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Washington, DC health insurance marketplace guide 2023

Open enrollment for individual/family plans runs through January 31 in the District

District of Columbia marketplace overview

The District of Columbia has a district-run health insurance exchange — DC Health Link — with several carriers offering coverage in both the individual and small group markets. Average premiums increased by more than 13% in both markets for 2023; in the individual/family market, premium subsidies grow to keep pace with the benchmark plan, helping to offset rate increases.

Unlike the rest of the country, there is no “off-exchange” market in the District; enrollment in individual and small group plans can only be done through DC Health Link. And Washington, D.C. has a requirement that residents maintain health coverage, with a penalty for non-compliance.

The plans available through DC Health Link include both standardized and non-standardized plans. All of the plans are compliant with the ACA, but standardized plans also conform to additional District-specific rules that include pre-deductible coverage for a variety of services. Starting in 2024, 

The annual open enrollment period for individual/family coverage is longer in Washington, D.C. than it is in most other states, continuing through January 31.

Outside of the open enrollment period, a qualifying event is required to enroll or make changes to coverage. But during the COVID public health emergency period, there has been an ongoing enrollment opportunity for uninsured DC residents. And Washington, D.C. is one of just six state-run exchanges where pregnancy is considered a qualifying life event, making it easier for someone who is pregnant to obtain health coverage.

Frequently asked questions about District of Columbia's ACA marketplace

In DC, coverage in the individual and small-group markets is only available through DC Health Link, the state-run exchange; there’s no option to select an off-exchange plan.

The District of Columbia was an early adopter in moving to implement a health insurance exchange. The Health Reform Implementation Committee (HRIC), formed at the direction of then-Mayor Vincent Gray, issued its final recommendations in October 2011. The D.C. City Council adopted many of the committee’s recommendations and passed a bill to create the District of Columbia Health Benefit Exchange Authority, which Gray signed into law in January 2012. The District of Columbia received federal approval to operate a state-based exchange in December 2012.

In June 2013, the exchange was rebranded as DC Health Link, and that name has continued to be used ever since.

There are several insurers that offer exchange plans in DC, although most of them offer plans for small businesses, as opposed to individual/family plans (unlike most exchanges, DC’s exchange has a robust small business market, due largely to the fact that small group plans cannot be purchased outside the exchange in DC). And most of the insurers have both HMO and PPO entities.

The following insurers offer individual/family plans in the Washington, DC exchange as of 2023:

  • Group Hospitalization and Medical Services (CareFirst PPO)
  • CareFirst Blue Choice (CareFirst HMO)
  • Kaiser of the Mid-Atlantic States.

The District of Columbia’s small-group insurers include:

  • Aetna Life (PPO)
  • Aetna Health (HMO)
  • CareFirst HMO
  • GHMSI/CareFirst PPO
  • Kaiser
  • Optimum Choice (a UnitedHealthcare HMO)
  • UnitedHealthcare of the Mid-Atlantic (HMO)
  • UnitedHealthcare Insurance Company (PPO)

In both markets, there was no change in insurer participation from 2022 to 2023; all of the same insurers have continued to offer coverage through DC Health Link.

In October 2022, the DC Department of Insurance, Securities, and Banking published the approved rate changes for 2023 health plans. The weighted average rate changes amounted to 13.6% for individual market plans, and 13.3% for small group plans. 

As had been the case in prior years, some of the approved rate increases were smaller than the insurers had proposed, due to adjustments made during the rate review process.

The following average rate changes were approved for DC’s individual market insurers:

  • Group Hospitalization and Medical Services (CareFirst PPO): 11.7% average rate increase. GHMSI had 7,925 enrollees in the individual market.
  • CareFirst Blue Choice (CareFirst HMO): 15% average rate increase. CareFirst had 3,758 enrollees in the individual market.
  • Kaiser of the Mid-Atlantic States: 17% average rate increase. Kaiser has 2,694 enrollees in the individual market.

