(a) The Authority shall:
(1) Establish the American Health Benefit Exchange to assist qualified individuals in the District with enrollment in qualified health plans;
(2) Establish a SHOP Exchange through which qualified employers may access coverage for their employees and shall enable any qualified employer to specify a level of coverage so that any of its employees may enroll in any qualified health plan offered through the SHOP Exchange at the specified level of coverage;
(3) Certify plans as qualified health plans as set forth in § 31-3171.09 and make such plans available to qualified individuals and qualified employers, as required by the Federal Act, with effective dates on January 1, 2014; provided, that the Authority shall not make available any health benefit plan that is not a qualified health plan.
(4) Have independent personnel authority to hire, retain, and terminate personnel as appropriate to perform the functions of the Authority consistent with Chapter 6 of Title 1 [§ l-601.01 et seq.], including establishing compensation and reimbursement consistent with the District’s wage grade and non-wage grade schedules;
(5) Have procurement authority independent of the Office of Contracting and Procurement, and shall not be subject to Chapter 3A of Title 2 [§ 2-352.01 et seq.]; except, that § 2-352.02(a), (b), (c), and (e) shall apply.
(6) Publish the average costs of licensing, regulatory fees, and any other payments required by the Authority, and the administrative costs of the Authority, on a website that is publically accessible, to educate consumers on these costs. This information shall include information on monies lost to waste, fraud, and abuse;
(7) Implement procedures for certification, recertification, and decertification, consistent with guidelines developed by the Secretary under section 1311(c) of the Federal Act and of this chapter, of health benefit plans as qualified health plans;
(8) Provide for the operation of a toll-free telephone hotline to respond to requests for assistance, utilizing staff who are trained to provide assistance in a culturally and linguistically appropriate manner;
(9) Provide for enrollment periods, as provided under section 1311(c)(6) of the Federal Act;
(10) Maintain a publically accessible website, through which enrollees and prospective enrollees of qualified health plans and dental plans may obtain standardized comparative information, including on health plan quality and performance, for such plans;
(11) Assign a rating to each qualified health plan offered through the exchanges in accordance with the criteria developed by the Secretary under section 1311(c)(3) of the Federal Act, and determine each qualified health plan’s level of coverage in accordance with regulations issued by the Secretary under section 1302(d)(2)(A) of the Federal Act;
(12) Use a standardized format for presenting health benefit options in the exchanges, including the use of the uniform outline of coverage established under section 2715 of the PHSA;
(13) Conduct eligibility determinations, in accordance with section 1413 of the Federal Act for the Medicaid program under title XIX of the Social Security Act, the Children’s Health Insurance Program under title XXI of the Social Security Act, or any other applicable District program pursuant to the policies and procedures established by the Department of Health Care Finance;
(14) Establish and make available, through a website that is publicly available, a calculator to determine the actual cost of coverage after application of any premium tax credit under section 36B of the Internal Revenue Code of 1986 and any cost-sharing reduction under section 1402 of the Federal Act, and, if feasible, which is designed to provide consumers with information on out-of-pocket costs for in-network and out-of-network services, taking into account any cost-sharing reductions;
(15) Grant a certification, subject to section 1411 of the Federal Act, attesting that, for purposes of the individual responsibility penalty under section 5000A of the Internal Revenue Code of 1986, an individual is exempt from the individual responsibility requirement or from the penalty imposed by that section because:
(A) There is no affordable qualified health plan available through the exchanges, or the individual’s employer, covering the individual; or
(B) The individual meets the requirements for another exemption from the individual responsibility requirement or penalty;
(16) Transfer to the Secretary of the United States Department of the Treasury the following:
(A) A list of the individuals who are issued a certification under paragraph (15) of this subsection, including the name and taxpayer identification number of each individual;
(B) The name and taxpayer identification number of each individual who was an employee of an employer who was determined to be eligible for the premium tax credit under section 36B of the Internal Revenue Code of 1986 because the employer:
(i) Did not provide minimum essential coverage; or
(ii) Provided the minimum essential coverage, but it was determined under section 36B(c)(2)(C) of the Internal Revenue Code of 1986 to either be unaffordable to the employee or did not provide the required minimum actuarial value; and
(C) The name and taxpayer identification number of:
(i) Each individual who notifies the Authority under section 1411(b)(4) of the Federal Act that he or she has changed employers; and
(ii) Each individual who ceases coverage under a qualified health plan during a plan year and the effective date of the cessation;
(17) Provide to each employer the name of each employee of the employer described in paragraph (16)(B) of this subsection who ceases coverage under a qualified health plan during a plan year and the effective date of the cessation;
