practice social work with authority to engage in the independent practice of psychotherapy by the state or territory where the person practices social work.

(21) Repealed.

(22) “Supplemental benefit” means health insurance coverage provided by the District to its employees in addition to the coverage provided through the Federal Employees Health Benefits Plan pursuant to § 1-621.01.

(Feb. 28, 1987, D.C. Law 6-195, § 2, 34 DCR 491; Mar. 23, 1995, D.C. Law 10-247, § 3, 42 DCR 457; May 21, 1997, D.C. Law 11-268, § 10(w), 44 DCR 1730; Mar. 24, 1998, D.C. Law 12-81, § 33, 45 DCR 745; Oct. 21, 2000, D.C. Law 13-178, § 2(a), 47 DCR 6844; June 18, 2003, D.C. Law 14-312, § 501, 50 DCR 306; June 11, 2004, D.C. Law 15-166, § 4(r), 51 DCR 2817; Mar. 8, 2007, D.C. Law 16-242, § 2(a), 54 DCR 601; May 2, 2015, D.C. Law 20-265, § 102, 62 DCR 1529.)

Prior Codifications

1981 Ed., § 35-2301.

Effect of Amendments

D.C. Law 13-178 added definitions contained in pars. (8A), (10A), (11A), (12A), (19A) and (19B).

D.C. Law 14-312 rewrote par. (7) which had read as follows: “(7) ‘Health maintenance organization’ means a public or private organization that is a qualifying health maintenance organization under federal regulations, or has been determined to be a health maintenance organization pursuant to regulations adopted by the State Health Planning and Development Agency of the District.”

D.C. Law 15-166, in par. (2A), substituted “Commissioner of the Department of Insurance, Securities, and Banking” for “Commissioner of Insurance and Securities”.

D.C. Law 16-242 rewrote par. (4); added pars. (6A), (6B), and (10C); and repealed par. (10).

The 2015 amendment by D.C. Law 20-265 rewrote (10A) and (19A).

Emergency Legislation

For temporary amendment of section, see § 2(a) 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), and § 2(a) 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).

For temporary amendment of section see § 6(a) of the Vendor Payment and Drug Abuse, Alcohol Abuse, and Mental Illness Coverage Emergency Amendment Act of 1998 (D.C. Act 12-396, Sept. 16, 1998, 45 DCR 6952).

For temporary (90 day) amendment of section, see § 4(r) of Consolidation of Financial Services Emergency Amendment Act of 2004 (D.C. Act 15-381, February 27, 2004, 51 DCR 2653).

Temporary Legislation

For temporary (225 day) amendment of section, see § 2(a) 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 45 DCR 3259).

For temporary (225 day) amendment of section, see §§ 2 to 4 of the Vendor Payment and Drug Abuse, Alcohol Abuse, and Mental Illness Coverage Temporary Act of 1998 (D.C. Law 12-181, March 26, 1999, law notification 46 DCR 3407).

References in Text

The “District of Columbia Health Occupations Revision Act of 1985,” referred to in paragraphs (18) and (19), is D.C. Law 6-99.

The “District of Columbia Health Occupations Revision Act of 1985 Amendment Act of 1994,” referred to in (1A), is D.C. Law 10-247, which is codified primarily throughout Title 3, Chapter 12.

Editor's Notes

Department of Insurance abolished: The Department of Insurance, including the Superintendent, was abolished and the functions thereof transferred to the Board of Commissioners of the District of Columbia by Reorganization Plan No. 5 of 1952. Reorganization Order No. 43, dated June 23, 1953, as amended, established, under the direction and control of a Commissioner, a Department of Insurance headed by a Superintendent. The Order provided for the organization of the Department, abolished the previously existing Department of Insurance, and provided that all functions and positions of the previous Department would be transferred to the new Department of Insurance, including the duties, powers, and authorities of all officers and employees; and that all personnel, property, records and unexpended balances relating to the functions and positions transferred would also be transferred to the new Department. The executive functions of the Board of Commissioners were transferred to the Commissioner of the District of Columbia by § 401 of Reorganization Plan No. 3 of 1967. The functions of the Superintendent of Insurance were transferred to the Department of Consumer and Regulatory Affairs by Reorganization Plan No. 1 of 1983, effective March 31, 1983. Pursuant to the provisions of D.C. Law 11-268, the Department of Insurance and Securities Regulation was established and the duties of the Superintendent of Insurance and the Insurance Administration were assumed by the Commissioner of Insurance and Securities, and the Insurance Administration in the Department of Consumer and Regulatory Affairs was abolished.