The insurers offer a total of 27 different plans in the individual market, for people who need to buy their own coverage. This is unchanged from the number of plans that they offered in 2022.

Only about 16% of DC Health Link’s individual market enrollees were receiving premium subsidies as of early 2022. That’s dramatically lower than the national average (about 89%), but it’s quite a bit higher than the year before, when only about 7% of DC Health Link enrollees were receiving premium subsidies. The increase is due to the American Rescue Plan’s subsidy enhancements, which took effect in the spring of 2021 and are available through the end of 2025, thanks to an extension created by the Inflation Reduction Act.

Although DC Health Link’s default is to have subsidy-eligible consumers receive 85% of their calculated subsidy up-front each month (and reconcile the difference on their tax returns), most of the District’s subsidy-eligible enrollees take more than 85% of their subsidy up-front.

Further down this page, you’ll find a detailed summary of how premiums have changed for DC Health Link plans over the years.

Here’s a look back at how premiums have changed in DC’s exchange over the years:

2015: Single-digit rate changes

The D.C. DISB approved 2015 premiums in September 2014. For individual plans, average rate changes by carrier varied from a 6.1% decrease to a 7.6% increase. For small-group plans, the range was a 17.2% decrease to a 12.7% increase. 

2016: Another round of single-digit rate hikes

Aetna discontinued its individual market plans in DC at the end of 2015, leaving just CareFirst and Kaiser for enrollees shopping for 2016 coverage. Regulators from the DISB reduced proposed rates across the board before approving them. The average approved rate increases ended up being 2% for CareFirst HMOs, 4.6% for CareFirst PPOs, and 6.6% for Kaiser.

Across the whole individual market — not including Aetna’s enrollees, which was a very small portion of the market — the average rate increase for 2016 was just 4.25%, which was far below the national average.

2017: Average rate increases ranged from under 2% to nearly 23%

DC DISB published a press release in May 2016 with details about the proposed rate changes that had been filed for 2017. In late September, they put out another press release with the approved average rate changes, which ranged from a 1.8% increase for CareFirst PPO to a 22.8% increase for CareFirst HMO.

For 2017, small-group rates in DC only increased by an average of 0.36%. By December 2016, SHOP exchange enrollments in DC had grown to 58,823, and by April 2017, it had reached 67,000. For comparison, California (which has 58 times as many people as DC) had 29,544 people covered under SHOP plans. But off-exchange small group plans are available in California, whereas the exchange is the only place small groups can purchased coverage in DC.

2018: Average increase of about 15.6%

Rate increases for 2018 were approved in October 2017 by DC regulators, with an increase of nearly 20% for CareFirst’s individual market plans (HMO and PPO) and 13% for Kaiser.

As initially filed, the proposed weighted average rate increase was 26.1%. But due to a smaller-than-proposed increase for CareFirst’s HMO, regulators reported that the average approved rate increase would be 15.64% for the individual market, before accounting for premium subsidies.

The lack of federal funding for cost-sharing reductions (starting in 2018) was fairly insignificant in DC, as very few DC Health Link enrollees receive CSR benefits. This is because CSR benefits only extend to 250% of the poverty level, and most people in that range are eligible for Medicaid instead in DC (Medicaid in the District is available to non-elderly adults with income up to 215% of the poverty level, which is much higher than the limit in the rest of the country).

In the small-group market, some insurers’ rate proposals were approved as filed, while others were adjusted during the rate review process. As initially filed, the small-group market was facing an average rate increase of 11.4%, but the final approved rates represent an average increase of 7.26%.

2019: Average rate increase of 13% in the individual market (down from the 15.5% that insurers proposed)

In September 2018, the DC Department of Insurance, Securities, and Banking published the final approved average rate changes for 2019, which ranged from a 9.9% increase for CareFirst PPO to a 20% increase for Kaiser. As proposed, the 2019 rates would have amounted to a weighted average increase of 15.5%. But the final approved rate hike amounted to a weighted average increase of 13% instead.