(18) Perform the duties required of the Authority by the Secretary, or the Secretary of the United States Department of the Treasury, related to determining eligibility for:
(A) Premium tax credits;
(B) Reduced cost-sharing; or
(C) Individual responsibility requirement exemptions;
(19) Select entities qualified to serve as Navigators in accordance with section 1311(i) of the Federal Act, and standards developed by the Secretary, and award grants to enable Navigators to:
(A) Conduct public education activities to raise awareness of the availability of qualified health plans and qualified dental plans;
(B) Distribute fair and impartial information concerning enrollment in qualified health plans and qualified dental plans, and the availability of premium tax credits under section 36B of the Internal Revenue Code of 1986 and cost-sharing reductions under section 1402 of the Federal Act;
(C) Facilitate enrollment in qualified health plans and qualified dental plans;
(D) Provide referrals to an office of health insurance consumer assistance or health insurance ombudsman, including the Office of Health Care Ombudsman and Bill of Rights, or any other appropriate District agency, for any enrollee with a grievance or question regarding his or her health benefit plan, coverage, or a determination under that plan or coverage; and
(E) Provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the exchanges;
(20) Review the rate of premium growth within and outside the exchanges and consider the information in developing recommendations on whether to continue limiting qualified employer status to small employers;
(21) Consult with stakeholders relevant to carrying out the activities required under this chapter, including:
(A) Educated health care consumers who are enrollees in qualified health plans or qualified dental plans;
(B) Individuals and entities with experience in facilitating enrollment in qualified health plans or dental plans;
(C) Representatives of small businesses and self-employed individuals;
(D) The Department of Health Care Finance;
(E) Individuals who have experience enrolling difficult-to-reach populations in public insurance programs;
(F) Public health experts;
(G) Health care providers; and
(H) Office of Health Care Ombudsman and Bill of Rights;
(22) Meet the following financial integrity requirements:
(A) Keep an accurate accounting of all activities, receipts, and expenditures and annually submit to the Secretary, Mayor, Council, and the Commissioner a report of the accountings;
(B) Fully cooperate with any investigation conducted by the Secretary pursuant to the Secretary’s authority under the Federal Act;
(C) Allow the Secretary, in coordination with the Inspector General of the United States Department of Health and Human Services, to:
(i) Investigate the affairs of the Authority;
(ii) Examine the properties and records of the Authority; and
(iii) Require periodic reports in relation to the activities undertaken by the Authority; and
(D) In carrying out its activities under this chapter, not use any funds intended for the administrative and operational expenses of the Authority for:
(i) Staff retreats;
(ii) Promotional giveaways;
(iii) Excessive executive compensation; or
(iv) Promotion of federal or District legislative and regulatory modifications not contemplated under the Federal Act; and
(23) Administer the hardship and affordability exemptions under Chapter 51 of Title 47.
(b) In addition to certifying qualified health plans, the Authority shall allow a health carrier to offer a plan that provides limited scope dental benefits meeting the requirements of section 9832(c)(2)(A) of the Internal Revenue Code of 1986 through the exchanges, either separately or in conjunction with a qualified health plan, if the plan provides pediatric dental benefits meeting the requirements of section 1302(b)(1)(J) of the Federal Act.
(c) Neither the Authority nor a health carrier offering qualified health plans through the exchanges may charge an individual a fee or penalty for termination of coverage if the individual enrolls in another type of minimum essential coverage because the individual has become newly eligible for that coverage or because the individual’s employer-sponsored coverage has become unaffordable under the standards of section 36B(c)(2)(C) of the Internal Revenue Code of 1986.
(d) The operations of the Authority are subject to the provisions of this chapter whether the operations are performed directly by the Authority or through an entity under a contract with the Authority.
Effect of Amendments
Expiration of Law
Section 2 of D.C. Law 23-223 provided that § 2(a)(2), (3), and (4) of the act shall expire on September 30, 2023.
Section 1012 of D.C. Law 22-168 provided that §§ 2(a)(2), (3), and (4) and 3(a) of the act shall expire on September 30, 2023.
The second section designated as Section 3 of D.C. Law 20-94 provided that §§ 2(a)(2), 2(a)(3), 2(a)(4) and 3(a) of the act shall expire at the end of fiscal year 2018 [September 30, 2018].
For temporary (90 days) amendment of this section, see § 2 of the Health Benefit Exchange Authority Establishment Emergency Amendment Act of 2013 (D.C. Act 20-49, April 15, 2013, 60 DCR 6337, 20 DCSTAT 1355).
For temporary (90 days) amendment of this section, see § 2 of the Health Benefit Exchange Authority Establishment Congressional Review Emergency Act of 2013 (D.C. Act 20-125, July 26, 2013, 60 DCR 11136, 20 DCSTAT 1821).
For temporary (90 days) amendment of this section, see § 3(a) of the Procurement Practices Reform Exemption Emergency Amendment Act of 2014 (D.C. Act 20-282, February 20, 2014, 61 DCR 1576).
For temporary (225 days) amendment of this section, see § 2 of the Health Benefit Exchange Authority Establishment Temporary Amendment Act of 2013 (D.C. Law 20-11, July 13, 2013, 60 DCR 7236, 20 DCSTAT 1757).