Code of the District of Columbia

§ 31–3171.16. Implementation and reports.

(a) The executive board shall:

(1) Study, in consultation with the advisory boards established under this chapter and with other stakeholders:

(A) The feasibility and desirability of the Authority engaging in:

(i) Selective contracting, either through competitive bidding or a negotiation process similar to that used by large employers, to reduce health care costs and improve quality-of-care by certifying only those health benefit plans that meet certain requirements, such as:

(I) Promoting patient-centered medical homes;

(II) Adopting electronic health records;

(III) Meeting minimum outcome standards;

(IV) Implementing payment reforms to reduce medical errors and preventable hospitalizations;

(V) Reducing disparities;

(VI) Ensuring adequate reimbursements;

(VII) Enrolling high-risk members and underserved populations;

(VIII) Managing chronic conditions and promoting healthy consumer lifestyles;

(IX) Value-based insurance design;

(X) Adhering to transparency guidelines; and

(XI) Uniform price and quality reporting;

(ii) Multistate contracting; and

(iii) Entering into a regional exchange;

(B) The rules under which health benefit plans should be offered inside and outside the exchanges in order to mitigate adverse selection and encourage enrollment in the exchanges, including:

(i) Whether any benefits should be required of qualified health plans beyond those mandated by the Federal Act, and whether any such additional benefits should be required of health benefit plans offered outside the exchanges;

(ii) Whether health carriers offering health benefit plans outside the exchanges should be required to offer either all the same health benefit plans inside the exchanges or, alternatively, at least one health benefit plan inside the exchanges;

(iii) Whether managed care organizations with Health Choice contracts should be required to offer products inside the exchanges;

(iv) Whether health carriers offering health benefit plans inside the exchanges should be required to also participate in the District medical assistance program; and

(v) Which provisions applicable to qualified health plans should be made applicable to qualified dental plans;

(C) The design and operation of the Authority’s Navigator program and any other appropriate consumer-assistance mechanisms, including:

(i) How the Navigator program could utilize, interact with, or complement private-sector resources, including insurance producers;

(ii) The infrastructure of the existing private sector health insurance distribution system in the District to determine whether private sector resources may be available and suitable for use by the Authority;

(iii) The effect the exchanges may have on private sector employment in the health insurance distribution system in the District;

(iv) What functions, in addition to those required by the Federal Act, should be performed by Navigators;

(v) What training and expertise should be required of Navigators, and whether different markets and populations require Navigators with different qualifications;

(vi) How Navigators should be retained and compensated, and how disparities between Navigator compensation and the compensation of insurance producers outside the exchanges can be minimized or avoided;

(vii) How to ensure that Navigators provide information in a manner culturally, linguistically, and otherwise appropriate to the needs of the diverse populations served by the Authority, and that Navigators have the capacity to meet these needs; and

(viii) What other means of consumer assistance may be appropriate and feasible, and how they should be designed and implemented;

(D) The design and function of the SHOP Exchange beyond the requirements of the Federal Act, to promote quality, affordability, and portability, including:

(i) Whether it should be a defined contribution/employee choice model or whether employers should choose the qualified health plan to offer their employees;

(ii) Whether the current individual and small group markets should be merged; and

(iii) Whether the SHOP Exchange should be made available to employers with 50 to 100 employees prior to 2016, as authorized by the Federal Act;

(E) How the Authority will ensure financial integrity in compliance with the Federal Act, including:

(i) A recommended plan for the budget of the Authority;

(ii) The user fees, licensing fees, or other assessments that should be imposed by the Authority to fund its operations, including what type of user fee cap or other methodology would be appropriate to ensure that the income of the Authority comports with the expenditures of the Authority; and

(iii) A recommended plan for how to prevent fraud, waste, and abuse; and

(F) How the Authority should conduct its public relations and advertising campaign, including what type of solicitation, if any, of individual consumers or employers, would be desirable and appropriate; and

(2) Report its findings under paragraph (1) of this subsection to the Mayor, Council, and public within 180 days of March 2, 2012.

(b)(1) The executive board shall prepare a plan that identifies how the Authority will be financially self-sustaining by January 1, 2015.

(2) The plan, which shall be certified by an independent actuary as actuarially sound, shall be submitted to the Mayor and Council not later than December 15, 2013.


(Mar. 2, 2012, D.C. Law 19-94, § 17, 59 DCR 213.)