In the small group market, the proposed rate increases were small or non-existent for the three largest insurers (based on enrollment), but quite significant for the insurers that have a smaller market share. However, the final average approved rate changes were generally much smaller than insurers had proposed, ranging from no change to about a 10 percent increase.

It’s noteworthy that although DC’s individual mandate wasn’t finalized until September, it appears that the insurers based their proposed premiums for 2019 (filed in June 2018) on the assumption that the mandate would end up being implemented in the District. Both Kaiser and CareFirst noted in their rate filings that they were not adding a premium load for the elimination of the federal mandate penalty. That likely explains why the approved rate increases in DC were not significantly smaller than the proposed increases, despite the fact that the official approval of the District’s individual mandate happened between when rates were initially filed and when they were approved.

2020: Average rate increase of 7.6% in the individual market

In April 2019, the DC Department of Insurance, Securities, and Banking instructed insurers to file two sets of rates for 2020: One based on the existing risk adjustment protocol in D.C., in which risk adjustment is calculated separately for individual market plans and small group plans, and a second set of rates that would apply if the District were to combine the two markets for risk adjustment purposes. (D.C. has a “modified” merged risk pool already, but risk adjustment calculations — and most other factors — are determined separately for the two markets.)

Not surprisingly, proposed rates were much lower under the combined risk adjustment scenario, as that’s generally an idea that passes risk from the more volatile individual market to the more stable small group market.

In September, DC DISB published a summary of the final rates, as well as an overview of how rates would change for plans that existed in both 2019 and 2020. For the individual market, DC Health Link’s insurers implemented an average rate increase of 7.6% for 2020.

For the small group market, DC Health Link’s insurers implemented an average rate increase of 8.4% for 2020.

With the exception of Kaiser, all of DC Health Link’s small group insurers proposed higher 2020 rates under the merged risk adjustment model, whereas proposed rates for the individual market would have been lower under the merged risk adjustment model.

At their October 2018 meeting, DC Health Link’s board of directors reported in December 2017 that 4,960 small businesses were enrolled in plans through DC Health Link’s small business marketplace, with a total of 77,596 covered members.

2021: Average rate increase of 0.2% for individual market plans

In May 2020, the DC Department of Insurance, Securities, and Banking published the proposed rate changes that insurers had submitted for 2021 health plans, which amount to a weighted average proposed rate increase of 3.8%.

But a much smaller overall average rate increase was ultimately approved, due to a significant reduction in the approved rate changes for CareFirst HMO. DCDISB announced in early October 2020 that the approved average rate increase for the individual market would be just 0.2% for 2021.

Group Hospitalization and Medical Services (CareFirst PPO) increased premiums by an average of 1.6%. CareFirst Blue Choice (CareFirst HMO) increased premiums by an average of 0.1%. And Kaiser decreased premiums by an average of 2%.

For the small group market, average premiums decreased by half a percent for 2021 as opposed to the 1.9% average rate increase that insurers had proposed (keeping in mind that although the exchanges in most states primarily serve individual market customers, that is not the case in DC; DC’s small business exchange enrollment is much higher than their individual market enrollment)

2022: Average increase of 5% for individual market plans

In May 2021, the DC Department of Insurance, Securities, and Banking published the proposed rate changes that insurers submitted for 2022 health plans. For the individual market, the weighted average proposed rate change was a 7.7% increase.

But as had been the case in prior years, the approved rate increases mostly ended up being smaller than the insurers had proposed, with an overall average increase of 5% for the individual market. And for the small group market, the overall average approved rate increase was 3.5%, down from the 6.2% increase that the insurers had proposed.

