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Do You Know Your Health Insurance Rights?

If you purchased insurance coverage from a licensed insurer you have several rights under District and federal laws or mandates. 

District’s Health Insurance Mandates

The District has mandates or requirements that insurers must include in every health insurance plan. To see a listing of these requirements, please follow this link [PDF].
 

DC Health Insurance Portability and Accountability Act or HIPAA

DC HIPAA helps you to purchase healthcare coverage when you change or lose a job, or move to another area. Specifically, the act:
  • Requires health insurers to renew your healthcare coverage or continue it in force unless you failed to pay premiums, committed fraud, terminated the policy, moved outside the service area, or ended membership in a bona fide association.
  • Limits health insurers’ authority to delay the beginning of your healthcare coverage.
  • Prohibits discrimination based on your health conditions or your dependents’ health conditions when purchasing healthcare coverage.
  • Limits the application of pre-existing condition exclusions (no pre-existing condition exclusion may be applied to pregnancy, genetic information and other situations).
  • Allows creditable coverage (most health care coverage) to reduce pre-existing condition exclusions, as long as, there is no significant break in healthcare coverage (more than 63 days).

Understanding Medicare Health Plan Choices and Supplemental Insurance or Medigap

 
DISB does not regulate either Medicare health benefits or Medigap policies. These are regulated by the Center for Medicare and Medicaid Services. DISB does regulate the insurance carriers which sell Medicare Advantage plans, prescription drug plans, and supplemental plans. We are providing some general information to help you make more informed choices on these products. DISB can help you with navigating the system between private and public plans. 
 

District’s Pre-Existing Condition Insurance Plan

 
If you are uninsured due to a pre-existing condition, you may be eligible to join the District’s Pre-Existing Condition Insurance Plan. For more information, please call (800) 220-7898 or log-on to www.pciplan.com to learn more and fill out an enrollment application. 
 

What is COBRA? 

The Consolidated Omnibus Budget Reconciliation Act also known as COBRA is an insurance program that allows some individuals to continue their group health insurance coverage sponsored by employers with more than 20 employees after voluntarily or involuntarily leaving their jobs.  
 
In March 2009, the Council of the District of Columbia approved the “Continuation of Health Coverage Act Emergency Amendment Act of 2009” also known as MINI-COBRA, which amends District law to allow certain involuntarily terminated employees to continue with their employer’s health benefits plan for a period of 90 days.  To view the laws on the District’s health coverage continuation, visit the DC Code, Title 32-Labor, Chapter 7a – Health Coverage Continuation.
 

Who do I contact if my claim is denied due to medical necessity?

 
The Ombudsman for the D.C. Department of Health Care Finance has the authority to respond to denied claims due to medical necessity. The Ombudsman can be reached at (877) 685-6391 or healthcareombudsman@dc.gov
 

What is the Medicare Appeals and Grievance Program?

 
The Centers for Medicare and Medicaid Services have a Medicare Appeals and Grievance Program where customers can submit a complaint or grievance on quality of care received from a provider. 
 

What new prevention-related services are available for women? 

Under the Affordable Care Act, eight new prevention-related services for women went into effect on August 1, 2012, where insurers are not allowed to charge co-pays. The new services include well-woman visits: mammograms, gestational diabetes screenings, domestic violence screenings, breastfeeding equipment and more. For additional information, visit http://www.healthcare.gov/prevention/index.html
 

What new rights are coming under the Affordable Care Act?

The passage of the Affordable Care Act brought in new consumer protections that will be rolled out in stages from 2010 through 2020. Below is a schedule of the new reforms. 
 

2013

  • Insurance company paperwork will be standardized in the first in a series of steps to reduce administrative costs.
  • Medicare payroll taxes will rise for couples making more than $250,000 per year and individuals making more than $200,000.
  • Medicare begins to gradually close the prescription drug “donut hole” over a seven-year period. 
  • A 2.3 percent sales tax on medical devices will begin. Many everyday items bought at drugstores will become exempt.
  • In Oct. 2013, the open enrollment period will begin for the District’s Health Benefit Exchange where individuals and small business employers can compare and buy health insurance plans.

 2014

  • The District will launch its Health Benefit Exchange on Jan. 1, 2014.
  • An income-based tax credit or federal subsidy will kick in for consumers who are not Medicaid eligible and need assistance in purchasing health insurance. 
  • D.C. Medicaid will expand to cover people up to 133 percent of the federal poverty line, about $28,300 for a family of four. Low-income childless adults will be covered for the first time.
  • Citizens and legal residents will be required to have health insurance, except in cases of financial hardship, or pay a fine to the Internal Revenue Service. Penalty starts at $95 per person in 2014, rising to $695 in 2016. Family penalty capped at $ 2,250. Low- and moderate-income families who do not get coverage at work will be eligible for subsidies or tax credits to make coverage affordable.
  • Employers with more than 50 workers will begin to be penalized if any of their workers get coverage through an exchange. The penalty is $2,000 times the number of workers at the company.
  • Insurers will be prohibited from denying coverage to adults with medical problems or refusing to renew their policy. Health plans cannot limit coverage based on pre-existing conditions or charge higher rates to those in poor health. Premiums can vary only by age, place of residence, family size and tobacco use.
  • Members of Congress begin receiving coverage through the exchanges.
To see when more consumer protections will kick-in, visit www.HealthCare.gov