§ 31–3102. Coverage.

(a) Except as described in subsection (b) of this section, each health insurer that offers individual or group health plans or certificates issued or delivered in the District to an employer or individual shall provide coverage for the medical and psychological treatment of drug abuse, alcohol abuse, and mental illness.

(b) The requirements of this chapter shall not apply to dread disease policies, student policies, nursing home policies, and home health care policies.

(c) Covered benefits for drug abuse, alcohol abuse, and mental illness in insurance policies and contracts subject to this chapter shall be limited to inpatient, residential, and outpatient services certified as necessary by a physician, psychologist, advanced practice registered nurse, or social worker.

(d) Before an insured party may qualify to receive benefits under this chapter, a physician, psychologist, advanced practice registered nurse, or social worker shall certify that the individual has a drug addiction or an alcohol addiction or a mental illness and prescribe appropriate treatment, which may include referral to other treatment providers.

(e) All drug abuse, alcohol abuse, and mental illness treatment or services eligible for health insurance coverage shall be subject to peer review procedures. These procedures may be initiated by a health insurer in the course of reviewing claims for payment.

(f) Repealed.

(g) All individual health benefit plans or certificates shall offer coverage for the medical and psychological treatment of drug abuse, alcohol abuse, and mental illness. Coverage shall be offered for at least the minimum levels set forth in §§ 31-3103 and 31-3104.

(h) Group health benefit plans or certificates that are the result of collective bargaining between a legally-certified union and the employer shall be required to include coverage for inpatient and outpatient treatment of drug abuse, alcohol abuse, and mental illness. The minimum levels of coverage set forth in §§ 31-3103 and 31-3104 shall not apply to those group health benefit plans or certificates until 5 years from February 28, 1987, unless the Mayor requests the Council to extend the exemption to a time certain and the Council, by resolution, approves the extension.

(i) If a large group health benefit plan offers a participant or beneficiary 2 or more benefit package options under the plan, the requirements of this chapter shall be applied separately to each option.

(j) A health insurer may require that substance abuse and mental illness insurance coverage shall be provided through a managed care system.

(Feb. 28, 1987, D.C. Law 6-195, § 3, 34 DCR 491; Apr. 30, 1988, D.C. Law 7-104, § 21, 35 DCR 147; Mar. 16, 1993, D.C. Law 9-192, § 2(a), (b), 39 DCR 9007; Mar. 23, 1995, D.C. Law 10-247, § 3, 42 DCR 457; Oct. 21, 2000, D.C. Law 13-178, § 2(b), 47 DCR 6844; Mar. 8, 2007, D.C. Law 16-242, § 2(b), 54 DCR 601; Apr. 24, 2007, D.C. Law 16-305, § 42, 53 DCR 6198.)

Prior Codifications

1981 Ed., § 35-2302.

Section References

This section is referenced in § 31-3103, § 31-3104, and § 31-3110.

Effect of Amendments

D.C. Law 13-178 added subsec. (i).

D.C. Law 16-242 rewrote subsecs. (a) and (b); in subsec. (e), substituted “a health insurer” for “an insurer”; repealed subsec. (f); in subsec. (g), substituted “health benefit plans or certificates” for “subscriber contracts or policies”; in subsec. (h), substituted “health benefit plans or certificates” for “health insurance policies or contracts”; in subsec. (i), substituted “health benefit plan” for “health plan”; and added subsec. (j).