During the open enrollment period for 2022 health plans, 15,989 people enrolled in individual market plans through DC Health Link. This was 29% lower than peak enrollment in 2016, and a decrease of 6% from the year before, despite the fact that nationwide exchange enrollment grew to a record high for 2022. There were enrollment decreases in only three states and Washington, D.C.; everywhere else saw enrollment growth during the open enrollment period for 2022 coverage.

Washington, D.C. has a higher income limit for Medicaid eligibility than the rest of the country (215% of the poverty level, as opposed to 138% of the poverty level in other states that have expanded Medicaid). Like the rest of the country, the District is receiving additional federal Medicaid funding during the COVID public health emergency period, on the condition that people not be disenrolled from Medicaid. So more people have become eligible for Medicaid in DC (given the higher income limits), and they have been able to remain on that coverage since the early days of the pandemic. This is likely a factor in the enrollment decrease for DC Health Link from 2021 to 2022.

The District has also been offering an ongoing special enrollment period related to the COVID-19 pandemic. This window, which allows uninsured residents to enroll in coverage through DC Health Link, continues through the end of the District’s pandemic emergency period.

Here’s a look back at individual market enrollment via DC Health Link (totals indicate the number of people who signed up each year during open enrollment):

  • 201410,714 people enrolled
  • 201518,465 people enrolled
  • 201622,693 people enrolled
  • 2017: 21,248 people enrolled. By mid-April, more than 19,000 people had effectuated coverage. Although enrollment at the end of open enrollment was lower than it had been a year earlier, effectuated enrollment was higher at the end of March; as of March 31, 2016, effectuated enrollment had been 17,266.
  • 201819,289 people enrolled (According to the October 2018 board meeting, the exchange had a total of 93,553 enrollees at that point, but 77,596 of them had small-group coverage)
  • 201918,035 people enrolled
  • 202017,538 people enrolled
  • 202116,947 people enrolled
  • 2022: 15,989 people enrolled

In most states, individual market enrollment in the exchange far surpasses small-group enrollment. But in DC, small group enrollment is much higher than individual market enrollment. There are no off-exchange small group plans in DC, and members of Congress and their staff use DC Health Link’s small group plans instead of the Federal Employees Health Benefits Program, which adds about 11,000 enrollees to DC Health Link’s small business plans.

According to US Census data, the uninsured rate was just 3.5% in DC in 2019 (but up from 3.2% in 2018); only Massachusetts had a smaller percentage of its residents without health insurance.

Open enrollment in Washington, D.C. runs from November 1 to January 31 each year. The District has permanently adopted this schedule, and will continue to use it in future years. So while open enrollment ends in mid-January in most states, that’s not the case in Washington, D.C.

DC Health Link has also been allowing uninsured residents to enroll at any time during the District’s COVID public health emergency, regardless of whether they have a specific qualifying event. And residents with certain qualifying life events can enroll at any time. 

As described in more detail below, pregnancy is a qualifying life event that allows a person to enroll in a plan through DC Health Link; there are only a few other states that allow this.

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Standardized plans in DC

DC Health Link offers both standardized and non-standardized plans. The standard plans can be identified by a green ribbon icon and the word “standard” in the plan name

Standard plans in the District cover a variety of services pre-deductible (unless they’re HSA-qualified plans, in which case they are limited by IRS rules to only covering certain preventive care pre-deductible).

Starting in 2023, DC Health Link’s standard plans cover numerous services to treat Type 2 diabetes with zero cost-sharing

And starting in 2024, DC Health Link’s standard plans will cover pediatric mental health office visits and prescriptions with $5 copays. This follows the recommendations that the exchange’s working group made in 2022, and is expected to significantly reduce barriers to pediatric mental health care in the District.

Special enrollment periods in DC

When the COVID pandemic began, nearly all of the state-run exchanges established special enrollment periods for uninsured residents. The open enrollment period for 2020 health coverage had already ended when the pandemic started, and public health officials wanted to make sure as many people as possible had health coverage during the public health crisis.

