Health plans - District of Columbia

Summary of differences between federal and state regulations

Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income Security Act (ERISA).

Federal ERISA plans generally do not have to comply with state laws. ERISA rules preempt or block state laws that relate to ERISA plans. State insurance laws, however, do apply.

One of the ways that D.C. goes beyond federal requirements is that domestic partners qualify for benefits if they are registered as domestic partners. Title 32, §32-702.

The amount of any health care insurance premium paid by an employer for a non-employee domestic partner is excluded in the computation of gross income. D.C. ACT 16-221; §47-1803.02(a)(2)(W)

DC law also includes the following provisions:

• All health insurers, hospitals or medical services corporations, and health maintenance organizations must reimburse for emergency services that are due to a medical emergency. §31.2808
• The plan must cover colorectal cancer screening. §31.2931
• The plan must cover prostate cancer screening. The coverage must not be more restrictive than or separate from coverage provided from 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. §31.2952
• The plan must cover the equipment, supplies, and other outpatient self-management training and education, including medical nutritional therapy, for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes, and non-insulin using diabetes if prescribed. §31.3002
• If the plan provides coverage on an expenses-incurred basis, and group service or indemnity-type contracts issued by a nonprofit health service plan, it must cover the medical and psychological treatment of drug abuse, alcohol abuse, and mental illness. Coverage is limited to inpatient, residential, and outpatient services. §31.3102
• If the plan provides coverage on an expenses-incurred basis, and group service or indemnity-type contracts issued by a nonprofit health service plan, it must cover newborn children from the moment of birth. §31.3801
• If the plan covers prescription drugs, it must cover orally administered anticancer medication on the same basis than provided for intravenously administered medications. Chemotherapy Pill Coverage Act of 2009.
• Group health plans must provide health insurance coverage for dependents younger than 26 years of age on the same terms that insurance benefits are provided to other covered dependents. A dependent must also be unmarried, have no dependents, be a resident of the District of Columbia or enrolled as a full time student in an accredited public or private institution of higher education, and not otherwise covered by any other group or individual health plan or entitled to Medicare. This does not apply to self-insured plans. This new provision stems from a temporary law (the Health Insurance for Dependents Temporary Act of 2010).
• On a temporary basis, the Healthy DC Act of 2008 establishes an option for premium subsidies for eligible program participants with employer-sponsored health coverage (DC Act 18-554, enacted 10/7/10)
• Group health plans must cover without any cost-sharing for the following women’s preventive health services and products:
• Breast cancer screening;
  • Breast feeding support, services, and supplies;
  • Screening for cervical cancer, including HPV testing;
  • Screening for gestational diabetes;
  • Screening and counseling for HIV;
  • Screening and counseling for interpersonal and domestic violence;
  • Screening and counseling for sexually-transmitted diseases;
  • Screening and counseling for Hepatitis B and C;
  • Well-woman preventive visits, including visits to obtain necessary preventive care, preconception care, and prenatal care;
  • Folic acid supplementation;
  • Breast cancer chemoprevention counseling and preventive medications;
  • isk assessment and genetic counseling and testing using the Breast Cancer Risk Assessment tool approved by the National Cancer Institute;
  • R and o Rh incompatibility screening.
• Evidence-based items or services that have in effect a rating of "A" or "B" in the recommendations of the United States Preventive Services Task Force as of September 19, 2017;
• Other products or services as defined by the Mayor.

State

Contacts

D. C. Department of Insurance, Securities and Banking

Department of Employment Services (Title 32)

Regulations

District of Columbia Code, Division V – Local Business Affairs, Title 31 – Insurance and Securities, Subtitle IV – Health and Related Insurance.

For information specific to health benefits for women, see the topic Women’s Health Rights.

Federal

Contact

Employee Benefits Security Administration (EBSA)

Regulations

29 CFR chapter XXV (Parts 2509 – 2590)