State Marketplace Profiles: District of Columbia
Final update made on October 1, 2013 (no further updates will be made)
Establishing the Marketplace
On December 20, 2011 the District of Columbia City Council gave final approval to a bill establishing the District of Columbia Health Benefit Exchange Authority (HBX) and in late January 2012, Mayor Vincent Gray (D) signed the legislation into law (Act 19-269).1 The bill was also subject to a 30-day Congressional review. In June 2013, the District of Columbia announced that its new marketplace would be called DC Health Link.2
Structure: The legislation defines the District of Columbia Health Benefit Exchange Authority as a quasi-governmental organization, specifically “an independent authority of the District government.”
Governance: DC Health Link is governed by an 11-member board. The Mayor appoints seven voting Board members all of whom are residents of the District of Columbia. Appointments are subject to confirmation by the Council. There are four non-voting ex-officio members, or their designees, the Director of the Department of Health Care Finance (DHCF), the Commissioner of the Department of Insurance, Securities, and Banking, the Director of the Department of Health, and the Director of the Department of Human Services. Each voting Board member will have demonstrated expertise in at least two of the following areas: individual or small employer coverage, health benefits plan administration, health care finance, administering a public or private health care delivery system, purchasing health plan coverage, prior experience in commercial insurance management, actuarial analysis, health care economics, human services administration, health care consumer interest advocacy, public health programs, or enrolling individuals into health benefit plans. At least one voting member must have knowledge of health care consumer interest advocacy.
Members of the Board or of the Marketplace staff cannot share any affiliation with an insurer, an agent or broker, a health professional, or a health care facility or clinic. Board members and Marketplace staff cannot be health care providers, unless they receive no compensation for medical services rendered; and the provider can have no ownership interest in a professional health care practice. Board members and staff cannot be members, board members, or employees of a trade association of carriers, health facilities, health clinics, or health professionals while serving on the Board. Additionally, they cannot accept employment with any carrier that participates on DC Health Link for at least one year after ending their service.
Current appointed Board members are:
- Mohammad Akhter, M.D., DC Department of Health
- Henry J. Aaron, Brookings Institution
- Leighton Ku, Center for Health Policy Research at George Washington University
- Khalid Pitts, Service Employees International Union
- Kate Sullivan Hare, Health Policy Insight & Strategy
- Diane C. Lewis, ALTA Consulting Group (Chair)
- Kevin Lucia, Health Policy Institute of Georgetown University
The Board hired an Executive Director in December 2012. In addition, the legislation calls for an Advisory Board consisting of nine members who are residents of the District to provide recommendations to the Board on issues ranging from insurance standards to covered benefits. The Advisory Board began meeting in January 2013.
The HBX established fifteen Advisory Working Groups to engage consumer and community groups in implementing aspects of the Exchange. Each working group, chaired by a Board member and vice-chaired by a member of the Advisory Board, is tasked with a specific issue to address. Stakeholders attend working group meetings and contribute to developing recommendations for the Board. As of June 2013, all working groups had completed their tasks.3
Contracting with Plans: The Board has the authority to “limit the number of plans offered in the exchanges using selective criteria or contracting, provided individuals and employers have an adequate number and selection of choices.” While the legislation grants the HBX the ability to enter into selective contracting with carriers, for the initial launch DC Health Link will contract with all licensed carriers that meet minimum Qualified Health Plan (QHP) requirements. Health plans participating in DC Health Link must offer at least one bronze level, one silver level, and one gold level plan, as well as a child-only plan at the same level of coverage as any other plan offered.4 The Department of Insurance, Securities and Banking (DISB) will develop one or more standardized benefit plans at the silver and gold metal levels for the 2015 plan year and for the bronze and platinum metal levels by the 2016 plan year. For each metal level in which they participate, carriers must offer at least one standardized plan.5 There will be no limit on the number of Qualified Health Plans (QHPs) sold through DC Health Link. Four insurers will offer a total of 301 products on DC Health Link in 2014, and DISB approved rates for plans sold in the individual and SHOP marketplaces in July 2013. Rates may not be adjusted for tobacco use or geography.