DC Health Link was among the exchanges where a COVID-related special enrollment period began in 2020. But unlike most of the other state-run exchanges, where the enrollment window lasted a month or two, DC’s has been ongoing ever since the spring of 2020, albeit mostly only for people who are uninsured. It will continue to automatically be extended until the end of the month when the COVID public health emergency in DC is allowed to expire (the rest of the state-run exchanges offered another COVID-related special enrollment period in 2021, in line with the special enrollment period that offered in 2021. But DC’s COVID-related special enrollment period never ended).

The special enrollment period allows uninsured people to sign up for individual market coverage through DC Health Link, and also allows employees of businesses insured through DC Health Link’s SHOP exchange to sign up for health coverage through their employers, without having to wait for their employer’s annual open enrollment period.

Once the American Rescue Plan was enacted, DC Health Link fully opened the enrollment window (as opposed to limiting it only to people who were uninsured), allowing people the opportunity to switch plans if necessary in order to best take advantage of the newly enhanced premium subsidies. DC Health Link confirmed that if people switched plans in 2021 during the COVID/American Rescue Plan enrollment window, any money they had spent toward their deductible and out-of-pocket limit would transfer to the new plan, assuming they enrolled in another plan from the same insurer.

As a result of the pandemic, DC Health Link is also allowing small groups to enroll, through at least the end of 2022, even if they don’t meet the participation and/or contribution requirements that are normally in place.

DC Health Link has also created a special enrollment period for people who lose their coverage because their credit/debit card auto-payment is declined, unless the reason for the decline is a lack of adequate funds or voluntary termination of the auto-payment by the enrollee.

Pregnancy now a qualifying event in DC

DC Health Link allows pregnant women to enroll in health coverage through the exchange year-round, with a special enrollment period triggered by the confirmation of the pregnancy by a health care provider. The coverage can be retroactive to the first of the month that the pregnancy is confirmed. From the date the pregnancy is confirmed by a health care provider, the woman has 60 days to enroll in an individual market plan through the exchange, or 30 days to enroll in a small group plan that her employer obtains via DC Health Link.

New York, Connecticut, New Jersey, Maryland, and Maine have similar special enrollment periods for pregnant women.

Modified merged risk pool

In most states, the individual and small group market risk pools are completely separate. But in Massachusetts and Maine, they’re merged (they used to be merged in Vermont as well, but that changed as of 2022). And Washington, D.C. has what’s often referred to as a “modified merged risk pool.” Essentially, the two risk pools are merged for the purpose of setting the index rate. But then the index rate is adjusted to be specific to each market, based on factors that are not uniform across the two markets. (Here’s more about how this works.)

So things like risk adjustment transfers, network size, morbidity, broker fees, and medical trend end up resulting in DC’s individual and small group markets having different rates and rate changes (the individual market tends to be more volatile, as is the case nationwide). Because morbidity is a factor that allows the rates to be adjusted after the index rate is set, the “modified merged risk pool” in DC is essentially much more similar to the separate risk pools in most other states, and is quite different from the truly merged risk pools in Maine and Massachusetts.

For 2020, however, DC instructed insurers to file two sets of rates — one consistent with the District’s existing approach, and the other based on merging the individual and small group markets for the purpose of risk adjustment calculations.

DC has implemented programs to ensure that all residents have access to health coverage, regardless of their income or health status. Medicaid coverage in DC is available to residents with income up to 215% of the poverty level. In addition, DC Health Alliance, Cover All DC, and Immigrant Children’s Program are available to DC residents regardless of immigration status.

DC Health Alliance and Immigrant Children’s Program are available at no cost, while Cover All DC allows residents to purchase full-cost private health insurance, even without a qualifying immigration status. The ACA prevents undocumented immigrants from buying coverage in the exchange, even without financial assistance, so DC created Cover All DC in order to provide an avenue for those residents to purchase coverage.