D.C. Law 16-305, in subsec. (d), substituted “has a drug addiction or an alcohol addiction or a mental illness” for “is suffering from drug abuse, alcohol abuse, or mental illness”.

Emergency Legislation

For temporary amendment of section, see § 2(b) 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), and § 2(b) 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) amendment of section, see § 2(b) 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 45 DCR 3259).

§ 31–3103. Drug abuse and alcohol abuse benefits.

(a) Covered benefits for services set forth in this section shall be 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.

(b)(1) 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, shall be a covered benefit.

(2) Treatment under this subsection shall be covered pursuant to § 31-3102 for a minimum of 12 days annually.

(c)(1) Additional treatment as a covered benefit under this chapter shall 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 shall include inpatient services, outpatient services, or any combination of these, certified as necessary by a physician, psychologist, advanced practice registered nurse, or social worker.

(2) Treatment under this subsection shall be covered pursuant to § 31-3102 for a minimum of 60 days per year for inpatient or residential care in a hospital or nonhospital residential facility and at a minimum rate of 75% for the first 40 outpatient visits per year and at a minimum rate of 60% for any outpatient visits thereafter for that year.

(d) Treatment regimens which include psychiatric, psychological, and other prescribed interventions shall be a covered benefit.

(e)(1) A group or individual health benefit plan, other than a long-term care policy, disability income policy, or supplemental policy covering a specified disease or other limited benefit unrelated to medical expenses, that is delivered, issued for delivery, or renewed in the District of Columbia shall not exclude the payment of benefits as set forth in the certificate of coverage for illnesses, injuries, or conditions sustained by an insured person because the insured was intoxicated or under the influence of any narcotic. This subsection shall not preclude a health insurer from excluding coverage for an insured individual for any illness, injury, or condition that is the direct result of the commission of a felony by the insured person.

(2) The Mayor may promulgate rules and regulations as are necessary or appropriate to carry out the provisions of this subsection.

(Feb. 28, 1987, D.C. Law 6-195, § 4, 34 DCR 491; Mar. 23, 1995, D.C. Law 10-247, § 3, 42 DCR 457; Mar. 8, 2007, D.C. Law 16-242, § 2(c), 54 DCR 601; Mar. 8, 2007, D.C. Law 16-247, § 3, 54 DCR 620.)

Prior Codifications

1981 Ed., § 35-2303.

Section References

This section is referenced in § 31-3102, § 31-3106, and § 31-3110.

Effect of Amendments

D.C. Law 16-242 rewrote subsec. (c)(2) which had read as follows: “(2) Treatment under this subsection shall be covered pursuant to § 31-3102 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.”

D.C. Law 16-247 added subsec. (e).

Editor's Notes

Section 4 of D.C. Law 16-247 provided: “This act shall apply to all individual and group health benefit plans delivered, issued for delivery, or renewed on the first day of the month beginning on or after 90 days after the effective date of this act.”

§ 31–3104. Mental illness benefits.

(a) Covered benefits for services set forth in this section shall be limited to coverage of 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.

(b) Treatment under this section shall be covered pursuant to § 31-3102 for a minimum of 60 days per year for inpatient or residential care in a hospital or nonhospital residential facility, and at a minimum rate of 75% for the first 40 outpatient visits per year and at a minimum rate of 60% for any outpatient visits thereafter for that year.

§ 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.”

§ 31–3106. Certification of nonhospital residential facilities and outpatient treatment facilities.

(a) The Mayor shall certify qualifying nonhospital residential facilities and outpatient treatment facilities in the District in accordance with rules issued pursuant to § 31-3111.

(b) Each certification issued by the Mayor shall state whether the facility is certified as a provider of treatment for drug abuse, alcohol abuse, mental illness, or a combination of these that shall be specified.

(c) To qualify for certification, a nonhospital residential facility or outpatient treatment facility shall demonstrate that:

(1) It offers an organized program for the treatment of drug abuse, alcohol abuse, mental illness, or any combination of these;

(2) It operates under the day-to-day supervision of an individual with demonstrable training and experience in the treatment of drug abuse, alcohol abuse, or mental illness;

(3) It employs sufficient numbers of professional staff members to deliver adequately the services offered to its patient caseload; and

(4) It offers and has the capacity to provide services for the durations specified in §§ 31-3103 and 31-3104.

