3.1 DC Health Insurance Policy Requirements

How DC Regulates Health Insurance

The Department of Insurance, Securities and Banking (DISB) is the District of Columbia's insurance regulator. Every health insurer, Health Maintenance Organization (HMO), and Preferred Provider Organization (PPO) that issues coverage to DC residents must hold a DISB certificate of authority and file its forms and rates for approval. Exam items frequently force you to separate "who runs coverage programs" from "who licenses producers and approves products" — DISB does the latter, while two sister agencies run public programs.

The 10-Day Free Look

DC requires a 10-day free look period on individual health insurance. The clock starts the day the policy is delivered to the owner, not the application date. If the owner returns the policy within 10 days, the insurer must refund 100% of premium paid, with no surrender charge and no proration. Worked example: a resident's individual major-medical policy is hand-delivered on March 3. She mails it back postmarked March 12 — that is the ninth day, so the carrier owes a full refund.

Trap: candidates confuse this with the 30-day free look that DC grants on long-term care (covered in 3.3); on the exam, individual health equals 10 days.

DC Health Link

DC operates DC Health Link, a state-based exchange rather than relying on the federal HealthCare.gov platform.

• Open enrollment runs annually, with special enrollment periods (SEPs) triggered by qualifying life events such as marriage, birth, loss of other coverage, or a permanent move into DC.
• DC Health Link is the only channel through which a resident may claim Advance Premium Tax Credits (APTC) and cost-sharing reductions; a plan bought directly off-exchange forfeits subsidies.
• Plans are sold in metal tiers — Bronze, Silver, Gold, and Platinum — defined by actuarial value (roughly the share of total costs the plan pays): Bronze ~60%, Silver ~70%, Gold ~80%, Platinum ~90%.
• DC uniquely requires all Members of Congress and their staff to buy coverage through its Small Business Health Options Program (SHOP), a quirk the exam likes to cite.

Know the difference between a SEP and open enrollment: outside open enrollment, an applicant must show a qualifying event and generally has 60 days to enroll.

ACA Mandates Built Into DC Plans

DC adopts the federal Affordable Care Act (ACA) in full and adds its own individual mandate. Every individual and small-group plan sold in the District must cover the ten Essential Health Benefits (EHBs):

1. Ambulatory (outpatient) patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance-use disorder services
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive, wellness, and chronic-disease management
10. Pediatric services, including oral and vision care

Pre-Existing Conditions and Rating

ACA-compliant plans may not exclude or surcharge pre-existing conditions, and they may not impose lifetime or annual dollar caps on EHBs.

Premiums may vary only by age (no more than a 3:1 ratio between oldest and youngest adults), tobacco use, geography, and whether coverage is individual or family — never by gender or health history.

DC Individual Mandate

Unlike federal law, which zeroed its penalty, DC keeps an individual responsibility requirement: residents without minimum essential coverage owe a penalty on the DC tax return (the greater of a flat per-person amount or a percentage of household income), unless they qualify for an exemption such as a short coverage gap or affordability hardship.

Medicaid and the Healthcare Alliance — 2026 Changes

DC Medicaid is administered by DHCF. Through FY 2025 the District covered adults up to 210% of the Federal Poverty Level (FPL) — far above the standard ACA expansion floor. Effective January 1, 2026, that adult threshold was lowered to 138% FPL (roughly $1,800/month for one person), aligning DC with standard expansion levels. Simultaneously, the DC Healthcare Alliance — coverage for residents ineligible for Medicaid, often due to immigration status — froze new enrollment for adults age 26 and older and cut its income limit to 138% FPL. Children's eligibility (ages 0–20) was unchanged.

The exam may anchor on the older 210% figure; the current correct answer for adults is 138% FPL.

Mental health parity: DC enforces federal parity, so financial requirements (copays, deductibles, out-of-pocket maximums) and treatment limits on mental health and substance-use benefits cannot be more restrictive than those on comparable medical/surgical benefits.

Other DC Mandates and Continuation Rights

DC layers several state mandates on top of the EHB list that the exam may probe:

• Dependent coverage to age 26 mirrors federal law, and DC extends coverage for a dependent who is incapable of self-support due to disability beyond that age.
• DC continuation (mini-COBRA) lets employees of small employers (fewer than 20) continue group coverage for 3 months after a qualifying event; federal COBRA covers employers with 20 or more for up to 18 or 36 months.
• External review: after exhausting internal appeals, a member may request an independent external review of an adverse benefit determination, with DISB overseeing the independent review organization process.
• Network adequacy and surprise-billing protections require carriers to maintain adequate provider networks and shield insureds from balance bills for out-of-network emergency care.

Exception to watch: short-term, limited-duration plans and certain grandfathered or large self-funded ERISA plans are not required to deliver the full EHB package, which is why an applicant comparing a cheap short-term plan to a marketplace plan can be misled — the short-term plan can still exclude pre-existing conditions and skip benefits like maternity. A producer who fails to disclose those gaps risks an unfair-trade-practice finding by DISB.