In the summer of 2019, the DC Health Link board of directors approved $650,000 for navigator/enrollment assister funding, $300,000 for outreach assistance (mostly via DC-area chambers of commerce), and $350,000 in funding for Metro Bus advertising.

DC has an individual mandate as of 2019

In the summer of 2017, the DC Health Link board created an ACA Working Group, comprised of insurers, small businesses, brokers, consumer advocates, and health care providers, with the goal of coming up with changes and improvements that DC could make at the local level to stabilize its insurance market and ensure that affordable coverage would continue to be available in the District.

In January 2018, the Working Group reconvened in order to address two new issues: President Trump’s October 2017 Executive Order that called for Association Health Plans to be expanded, and the December 2017 GOP tax bill that repealed the individual mandate (with a delayed implementation; the individual mandate will be repealed as of 2019).

In mid-February, the Working Group unanimously voted to recommend that DC implement its own individual mandate. The following week, the DC exchange board approved a resolution calling for an individual mandate in DC, and noting that without an individual mandate, enrollment in individual market plans in DC was projected to drop by 15% in 2019, with an associated premium increase of about 7% (healthy people would drop coverage, leaving a risk pool with overall poorer health and a smaller population over which to spread the costs, resulting in higher premiums for everyone). As of 2018, with the federal individual mandate in place, 96% of DC’s residents had health insurance.

In March 2018, DC Mayor, Muriel Bowser, unveiled her proposed Fiscal Year 2019 Budget, which included $1.1 million for the implementation of an individual mandate in DC. That money would cover technology adjustments, changes to the DC tax code, and efforts to publicize the local individual mandate.

The city council considered Mayor Bowser’s budget and published their own proposed budget in mid-May. The DC City Council’s proposed Budget Support Act of 2018 included an individual mandate, with a penalty for non-compliance, effective as of January 2019 in DC. The city council approved the budget in June, with the individual mandate intact.

Republicans in Congress tried to intervene at that point, however, with a measure (which passed the House in July) that would have blocked the District from using local funding to implement an individual mandate. But the measure failed in the Senate in early August, paving the way for DC to move forward with their individual mandate.

The DC Budget was transmitted to Mayor Bowser in mid-August, and she signed it on September 5 (the final budget is here). The mandate, dubbed the “Individual Taxpayer Health Insurance Responsibility Requirement,” took effect in January 2019.

The mandate called for in the DC budget is much like the ACA’s federal mandate, but with some specifics to tailor it to DC’s needs. This chart provides an overview of how DC’s proposed mandate compared with the federal mandate, as of early 2018. But some changes were made along the way. For example, the early draft called for an exemption for people who have a gap in coverage of three months or less — instead of less than three months, as is the case under the federal mandate — but that modification was not included in the final version of the District’s mandate; people who are uninsured for three months in 2019 face a penalty in DC):

  • The mandate penalty is the same amount as the federal mandate penalty was in 2018 ($695 per uninsured adult, or 2.5 percent of household income, whichever is greater), but the maximum penalty is tied to the average cost of a bronze plan in DC, as opposed to the average nationwide cost of a bronze plan. The ACA penalty was supposed to be inflation-adjusted annually starting in 2017 (the adjustment was $0 for 2017 and 2018), so DC will be responsible for setting the inflation adjustment each year.
  • Most of the exemptions that apply to the federal penalty also apply in DC, but with some changes. People with DC Healthcare Alliance coverage are considered covered and not subject to a penalty (under the ACA’s individual mandate, DC Healthcare Alliance is not considered minimum essential coverage), as are those covered under the Immigrant Children’s Program. People with fairly high incomes (up to 222 percent of the poverty level for people age 21 and older, and up to 324 percent of the poverty level for people up to age 20) are not subject to the penalty (Medicaid eligibility extends to these levels in DC, so this exemption basically just means people who are eligible for Medicaid are not subject to the penalty if they’re uninsured).
  • If the federal penalty is ever reinstated, people in DC would not be subject to two penalties. If that were to happen, the amount of the DC penalty would be reduced by the amount that the person owes under the federal penalty.
  • Crucially, new association health plans (AHPs) created under relaxed federal rules do NOT qualify as coverage under the DC mandate. But AHPs that already met federal rules as of 2017 (and are considered minimum essential coverage) continue to be considered coverage under DC’s mandate in 2019.
  • Money collected via the DC individual mandate penalty will be used for outreach to get uninsured people covered, and “activities that increase the availability of health insurance options or increase the affordability of insurance premiums in the individual health insurance market.

