If you purchased insurance coverage from a licensed insurer here in the District of Columbia, you have an abundance of rights under District and federal laws and mandates. Below is a list of protections you have as a consumer of health insurance in Washington, DC. If you do not think these rights are being upheld, contact our Consumer Services Division at [email protected] or send a fax to (202) 354-1085. For more on our complaint process including access to the online complaint form, select here.
District’s Health Insurance Mandates
The District has mandates for all major medical health plans. To see a list of these requirements, select here [PDF].
Affordable Care Act Protections
What rights do I have under the Affordable Care Act?
The passage of the Affordable Care Act issues new consumer protections that continue to be implemented incrementally from 2010 through 2020. Below is a list of items to be aware of in 2016 and some of the protections consumers are already enjoying.
- Open Enrollment: The open enrollment season for DC Health Link is Nov. 1, 2016 – Jan. 31, 2017. If you are eligible for a special enrollment period you may be eligible to enroll in a plan before open enrollment.
- Premium Assistance: Consumers who need assistance in purchasing health insurance will be eligible for an income-based tax credit or federal subsidy only if they are not eligible for other types of health insurance such as affordable employer-sponsored insurance, Medicaid, CHIP, Medicare and TRICARE. This subsidy is generally available for individuals and families whose household income is 100%-400% of the federal poverty level or $24,250 - $97,000. Select here to view an estimate of your subsidy and contact DC Health Link to see if you qualify for help.
- Medicaid Expansion: In 2011, DC expanded its Medicaid eligibility requirement to cover 21,000 newly eligible residents, depending on your eligibility category you may qualify for a free or low-cost program even if you earn as much as $94,000 for a family of four. You can apply for Medicaid either directly through the DC Medicaid office or DC Health Link.
- Individual Mandate: With exceptions for individuals experiencing financial hardship, citizens and legal residents are required to have health insurance otherwise they must pay a fine to the Internal Revenue Service. The penalty is 2.5% of household income or $695 per person ($347.50 per child under the age of 18), whichever is the higher amount. As mentioned above, low and moderate income families who do not get coverage at work will be eligible for tax credits or Medicaid in order to make coverage affordable.
- Employer Mandate: Employers with more than 50 full-time employees will be penalized if any of their workers get coverage through an exchange or if they do not provide health insurance to at least 95% of their full-time employees. The penalty is $2,000 times the number of full-time-employees who are not offered coverage and $3,000 per full-time employee who receives cost assistance through the exchange.
- Pre-Existing Conditions: Since Jan. 1, 2014, insurers are prohibited from denying coverage or refusing to renew a policy to individuals based on medical history. Health plans can no longer 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 and family size.
- Free Preventive Services for Women: On Aug. 1, 2012, twenty-two preventive services for women became mandatory for all non-grandfathered health insurance plans. Insurers are not allowed to charge co-pays for some of these services which include well-woman visits, mammograms, gestational diabetes screenings, domestic violence screenings, breastfeeding equipment and much more. You can view all required preventive services for all adults, women and children.
To learn more about the Affordable Care Act and its consumer protections, visit HealthCare.gov.
Understanding Medicare and COBRA
Understanding Medicare Health Plan Choices and Supplemental Insurance or Medigap
Medicare is a federal health insurance program for individuals who are either 65 and over, qualified persons with disabilities, and/or individuals with End Stage Renal Disease. A Medigap policy is a plan sold by a private insurance company which fills or supplements gaps in Medicare coverage.
DISB does not regulate either Medicare health benefits or Medigap policies. These are regulated by the Centers for Medicare and Medicaid Services. However, DISB regulates the insurance Medicare Advantage plans, prescription drug plans and supplemental plans. 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 they voluntarily or involuntarily leave their jobs. For employers with fewer than 20 employees, the Council of the District of Columbia approved the “Continuation of Health Coverage Act Emergency Amendment Act of 2009” also known as MINI-COBRA.
Under COBRA, enrollees may be forced to contribute up to 103% of the share of their monthly premiums, as a result unemployed individuals and families may find the cost of COBRA unaffordable. Individuals who lose their job will be eligible for a special enrollment period where they can enroll in a qualified health plan through DC Health Link; depending on their household income they may be eligible for financial assistance in paying their monthly premiums and out-of-pocket costs.
Complaints and Appeals
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 and other disputes you may have with your insurance company. The Ombudsman can be reached at (877) 685-6391 or [email protected].
What if I disagree with my Medicaid or DC Healthlink Eligibility Results?
You have the right to a Fair Hearing regarding your health insurance determination. You can appeal a denial, termination, or change in your eligibility for Medicaid. You can also appeal the amount of premium tax credits you were awarded. Select here for more information on your DC Health Link Appeal Rights.
What is the Medicare Appeals and Grievance Program?
The Centers for Medicare and Medicaid Services have a Medicare Appeals and Grievance Program where Medicare enrollees can submit an appeal on a coverage or payment decision. Additionally, Medicare enrollees can submit a complaint or grievance on coverage quality of care received from a provider.