District of Columbia Health Insurance Protection Guidelines.
Affordable Health Insurance in the District of Columbia...

Here are some of the main features you will want to know about regarding acquiring and keeping Group Health Care Plans in the District of Columbia...

• You have to be eligible for the group health plan.
     For example, your employer may not give health benefits to all employees. Or, your employer may offer a health maintenance organization (HMO) plan that you cannot join because you live outside of the plan’s service area.
• You cannot be turned away or charged more because of your health status.
     This protection is called nondiscrimination. Employers may refuse or restrict coverage for other reasons (such as part time employment) as long as these are unrelated to health status and applied consistently.
• Know your health insurance plan's rules. Then follow them.
     Remember, if you don't follow the rules, your insurer can deny your claim and you'll wind up getting stuck with the bill. For example, is your alergist included in your health plan's network of doctors or do you need pre-authorization for outpatient surgery.
• Discrimination due to health status is not permitted.
     The ABC Company offers two different health plans. Full time employees are offered a high option plan that covers prescription drugs; part time employees are offered a low option plan that does not. This is permitted under the law. By contrast, in a cost-cutting move, ABC restricts its high option plan to employees who can pass a physical examination. This is not permitted under the law.
• You must be given a special opportunity to sign up for your group health plan if certain changes happen to your family.
     In addition to any regular enrollment period your employer or group health plan offers, you must be offered a special, 30-day opportunity to enroll in your group health plan after certain events. You can elect coverage at this time. If your group health plan offers family coverage, your dependents can elect coverage as well. Enrollment during a special enrollment period is not considered late enrollment.
• When you begin a new job, your employer may require a waiting period before you can sign up for health coverage.
     This waiting period is called an affiliation period, and you will not have health insurance coverage during this time. An affiliation period cannot exceed 60 days (90 days for late enrollees), and you cannot be charged a premium during it.
• An insurer may require that the parent enroll a dependent within the 30 days in order to continue coverage beyond the 30 days.
  In the District of Columbia, newborns, adopted children and children placed for adoption are automatically covered under the parents’ fully insured health plan for the first 30 days, if the plan covers dependents.
• If you have to take leave from your job due to illness, the birth or adoption of a child, or to care for a seriously ill family member, you may be able to keep your group health coverage for a limited time.
     A federal law known as a Family and Medical Leave Act (FMLA) guarantees you up to 12 weeks of job protected leave in these circumstances. If you qualify for leave under FMLA, your employer must continue your health benefits. You will have to continue paying your share of the premium. The FMLA applies to you if you work at a company with 50 or more employees. If you qualify for leave under FMLA, your employer must continue your health benefits. You will have to continue paying your share of the premium. For more information about your rights under FMLA, contact the U.S. Department of Labor.
• The District of Columbia also has a law that requires employers to continue your health benefits while you take a leave of absence because you are taking family or medical leave.
     This law covers some workers who are not covered by the FMA. The D.C. law applies to all employees, not just employers with 50 or more employees. You are eligible for D.C. family or medical leave if you have worked for 1000 hours for one year. You can take up to 16 weeks of D.C. family leave during a 12-month period (24 month period to care for a family member). You can take up to 16 weeks for medical leave during a 24-month period. Where the District of Columbia and federal law differ, employers are required to give you the benefit of the more generous law.
• CAN A GROUP HEALTH PLAN LIMIT MY COVERAGE FOR PRE-EXISTING CONDITIONS?
     When you first enroll in a group health plan, the employer or insurance company may ask if you have any pre-existing conditions. Or, if you make a claim during the first year of coverage, the plan may look back to see whether it was for such a condition. If so, it may exclude coverage for services related to that condition for a certain length of time. However, federal and state laws protect you by placing limits on these pre-existing condition exclusion periods under group health plans. In some cases your protections will vary, depending on the type of group health plan.
• Most health insurance coverage is creditable coverage.
     When you join a new group health plan, the law protects you from a new pre-existing condition exclusion period, provided you maintain continuous creditable coverage.
• What is creditable coverage?
     Most health insurance counts as creditable coverage, including:
  
  * Federal Employees Health Benefits (FEHBP)
      Medicare
  * Group health insurance (including COBRA)
      Military health coverage
  * Indian Health Service
      (CHAMPUS)
  * Individual health insurance
      State health insurance
  * Medicaid
      high risk pools
  
  In most cases, you should get a certificate of creditable coverage when you leave a health plan. You also can request certificates at other times. If you cannot get one, you can submit other proof, such as old health plan ID cards or statements from your doctor showing bills paid by your health insurance plan.
• Coverage counts as continuous if it is not interrupted by a break of 63 or more days in a row.
     You can get continuous coverage under one plan, or under several plans as long as you don’t have a lapse of 63 or more consecutive days. Take Jim, who has diabetes. ABC Company covered him under its group health plan for 9 months, but he lost his job and health coverage. Then, 45 days later, Jim found a new job at 123 Corporation and had health coverage for 9 more months. Jim changed jobs again. His new company, EDF, has a health plan that covers care for diabetes but excludes pre-existing conditions for 12 months. EDF must cover Jim’s diabetes care immediately, because his 18 months of prior continuous coverage are credited against the 12-month exclusion.
  
  Now consider a slightly different situation. Assume Jim was uninsured for 90 days between his jobs at ABC and 123. In this case, EDF will credit coverage only under 123’s plan toward the 12-month pre-existing condition exclusion period. EDF’s plan will begin paying for Jim’s diabetes care in 3 months (1 year minus 9 months). Jim does not get credit for his coverage at ABC since he had a break of more than 63 consecutive days.

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