The District’s individual mandate and associated penalty weren’t signed into law until September 2018, and there wasn’t a lot of publicity about the new mandate during open enrollment. So on February 15, 2019 — more than a week after open enrollment had ended in the District — DC Health Link announced that they would grant a 60-day special enrollment period to people who find out about the District’s new individual mandate penalty while filing their 2018 taxes. 

Massachusetts has an individual mandate that predates the ACA, and that continues to be in effect. New Jersey, Rhode Island, and California have also created individual mandates. Vermont has created an individual mandate but does not have a penalty for non-compliance. 

CSR funding fairly insignificant in DC

Throughout the country, the Trump administration’s decision to cut off funding for cost-sharing reductions (CSR) had a significant impact on premiums for 2018. In many states, insurers had already filed rates based on the assumption that CSR funding would end, and in some of the other states, insurers scrambled to revise their filings to add the cost of CSR during an emergency refiling window that the federal government opened just before the start of open enrollment (CSR funding was eliminated on October 12; open enrollment began on November 1).

But CSR funding has a very minimal impact in the District. DC Health Link’s executive director, Mila Kofman, explained that only 300 people in DC receive CSR benefits, and the total cost is about $150,000 per year (as opposed to CBO’s nationwide cost estimate of about $7 billion in fiscal year 2017 and $10 billion in fiscal year 2018).

The reason so few people in DC receive CSR is that DC Medicaid covers people with income up to 215% of the poverty level (as opposed to 138% in most states that have expanded Medicaid). Under the ACA, CSR benefits extend to 250% of the poverty level, although they’re most robust for people with income up to 200% of the poverty level. But in DC, people with income up to 215% of the poverty level are on Medicaid instead of private plans in the exchange, which means they’re not using CSR.

Although the rate filings for CareFirst and Kaiser note that rates were developed based on the assumption that CSR funding would continue in 2018, it appears that it didn’t make much of a difference one way or the other, since it’s such a small factor in the cost of coverage in DC.

So while CSR funding is not a significant factor in DC itself, the overall issue of CSR funding had an impact on the regional insurers that offer coverage in the DC area: Filings in Virginia were based on the assumption that CSR funding would not continue; rate that were initially approved in Maryland were based on the assumption that CSR funding would continue, but those rates were revised in late October to add the cost of CSR to on-exchange silver plans instead.

(Ultimately, the lack of CSR funding has turned out to be a smaller issue than anticipated, because insurers in most states simply added the cost of CSR to their premiums for 2018, and have continued to do that ever since. In most cases, they added the cost only to silver plan premiums, which results in much larger premium subsidies, and lower after-subsidy premiums for people who buy bronze and gold plans. This has been an overall win for consumers, making coverage more affordable than it would otherwise have been.)

DC Health Link's robust small-business exchange

DC Health Link’s SHOP (small business) exchange had more than 87,000 enrollees as of November 2022. This was far more than any other SHOP exchange in the country, and dwarfed the size of DC Health Link’s individual/family market enrollment.

DC Health Link also has eight participating insurers offering small business plans, versus just three in the individual market. Most states no longer have functional SHOP exchanges anymore, and those that do tend to have just a few participating insurers. 

