Health Insurance Marketplace in the District of Columbia
If you live in the District of Columbia, DC Health Link is the Health Insurance Marketplace to serve you. Instead of HealthCare.gov, you’ll use the DC Health Link website to apply for coverage, compare plans, and enroll. Visit DC Health Link now to learn more.
Choosing the Right Health Insurance Plan
There are a number of different tiers of plans available on the DC Health Insurance Exchange. Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below:
NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.
Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you.
Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services.
Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you.
Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the DC insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently.
DC health insurers don’t have to offer every tier of plan, but within the DC health insurance exchange, all health insurance companies must offer at least one silver plan and one gold plan to consumers.
Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.
The District of Columbia will expand its Medicaid program in 2014 to cover households with incomes up to 133% of the federal poverty level. That works out to about $15,800 a year for 1 person or $32,500 for a family of 4. You can find out whether you qualify for Medicaid in the District of Columbia 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.
If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know with the form below and we’ll get right back to you.
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Accountable Care Organizations in DC
ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.
- Joslin Diabetes Center, Inc. DC – Health Care Innovation Award
- Mary’s Center For Maternal Child Care DC – Health Care Innovation Award
- George Washington University DC – Health Care Innovation Award
- San Francisco Community College DC – Health Care Innovation Award
- District of Columbia DC – Medicaid Emergency Psychiatric Demonstration
- Unity Health Care-Anacostia Health Center – 91824 Washington, DC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Unity Health Care-East of the River Health Center – 91803 Washington, DC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Unity Health Care-Federal City Shelter-CCNV – 91806 Washington, DC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Unity Health Care-Hunt Place Health Center – 91821 Washington, DC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Unity Health Care-Southwest Health Center – 91831 Washington, DC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Unity Health Care-Walker Jones Health Center – 91822 Washington, DC – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Medical House Calls Program at MedStar Washington Hospital Center Washington, DC – Independence at Home Demonstration
- Stephanie Bruce MD Washington, DC – Innovation Advisors Program
- Providence Hospital Washington, DC – Strong Start for Mothers and Newborns
- Howard University Hospital Washington, DC – Strong Start for Mothers and Newborns
- Mary’s Center Washington, DC – Strong Start for Mothers and Newborns
- Community of Hope’s Family Health and Birth Center Washington, DC – Strong Start for Mothers and Newborns
- MedStar Washington Hospital Center Washington, DC – Strong Start for Mothers and Newborns
- Unity Health Care Washington, DC – Strong Start for Mothers and Newborns
The Insurance Exchange/Marketplace
What has been done, not been done, or left up to the federal government to do.
Establishing the Exchange in District of Columbia
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
The creation of the DC Exchange built on implementation efforts by the Health Reform Implementation Committee (HRIC) established by Mayor Gray through an Executive Order in May 2011.3 The Committee was comprised of Directors of District government agencies implementing health reform and oversees subcommittees for insurance, communications, health delivery system, Medicaid expansion and eligibility, Exchange operations, and Exchange information technology. In October 2011, the HRIC submitted final recommendations to the Mayor for the establishment of a health insurance exchange, many of which were incorporated in the final legislation.4
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: The Exchange is governed by an 11-member board. The Mayor appoints seven voting Board members all of whom will be residents of the District of Columbia. Appointments will be subject to confirmation by the Council. There will be 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 Exchange 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 Exchange 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 Exchange Board. Additionally, they cannot accept employment with any carrier that participates in the Exchange for at least one year after ending their service.
Current appointed Board members are:
- Mohammad Akhter, M.D., DC Department of Health (Chair)
- 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, Robert Wood Johnson Foundation
- Diane C. Lewis, health care policy consultant
- Kevin Lucia, Health Policy Institute of Georgetown University
The Exchange 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 Exchange 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. Most working groups have completed their work; however, as of June 2013, the Financial Sustainability and Quality groups continue to meet.5
Contracting with Plans: The Exchange 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 the Exchange will contract with all licensed carriers that meet minimum Qualified Health Plan (QHP) requirements. Health plans participating in the Exchange 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.6 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.7 There will be no limit on the number of Qualified Health Plans (QHPs) sold on the Exchange.
In May 2013, four insurers filed a total of 34 individual plans and 259 small group products for approval with DISB and in June submitted proposed rates.89 DISB will review rate and form filings to ensure carrier compliance with federal standards and will also review carrier certification submissions. In addition, the Exchange is contracting with an actuarial firm to review rate filings and provide input to DISB throughout the process. Rates may not be adjusted for tobacco use or geography. DISB will notify carriers of approval or disapproval of plan rate and form filings and carrier certification by June 30. Approved carriers must submit documentation for final certification by August 11 and DISB will notify carriers of final certification by August 23.10
In June 2013, the DC City Council passed legislation requiring carriers to sell all individual and small group products through the Exchange, effectively dissolving the non-Exchange individual and small group markets. Individual plans may only be offered through the Exchange beginning on January 1, 2014, while small group plans have until January 1, 2015 to transition to the Exchange.11 In addition, the SHOP and Individual Exchange markets will be merged into a single risk pool.10
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 Exchanges to standardize the information that their QHPs collect and report through QIPs.12 The Board approved the recommendations in June 2013.13
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 2016.14
Dental and Vision Benefits: DC’s Exchange authorizing legislation requires the Exchange 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.15 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.16
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 the Exchange.