In June 2013, the DC City Council passed legislation requiring carriers to sell all individual and small group products through DC Health Link, effectively dissolving the non-Marketplace individual and small group markets. Individual plans may only be offered through the Marketplace beginning on January 1, 2014, while small group plans have until January 1, 2015 to transition to DC Health Link.6 In addition, the SHOP and individual markets will be merged into a single risk pool.7
In May 2013, the Quality Working Group recommended that the HBX specify the requirements and format for a standardized Quality Improvement Plan (QIP) for 2015, taking into account federal requirements. The working group also recommended that the HBX work with the Maryland and Virginia Marketplaces to standardize the information that their QHPs collect and report through QIPs.8 The Board approved the recommendations in June 2013.9
Carriers must meet the Affordable Care Act’s network adequacy standards in 2014. The HBX will work with DISB to gather network adequacy data and assess where deficiencies remain in order to establish DC-specific network standards by 2016.10
Dental and Vision Benefits: DC’s Exchange authorizing legislation requires DC Health Link to offer stand-alone dental plans. The pediatric essential health benefit may be offered as a stand-alone dental plan, embedded in a QHP, or in conjunction with a QHP as long as the plans are priced separately and are available for purchase separately at the same price.11 Issuers offering stand-alone pediatric dental plans may offer non-pediatric dental plans as well. QHPs are required to make clear whether or not they offer the pediatric dental essential health benefit. In April 2013, the Board approved a $1,000 out-of-pocket maximum for Qualified Dental Plans (QDPs) with one child enrollee and a $2,000 limit for plans with two or more child enrollees.12
Risk adjustment, Reinsurance, and Risk corridors: In April 2012, the HRIC’s Insurance Subcommittee recommended the District opt into a federally administered risk adjustment and reinsurance program for DC Health Link.
Consumer Assistance and Outreach: In April 2013, the Board voted to establish an In-Person Assister (IPA) Program to focus on outreach and enrollment of the uninsured and hard-to-reach populations in all eight of the District’s wards.13
Grantee organizations will recruit and hire individual assisters, known as DC Health Link Assisters to conduct education and enrollment assistance. In August 2013, the HBX awarded $6.4 million in grant funding to 35 community-based organizations to fund education and enrollment assistance services. Awardees include faith-based organizations, community health care providers, business associations, consumer advocacy groups, and organizations serving those with HIV/AIDS. DC Health Link Assisters must complete five days of training courses (over 30 hours total) and pass daily tests, a final exam, and a criminal background check in order to be certified. By mid-September, 94 assisters had been certified and the Marketplace expects to certify over 100 more assisters in October.14
In June 2013, DC launched partnerships with the DC Chamber of Commerce and the Greater Washington Hispanic Chamber of Commerce to conduct outreach and inform small business owners about the insurance options available to them through DC Health Link.15 In September 2013, DC Health Link announced a partnership with the city’s professional soccer team, DC United, to raise awareness about the Marketplace among young adults, particularly black and Hispanic men.16 Also in September, DC Health Link launched a partnership with CVS to raise awareness of the law. All 59 CVS locations in the District of Columbia will provide informational brochures, in English and Spanish, and almost 30 locations will host special enrollment events during which DC Health Link Assisters will be onsite to answer consumer questions and provide enrollment assistance.17
In September 2013, DC Health Link launched a six-month advertising campaign to raise awareness of the DC Health Link Marketplace and inform consumers about how to sign up for coverage. The campaign is focused on advertising in outdoor spaces, such as buses, bus stops, Metro stops, and billboards. The advertisements will be concentrated in neighborhoods with particularly high concentrations of the uninsured. Advertisements for DC Health Link are also featured on cable television, newspapers, radio, and the internet.18
It is expected that when customers need a recommendation for selecting a particular plan, DC Health Link Assisters will refer them to a broker for assistance. In order to sell products on DC Health Link, brokers must be licensed to sell insurance in DC and must complete eight hours of training. Brokers may sell in the individual market and/or the small group market and must be appointed with each carrier offering products in the market(s) they intend to participate in. The Marketplace will not compensate brokers, as they will continue to be paid for their services by insurance carriers.19
In July 2013, the HBX selected a vendor to design, build, staff, and operate the DC Health Link contact center. As of early September, 23 customer service representatives has been hired, a third of whom speak Spanish or Amharic. The contact center opened with a soft launch on September.20
Small Business Health Options Program (SHOP) Marketplace: The SHOP Marketplace will be limited to small businesses with 50 or fewer employees in 2014 but will expand to include businesses with up to 100 employees in 2016.21 Legislation approved by the DC City Council in June 2013 requires all small business owners to purchase coverage through DC Health Link, as of 2015.6 SHOP employers may offer their employees all QHPs offered by all issuers in one metal level, all QHPs that one issuer offers in any two contiguous metal levels, or a single QHP offered by one issuer.22 Employers must contribute at least 50% of the employee’s reference plan premium and must have a participation rate of two-thirds of qualified SHOP employees who do not have another source of coverage.23
Financing: The legislation authorizes the Health Benefit Exchange Authority to charge user fees, licensing fees, and other assessments on health carriers selling qualified dental or health plans inside and outside the Marketplace. All revenue will be maintained in a non-lapsing fund to be administered by the Board. In May 2013, the Financial Sustainability Working Group recommended using the existing 2% premium tax and/or the .3% DISB operating assessment to support DC Health Link. If the HBX staff determines this is not feasible or that additional funds are needed, a broad-based assessment on all health insurance premiums should be used.24 In June 2013, the Board approved the recommendation.25
Essential Health Benefits (EHB): The Affordable Care Act requires that all individual and small-group plans sold in a state, including those offered through the Marketplace, cover certain defined health benefits. States must decide whether to benchmark their EHB plan to one of ten plans operating in the state or default to the largest small-group plan in the state. States were encouraged to select the benchmark EHB plan by the end of September 2012. In August 2012, the HRIC’s Insurance Subcommittee released a proposed EHB recommendation for the District which will be considered by the DC Health Link Board and the Mayor after a month of public comment.26 With the help of subcontractors, the Insurance Subcommittee recommended BlueCross BlueShield CareFirst BluePreferred plan as the District’s EHB benchmark plan.