DC Health Link’s robust SHOP exchange stems from the fact that there is no “off-exchange” market in DC for individual or small group plans; they can only be purchased through DC Health Link. And the Grassley Amendment to the ACA dictates that Congress and Congressional staffers can only be offered coverage through the exchange—as opposed to the FEHBP that’s available to other federal government employees.

(As of mid-2015, members of Congress and their staffers accounted for 16,100 of the small business enrollees in DC. That had fallen to about 11,000 by early 2017.)

DC Health Link is the designated marketplace for members of Congress and their official office staff following a rule issued by the Office of Personnel Management, which oversees benefits for federal employees. Congress and their staffers are eligible to continue receiving the federal employer contribution toward their coverage so long as they select a plan through DC Health Link’s SHOP exchange (note that they do not enroll in individual market plans, as they would not be eligible for an employer contribution for those plans; instead, they enroll in SHOP plans, which are jointly funded by employers and employees).

DC Health Link began allowing small businesses to enroll in small group plans via the exchange at any time during 2020, even if they couldn’t meet the employer contribution and/or employee participation requirements. And this provision has been extended through 2022. Normally, small groups that can’t meet the contribution or participation requirements are limited to signing up between November 15 and December 15 (this is an ACA rule, not specific to DC, but the extended window throughout 2022 is specific to DC).

Funding plan created controversy

The District of Columbia’s health insurance marketplace, DC Health Link, was identified as the nation’s second most expensive on a per-enrollee basis in 2014, and its long-term funding plan triggered a lawsuit. The exchange’s 2015 fiscal year budget was about $28 million, but Executive Director, Mila Kofman requested $32.5 million for the 2016 fiscal year, in order to cover the cost of adding 19 full-time positions to their staff (instead of relying on contract workers).

DC Health Link’s funding plan was formed to meet the requirement that all state-run exchanges be self-sufficient by 2015. A number of state-run exchanges have placed a tax on premiums sold through the exchange.

However, given the District’s small population, a premium tax would have to be very high to sustain DC Health Link — 17 percent according to a Washington Post article. Accordingly, the D.C. Council approved a one percent tax on premiums for all health-related insurance plans sold in the District — not just those sold on the exchange.

The tax is designed to apply to plans that can’t be sold on the exchange, including hospital indemnity plans, disability coverage, and long-term care plans. There is no off-exchange market for ACA-compliant health insurance in DC, and grandmothered plans were not allowed to remain in force in the District. But “health-related” plans has a much wider scope, and includes many products that were never intended to be sold in the exchange.

Many insurers that sell health-related insurance products outside of the marketplace were vehemently opposed to the plan, but the exchange has defended the tax by pointing out that people who have access to health insurance are more likely to buy the supplemental products sold outside the exchange. They view the exchange as a sales booster for other health-related insurance products, and want those carriers to bear part of the revenue burden for the exchange. And the funding proposal had strong support from the exchange’s insurers, as well as local advocacy and business groups.

But the American Council of Life Insurers filed a lawsuit in July 2014, claiming the tax was unconstitutional and a violation of the ACA. A U.S. District Court judge dismissed the suit in November 2014, writing that the ACA gave state-run exchanges broad authority to establish funding mechanisms.

In December 2014, the American Council of Life Insurers appealed the November ruling to the U.S. Court of Appeals for the D.C. Circuit. In March 2016, the appeals court vacated the district court’s dismissal of the case, allowing the possibility that it could once again move forward.

Meanwhile, in January 2015, the DC Council passed a temporary version of the exchange’s proposed funding model, imposing the 1% tax on all health plans and health-related plans. Then in May 2015, the Council approved the assessment to take effect immediately in order to fund the exchange’s 2016 fiscal year; the collection of assessments to fund the exchange has continued since then.

The assessments are collected annually, starting in the summer of 2015. In July 2015, the board approved a measure that lays out exactly what products are exempt from the assessment, and also provides a means for assessed carriers to appeal their assessments.

District of Columbia health insurance exchange links

DC Health Link

DC Health Benefit Exchange Authority

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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