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, with a particular focus on the LGBT community, those with limited English proficiency, and those without easy access to the internet. Organizations known as IPA Entities will recruit and hire individual assisters to carry out in-person services. The HBX will develop a training curriculum and assisters must pass a competency exam in order to become certified.17 In May 2013, the HBX released a Request for Applications (RFA) for organizations to serve as IPA Entities. Applications are due by June 24 and grants will be awarded at the end of July.18
In April 2013, the HBX released a Request for Proposals (RFP) for a contractor to design, build, and operate a contact center. The contractor will also be responsible for hiring and training customer service representatives. Applications were due in mid-May and are under review by the HBX.19 In June 2013, the HBX issued a RFP for a vendor to develop and implement a communications and marketing campaign to educate individuals and small businesses about the Exchange. Applications must be submitted by June 24.20 Also in June, 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.21
Small Business Health Options Program (SHOP) Exchange: The SHOP Exchange 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 2016.22 Legislation approved by the DC City Council in June 2013 requires all small business owners to purchase coverage through the Exchange, as of 2015.11 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.23 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.24
Information Technology (IT): The District plans to build the DC Access System (DCAS), an integrated eligibility system for Medicaid, the Exchange, and other human services programs. In July 2012, the Department of Health Care Finance and the Department of Health Services jointly released a final Request for Proposals to procure a Systems Integration vendor to implement DCAS and awarded a contract in January 2013.2526 Earlier in the year the Department of Health Care Finance solicited subcontractors to facilitate the development of the Exchange’s IT system and develop an IT blueprint.27 In May 2013, the Exchange completed a second wave of testing conducted by the federal government, successfully establishing a secure connection and exchanging information with the federal data hub.28
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 Exchange. All revenue will be maintained in a non-lapsing fund to be administered by the Exchange 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 the Exchange. 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.29 In June 2013, the Board approved the recommendation.30
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 Exchange, 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 Exchange Board and the Mayor after a month of public comment.31 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 Exchange and the first year of operations.32
Expansion of Medicaid
From 2014 to 2017, the federal government will pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA.
As the ACA was originally written, states would lose all Medicaid funding if they refused to expand their program to the ACA minimum.
However, the Supreme Court in June 2012 ruled that the federal government could not withhold Medicaid funding for states that chose not to expand their programs. The decision effectively allowed state officials to opt out of the expansion, and some have said they will do just that.
The District of Columbia is participating in Medicaid expansion.
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 exchange.33 Final approval is contingent upon the District demonstrating its ability to perform all required Exchange activities on time and comply with future guidance and regulations as well as the Exchange’s ability to ensure a sustainability model.
Additional information on the District of Columbia’s Health Benefit Exchange Authority can be found at: http://hbx.dc.gov/.
- 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.
- District of Columbia Executive Order #2011-106. “Establishment- Mayor’s Health Reform Implementation Committee.”
- “Recommendations on the Establishment of a Health Insurance Exchange by and for the District of Columbia.” Mayor’s Health Reform Implementation Committee. October 18, 2011.
- 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. “Private Insurers Submit 293 Health Insurance Policies for Approval to Offer to Individuals, Small Businesses on DC Exchange.” May 17, 2013.
- DC Health Benefit Exchange Authority. “Health Insurers File Almost 300 Health Plans for Sale on the DC Exchange.” June 7, 2013.
- DC Health Benefit Exchange Authority. Carrier Reference Manual. June 2013.
- “Better Prices, Better Quality, Better Choices for Health Coverage Emergency Amendment Act of 2013.” 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 Health Benefit Exchange Authority. Request for Applications In-Person Assister Program. May 24, 2013.
- DC Health Benefit Exchange Authority. Request for Proposals Contact Center. April 15, 2013.
- DC Health Benefit Exchange Authority. Request for Proposals Full Service Communications and Marketing Services. June 3, 2013.
- “DC Exchange Launches New Partnerships with Leading Business Advocates.” June 18, 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.
- District of Columbia Department of Human Services in conjunction with the District of Columbia’s Department of Health Care Finance. Draft Statement of Work for System Implementation. District of Columbia Access System. 2012.
- Washington Business Journal. “DC awards $49 million IT contract for health exchange to Infosys.” January 9, 2013.
- DC Department of Health Care Finance. DHCF Announces Contract Awards for District’s Health Benefit Exchange IT System and Health Information Exchange Network. March 27, 2012.
- DC Health Benefit Exchange Authority. “DC Exchange Is First to Pass Wave 2 of Federal IT Systems Testing.” May 9, 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.
- HealthCare.gov. “Creating a New Competitive Marketplace: Health Insurance Exchange Establishment Grants Awards List.”
- Letter from HHS to Mayor Gray. December 14, 2012.