For the purposes of this chapter, the term:
(1) "Benefits" means the health care services covered by a health insurer under a health benefits plan.
(2) "Department" means the Department of Insurance, Securities, and Banking.
(3) "Health benefits plan" shall have the same meaning as provided in § 31-3131(4).
(4) "Health insurer" shall have the same meaning as provided in § 31-3131(5).
(5) "In-network" means providers or health care facilities that have entered into a contract or agreement with a health insurer pursuant to which such entities are obligated to provide benefits to individuals enrolled with the health insurer's health benefits plan.
(6) "Market conduct examination" means an examination conducted by the Department to evaluate the practices and operations of a health insurer.
(7) "Medicaid" means the medical assistance programs authorized by Title XIX of the Social Security Act, approved July 30, 1965 (79 Stat. 343; 42 U.S.C. § 1396 et seq.), and by § 1-307.02, and administered by the Department of Health Care Finance.
(8) "Medication-assisted treatment" means the use of opioid addiction treatment medication to treat substance use disorders.
(9) "Mental health condition" means any condition or disorder involving mental illness that falls under any of the diagnostic categories listed in the mental disorders section of the current edition of the International Classification of Diseases or that is listed in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.
(10) "MHPAEA" means and includes the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, approved October 3, 2008 (Pub. L. No. 110-343; 122 Stat. 3881), and any federal guidance or regulations implementing MHPAEA, including 45 C.F.R §§ 146.136, 147.136, 147.160, and 156.115(a)(3).
(11) "Non-quantitative treatment limitation" means limitations imposed by a health insurer on the scope or duration of mental health condition and substance use disorder benefits for treatment, including:
(A) Medical management standards limiting or excluding benefits based on medical necessity, medical appropriateness, or whether the treatment is experimental or investigative;
(B) Formulary design for prescription drugs;
(C) For health benefit plans with multiple network tiers, such as preferred providers and participating providers, network tier design;
(D) Standards for provider admission to participate in a network, including reimbursement rates;
(E) Health benefits plan methods for determining usual, customary, and reasonable charges;
(F) Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective, including fail-first policies or step therapy protocols;
(G) Exclusions based on the failure to complete a course of treatment;
(H) Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services provided under the health benefits plan or coverage;
(I) In and out-of-network geographic limitations;
(J) Standards for providing access to out-of-network providers;
(K) Limitations on inpatient services for situations where the participant is a threat to self or others;
(L) Exclusions for court-ordered and involuntary holds;
(M) Experimental treatment limitations;
(N) Service coding;
(O) Exclusions for services provided by clinical social workers; and
(P) Network adequacy.
(12) "Out-of-network" means providers or health care facilities who have not entered into a contract or agreement with a health insurer pursuant to which such entities are obligated to provide benefits to individuals enrolled with the health insurer's health benefits plan.
(13) "Prescriber" shall have the same meaning as provided in § 48-841.02(3).
(14) "Prior authorization" means the process of obtaining prior approval from a health insurer for the provision of prescribed procedures, services, or medications.
(15) "Provider" shall have the same meaning as provided in § 31-3131(7).
(16) "Step therapy" shall have the same meaning as provided in § 48-855.01(12).
(17) "Substance use disorder" means a problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by symptoms identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.
(Mar. 13, 2019, D.C. Law 22-242, § 2, 66 DCR 930.)
Structure District of Columbia Code