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DEPARTMENT OF INSURANCE, SECURITIES AND BANKING
NOTICE OF FINAL RULEMAKING
The Acting Commissioner of the Department of Insurance, Securities and Banking, pursuant to the authority set forth in section 23 of the Health Maintenance Organization Act of 1996, effective April 9, 1997 (D.C. Law 11-235; D.C. Official Code §§ 31-3401, et seq.); section 25 of the Hospital and Medical Services Corporation Regulatory Act of 1996, effective April 9, 1996 (D.C. Law 11-245; D.C. Official Code § 31-3508); and section 28 of Chapter V of the Life Insurance Act of 1934, approved June 19, 1934 (48 Stat. 1166; D.C. Official Code § 31-4712), hereby gives notice of the adoption of a new chapter 44 to be entitled “Child-Only Policies” of Subtitle A, “Insurance,” of Title 26 of the District of Columbia Municipal Regulations (DCMR). The new chapter 44 will establish open enrollment periods and impose certain other conditions for issuers of child only policies in the District.
A Notice of the Emergency and Proposed Rulemaking was published in the D.C. Register on December 24, 2010, at 57 DCR 12281. The Notice of Emergency and Proposed Rulemaking originally indicated that the new “Child-Only Policies” chapter would be placed in chapter 42. Chapter 42 is currently exists in Subtitle A of Title 26. Therefore, as a technical amendment, the rulemaking was renumbered from chapter 42 to chapter 44. No substantive changes were made to the rulemaking. The rules shall become effective upon the publication in the D.C. Register.
Subtitle A, INSURANCE, Title 26 of the District of Columbia Municipal Regulations is amended as follows:
A new chapter 44, CHILD-ONLY POLICIES, is added to read as follows:
CHAPTER 44 CHILD-ONLY POLICIES
4401 SCOPE OF CHAPTER
4401.1 This chapter is applicable to child-only policies issued on or after September 23, 2010.
4402 CHILD-ONLY POLICY
4402.1 Carriers shall issue or deliver a child-only policy in the District in accordance with the requirements of this chapter.
4403 OPEN ENROLLMENT PERIODS
4403.1 A carrier issuing or delivering child-only policies in the District shall accept applications for coverage during the open enrollment periods outlined in this chapter.
4403.2 Each carrier issuing child-only policies shall hold open enrollment periods twice a year from:
(a) January 1 thru January 31 of each year; and
(b) July 1 thru July 31 of each year.
4403.3 During the open enrollment periods, any applicant for a child-only policy shall be offered coverage on a guaranteed issue basis, without any limitations or riders based on medical condition or health status.
4403.4 Notice of the open enrollment period and instructions on how to apply during the open enrollment period shall be displayed prominently on the carrier’s website for the duration of the open enrollment period.
4403.5 During open enrollment, a carrier may request from an applicant information to determine whether the proposed insured has substantially similar coverage available and may obtain an attestation from an applicant that the proposed insured does not have substantially similar coverage available.
4403.6 Applications for coverage during the open enrollment period under paragraph 4403.2(a) of this section that are received:
(a) On or before January 15 shall become effective on the first day of February of the same year; and
(b) After January 15 shall become effective no later than February 16 of the same year.
4403.7 Applications for coverage during the open enrollment period under paragraph 4403.2(b) of this section that are received:
(a) On or before July 15 shall become effective on the first day of August of the same year; and
(b) After July 15 shall become effective no later than August 16 of the same year.
4403.8 Notwithstanding the provisions of subsection 4403.1 of this section, a carrier may reject an application during the open enrollment period if the child has other substantially similar coverage available.
4404 APPLICATIONS RECEIVED OUTSIDE OPEN ENROLLMENT PERIOD
4404.1 If a carrier receives an application for a child-only policy outside the open enrollment periods, the carrier shall accept the application if the applicant meets the criteria set forth in section 4405 of this chapter.
4404.2 Except as provided in subsection 4404.1 of this section, if a carrier receives an application for a child-only policy outside the open enrollment period, the carrier may deny the application and notify the applicant of the next open enrollment period and how to apply for coverage during the open enrollment period.
4404.3 If a carrier accepts an application outside the open enrollment period, the carrier shall offer coverage on a guaranteed issue basis, without any limitations or riders based on medical condition or health status.
4405 COURT ORDERED COVERAGE
4405.1 Carriers issuing child-only policies shall accept an application for a child-only policy outside of the open enrollment periods described in section 4403 of this chapter if a court has ordered health benefits be provided to the child.
4405.2 A carrier may request a copy of a valid court order mandating health benefits for the child.
4406 UNDERWRITING
4406.1 A carrier may not deny issuance of a child-only policy due to medical underwriting.
4406.2 A carrier may conduct medical underwriting to determine the appropriate premium rate for a child-only policy.
4499 DEFINITIONS
4499.1 For the purpose of this chapter, the term:
Applicant means a child or an individual on behalf of a child who submits an application for a child-only policy.
Carrier means an insurer, nonprofit health service plan, group hospital and medical service corporation, or a health maintenance organization.
Commissioner means the Commissioner of the Department of Insurance, Securities and Banking.
Child means an individual under the age of nineteen (19).
Child-only policy means an individual health benefit plan issued or delivered to a child in the District of Columbia.
Health benefit plan means a health insurance contract issued by a carrier that includes benefits for medical care. “Health benefit plan" does not include:
(a) Any of the following:
(1) Coverage only for accident or disability income insurance;
(2) Coverage issued as a supplement to liability insurance;
(3) Liability insurance, including general liability insurance and automobile liability insurance;
(4) Workers’ compensation or similar insurance;
(5) Automobile medical payment insurance;
(6) Credit-only insurance;
(7) Coverage for on-site medical clinics; and
(8) Other similar insurance coverage, specified in federal regulations issued pursuant to the Health Insurance Portability and Accountability Act of 1996, approved August 21, 1996 (Pub. L. No. 104-191; 110 Stat. 1936).
(b) The following benefits if they are provided under a separate contract of insurance:
(1) Limited-scope dental or vision benefits;
(2) Benefits for long-term care, nursing home care, home health care, community-based care, or any combination of these benefits; and
(3) Similar, limited benefits as are specified in federal regulations issued pursuant to the Health Insurance Portability and Accountability Act of 1996, approved August 21, 1996 (Pub. L. No. 104-191; 110 Stat. 1936).
(c) The following benefits if offered as independent, non-coordinated benefits:
(1) Coverage only for a specified disease or illness; and
(2) Hospital indemnity or other fixed indemnity insurance.
(d) The following benefits if offered as a separate insurance policy:
(1) Medicare supplemental health insurance, as defined under § 1882(g)(1) of the Social Security Act;
(2) Coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code; and
(3) Similar supplemental coverage provided to coverage under an employer sponsored plan.
“Individual health benefit plan” means a health benefit plan issued or delivered to an individual, including:
(a) A certificate issued or delivered to an individual in the District that evidences coverage under a policy or contract issued to a trust or association or other similar group of individuals, regardless of the situs of the delivery of the policy or contract, if the individual pays the premium and is not being covered under the policy or contract under either federal or State continuation of benefits provisions; and
(b) Short-term limited duration insurance.
“Substantially similar coverage” means coverage under any group health benefit plan or employer-sponsored plan that provides health benefits to the employees of the employer. “Substantially similar coverage” does not mean a policy or contract issued to a trust or association or other similar group of individuals that is an individual health benefit plan.
