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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. 

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.

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 health care 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 health care coverage.
  • Prohibits discrimination based on your health conditions or your dependents’ health conditions when purchasing healthcare coverage

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. For additional information about Medigap policies in the District you can visit the Medicare.gov website. DISB can help you with navigating the system between private and public plans.

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 DC 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 www.hhs.gov/healthcare/facts/factsheets/2012/03/women03202012a.html.

What new rights are coming under the Affordable Care Act?

The passage of the federal Affordable Care Act brought in new consumer protections that will be rolled out in stages from 2010 through 2020. Below is are some new reforms that are already in place to protect you and your family.
  • The third season of open enrollment for DC Health Link is November 1, 2015 - January 31, 2016.
  • An income-based tax credit or federal subsidy is available for some consumers who are not Medicaid eligible but do need financial assistance in purchasing health insurance.
  • 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. The penalty for not having coverage in 2016 will be the higher of 2.5% of your yearly household income or $695 per person ($347.50 per child under the age of 18). Low- and moderate-income families who do not get coverage at work will be eligible for subsidies or tax credits to make coverage affordable.
  • 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. In the District of Columbia, premiums can vary only by age and family size, but not place of residence or tobacco use.

To see when more consumer protections will kick-in, visit HealthCare.gov. For more information about private insurance coverage in the District, visit  DC Health Link.