For the purposes of this chapter, the term “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 of the Department of Insurance, Securities, and Banking.
§ 4–632. Establishment of Healthy DC Program; administration.
(a) There is established the Healthy DC Program (“Program”), which shall provide affordable health benefits to eligible individuals.
(b) The Program shall be administered by the Department of Health Care Finance, established by Chapter 7D of Title 7.
(c) The Program shall be funded through the Healthy DC and Health Care Expansion Fund, established by § 31-3514.02.
(d)(1) The Program shall be subject to the availability of funding.
(2) Nothing in this chapter shall be construed to create or constitute an entitlement to health insurance or health or medical benefits.
§ 4–633. Program eligibility.
(a) An individual shall be eligible for the Program if the individual:
(1) Has resided in the District for at least 6 months at the time of application to the Program;
(2) Resides in a household having a gross household income not exceeding 400% of the federal poverty guidelines as updated periodically in the Federal Register by the United States Department of Health and Human Services under the authority of 42 U.S.C. § 9902(2); and
(3) Does not qualify for:
(A) The DC HealthCare Alliance;
(B) Medicare;
(C) Medicaid; or
(D) Other federal health-benefits programs; and
(4)(A) Has not had health insurance during the 6-month period prior to application to the Program;
(B) Has had health insurance during the 6-month period prior to application to the Program but the insurance was terminated due to:
(i) The loss of employment;
(ii) A death of a spouse, domestic partner, or family member who maintained the individual as a beneficiary on a health-insurance plan;
(iii) Changes in student status, including graduation, a leave of absence, or reduction to part-time study;
(iv) A change of employment to a new employer who does not provide group health insurance;
(v) A legal annulment, separation, divorce, or the dissolution of a domestic partnership;
(vi) The loss of financial eligibility under Medicaid or the DC HealthCare Alliance;
(vii) The cancellation or discontinuation of a group health insurance contract by a health insurer; or
(viii) Any other reason as determined by the Mayor; or
(C) Has health insurance but the annual cost to the individual is deemed unaffordable, as determined by the Mayor.
(b) Eligibility for the Program shall not be subject to any pre-existing condition exclusions.
§ 4–634. Program benefits; affordability.
(a) The Program shall provide, at a minimum, health and medical benefits that are equal to those provided to individuals enrolled in the DC HealthCare Alliance.
(b) The Program shall limit annual premium costs for program participants as follows:
(1) For a program participant with a gross household income of 300% of the federal poverty guidelines or less, the annual premium shall not exceed 3% of the participant’s gross household income; and
(2) For a program participant with a gross household income that exceeds 300% of the federal poverty guidelines, the annual premium shall not exceed 5% of the participant’s gross household income.
§ 4–635. Program implementation.
(a) The Mayor shall make the Program available to eligible individuals by January 1, 2010.
(b) To meet the deadline set forth in subsection (a) of this section, the Mayor is authorized to enter into a contract with one or more health insurers to administer the Program.
(c) Any contract entered into pursuant to this section shall require annual reporting of clinical-quality measurements and utilization data to the Mayor.
§ 4–636. Prohibitions.
It shall be unlawful for a health insurer to eliminate or restrict the availability of a health insurance plan offered in the District with the intent of shifting beneficiaries to the Program. An entity found to be in violation of this section shall be subject to a fine of not less than $10,000.
§ 4–637. Disposition of fines and penalties.
Fines and penalties collected pursuant to this chapter shall be deposited in the Healthy DC and Health Care Expansion Fund, established by § 31-3514.02.