(d) Nothing in this section shall be construed as superseding the requirements of chapter 5 of Title 44.

(e) Any certification issued pursuant to this section shall be issued as a Public Health: Human Services Facility endorsement to a basic business license under the basic business license system as set forth in subchapter I-A of Chapter 28 of Title 47.

(Feb. 28, 1987, D.C. Law 6-195, § 7, 34 DCR 491; Apr. 20, 1999, D.C. Law 12-261, § 2003(kk), 46 DCR 3142; Oct. 28, 2003, D.C. Law 15-38, § 3(y), 50 DCR 6913.)

Prior Codifications

1981 Ed., § 35-2306.

Section References

This section is referenced in § 44-1204.

Effect of Amendments

D.C. Law 15-38, in subsec. (e), substituted “Public Health: Human Services Facility endorsement to a basic business license under the basic” for “Class A Public Health: Human Services Facility endorsement to a master business license under the master”.

Cross References

Substance abuse treatment certification requirements, see § 44-1204.

Emergency Legislation

For temporary (90 day) amendment of section, see § 3(y) of Streamlining Regulation Emergency Act of 2003 (D.C. Act 15-145, August 11, 2003, 50 DCR 6896).

Delegation of Authority

Delegation of authority pursuant to D.C. Law 6-195, “Drug Abuse, Alcohol Abuse, and Mental Illness Insurance Act of 1986.”, see Mayor’s Order 88-50, February 25, 1988.

§ 31–3107. Preservation of certain benefits.

Nothing in this chapter shall serve to diminish the benefits of any insured person or prevent the offering or acceptance of benefits that exceed the minimum benefits required by this chapter.

§ 31–3108. Notification of coverage and benefits.

All individual and group health benefit plans shall contain statements, in easily readable type and in easily understandable language, approved by the Commissioner, to inform policyholders and beneficiaries of the coverage and benefits provided or offered pursuant to this chapter.

§ 31–3109. Filing and rate requirements.

(a)(1) Notwithstanding the provisions of any other law, any health insurer that issues health benefits plan or certificates in the District shall file with the Commissioner all rates and rating plans, rules, and classifications that it proposes to use in providing or offering the coverage required by this chapter.

(2) Each health insurer shall initially file the documents required by this section no later than 120 days after the effective date of rules issued pursuant to § 31-3111 and shall thereafter file any changes in rates and rating plans, rules, and classifications related to the coverage required by this chapter in a timely manner in accordance with rules issued by the Commissioner.

(3) The Commissioner shall make the documents filed pursuant to this section available for public inspection during normal business hours.

(b)(1) The rates and charges filed pursuant to subsection (a) of this section shall be subject to review by the Commissioner for a period of 90 calendar days from the date of filing. If after 90 days the Commissioner has not made a final determination on the final rates or charges proposed, the health insurer may begin charging the proposed rate. The rates and charges shall remain in effect unless and until, in accordance with the provisions of this section, changed by the health insurer or disapproved by the Commissioner.

(2) Except as otherwise provided in § 31-3110(d)(2), rates and charges for the coverage required by this chapter shall not be excessive and shall be reasonably related to the cost of providing the coverage based on the following factors:

(A) Past and prospective experience within the covered group, or within the geographic region of the District or other regions, concerning the proportion of beneficiaries who use the coverage and the average duration of use;

(B) Usual, customary, and reasonable charges by providers of treatment for drug abuse, alcohol abuse, and mental illness within the District or other regions; and

(C) Past and prospective experience within the covered group, or within the geographic region of the District or other regions, concerning claims filed or services required for physical diseases and disorders by beneficiaries who obtain treatment for drug abuse, alcohol abuse, or mental illness or whose household includes an individual who has obtained treatment for drug abuse, alcohol abuse, or mental illness.