In September 2010, the District of Columbia Department of Health Care Finance received a federal Exchange Planning grant of $1 million. The same Department received a federal Level One Establishment grant of $8.2 million in August 2011 to leverage the data, information, and indicators gathered in the preliminary planning effort into a comprehensive project design. In September 2012, the District of Columbia received a Level Two grant of $73 million to develop an IT system and to fund creation of the DC Health Link Marketplace and the first year of operations.27
On December 14, 2012, the District of Columbia received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a State-based Marketplace.28 While consumers are able to enroll in QHPs through the online DC Health Link portal as of October 1, the system is not yet ready to calculate subsidy amounts or to determine Medicaid eligibility. These two functions are expected to become available online around November 1. Consumers who enroll into coverage prior to November 1 and are eligible for subsidies will be notified by email in November.29
D.C. Act 19-269. Enrolled Original. Health Benefit Exchange Authority Establishment Act for the District of Columbia. January 17, 2012.
“DC Unveils New Name and Logo for Health Insurance Marketplace.” June 13, 2013.
Health Benefit Exchange Authority. Advisory Working Groups.
DC Health Benefit Exchange Authority. Resolution to establish additional QHP certification standards to promote benefit standardization in the Exchange. March 13, 2013.
DC Health Benefit Exchange Authority. Resolution to establish further EHB standards and to establish additional QHP certification standards. March 22, 2013.
DC Health Benefit Exchange Authority. Carrier Reference Manual. June 2013.
DC Health Benefit Exchange Authority. Quality Working Group Report. May 29, 2013.
DC Health Benefit Exchange Authority. Resolution to establish a strategy for the DC Health Benefit Exchange to improve the quality of care offered by Qualified Health Plans, including through quality reporting requirements. June 6, 2013.
DC Health Benefit Exchange Authority. Network Adequacy Working Group Report. March 5, 2013.
DC Health Benefit Exchange Authority. Dental Working Group Report. April 13, 2013.
DC Health Benefit Exchange Authority. Resolution to establish a reasonable out-of-pocket maximum for Qualified Dental Plans. April 18, 2013.
Consumer Assistance and Outreach Advisory Committee. In-Person Assister Recommendations to the DC Health Benefit Exchange Board. April 15, 2013.
“DC Exchange Launches New Partnerships with Leading Business Advocates.” June 18, 2013.
“DC Health Link Fields Deal with D.C. United.” September 12, 2013.
“DC Health Link Partners With CVS/pharmacy to Raise Awareness of Health Law." September 18, 2013.
“Health exchange partners with D.C. United in big campaign.” September 11, 2013.
DC Health Benefit Exchange Authority. “Brokers – What You Need to Know to Sell in DC Health Link."
DC Health Link. Contact Center Encounter Summary Report. September 2013.
DC Health Benefit Exchange Authority. Resolution to establish a transition process for individual and small business health benefit plan enrollees into the Marketplace Exchange. March 13, 2013.
DC Health Benefit Exchange Authority. Resolution to establish the range of plan selection choices for plan year 2014, within the SHOP Exchange. April 4, 2013.
DC Health Benefit Exchange. Resolution to establish the minimum employer contribution and minimum employee participation standards within the SHOP. April 8, 2013.
DC Health Benefit Exchange Authority. Recommendations of the Working Group on Financial Sustainability. May 23, 2013.
DC Health Benefit Exchange Authority. Resolution to establish a financial sustainability plan for the operating costs of the DC Health Benefit Exchange. June 6, 2013.
District of Columbia Health Benefits Exchange Insurance Subcommittee. Essential Health Benefits Bulletin. August 29, 2012.
District of Columbia Health Insurance Marketplace Grants Awards List.
Letter from HHS to Mayor Gray. December 14, 2012.
“Key Functions of D.C. Health Exchange Delayed.” September 25, 3013.