(3) Rates and charges for the coverage required by this chapter may include a reasonable margin for underwriting profit and contingencies.

(c)(1) The Commissioner shall review all rates and rating plans, rules, and classifications filed pursuant to this section to determine compliance with this chapter.

(2) The Commissioner may, following a hearing pursuant to § 2-509, order adjustments in rates and rating plans, rules, and classifications that the Commissioner determines to be excessive or otherwise not in compliance with this chapter. The Commissioner may order the insurer to refund to its policyholders a sum equal to the amount of the rate or charge determined to be excessive.

(d) Nothing in this section shall be construed to require uniformity in rates, classifications, rating plans, or charges.

(Feb. 28, 1987, D.C. Law 6-195, § 10, 34 DCR 491; May 21, 1997, D.C. Law 11-268, § 10(w), 44 DCR 1730; Mar. 8, 2007, D.C. Law 16-242, § 2(g), 54 DCR 601.)

Prior Codifications

1981 Ed., § 35-2309.

Section References

This section is referenced in § 31-3110.

Effect of Amendments

D.C. Law 16-242, in subsecs. (a)(1), (a)(2), and (b)(1), substituted “health insurer” for “insurer”; and, in subsec. (a)(1), substituted “health benefits plan or certificates” for “health insurance policies or contracts”.

Editor's Notes

Department of Insurance abolished: See Historical and Statutory Notes following § 31-3101.

§ 31–3110. Health maintenance organizations.

(a) The requirements of this chapter shall apply to health maintenance organizations 5 years from February 28, 1987, unless the Mayor requests the Council to extend the exemption to a time certain and the Council, by resolution, approves the extension.

(b) Upon becoming subject to the requirements of this chapter, each health maintenance organization shall:

(1) Provide to its members the coverage and benefits required by §§ 31-3102, 31-3103, and 31-3104;

(2) Ensure that deductible or copayment plans, durational limits, and methods of determination adopted with respect to coverage of the benefits required by §§ 31-3102, 31-3103, and 31-3104 result in coverage that is determined by the Commissioner to be at least equivalent in actuarial value to the average actuarial value of the plans provided by the health insurer with the largest number of enrollees in the District; and

(3) Provide the notification of coverage and benefits required by § 31-3108.

(c) Each health maintenance organization may provide the treatment required by §§ 31-3103 and 31-3104 directly by its staff or by referring its members to a hospital or other treatment facility that provides those services under a contract or agreement with the health maintenance organization. Nothing in this chapter shall require the alteration of any terms and conditions of the health maintenance organization membership contract relating to prior approval by the health maintenance organization for treatment provided to its members by other treatment facilities.

(d)(1) Each health maintenance organization, within 120 days after becoming subject to the requirements of this chapter, shall file with the Commissioner the membership contracts it proposes to use, identifying its charges for all services and the portion of charges attributable to the services required by this chapter.

(2) The provisions of § 31-3109, except for subsection (b)(2) of this section, shall apply thereafter to the membership contracts and charges filed and implemented by health maintenance organizations. Rates and charges for the coverage required by this chapter shall not be excessive and shall be reasonably related to the cost of providing the coverage.

§ 31–3111. Duties of Mayor.

(a) The Mayor shall, within 120 days from February 28, 1987, issue rules to implement all sections of this chapter except § 31-3110. The Mayor shall issue rules to implement § 31-3110 no later than 5 years from February 28, 1987.

(b) The Mayor shall provide the coverage and benefits set forth in this chapter to employees of the District and their dependents who are insured through the District of Columbia Employees’ Health Benefits Program. For District employees and their dependents who are insured through the Federal Employees’ Health Benefits Program, the Mayor shall provide supplemental coverage and benefits that comply with the requirements of this chapter no later than February 28, 1994.

§ 31–3112. Excluded programs.

This chapter shall not be applicable to the District of Columbia Alliance Program, Medicaid Program, and Post-1987 District of Columbia Employees’ Health Insurance Benefits Plan.