HR-9396-119
Forwarded by Subcommittee to Full Committee by Voice Vote.
Sponsored by Craig Goldman (R-TX)
What it does
This bill would require group health plans and health insurance issuers that use prior authorization to publicly report detailed data, including approval and denial rates by item and service, appeal outcomes, average decision times, and the extent to which artificial intelligence or automated technology was used to make determinations. Starting with plan years after January 1, 2027, this data must be submitted to federal regulators and posted on plans' public websites, and starting in 2029 it must also appear on ACA exchange comparison tools when consumers shop for plans.
Who benefits
Patients and consumers seeking to compare health plans, who would gain access to denial-rate and appeal-success data not previously public; patient advocacy groups and researchers studying insurer behavior; physicians and providers who could use the data to negotiate or advocate for patients; and the ACA exchanges, which would gain a new comparison tool.
Who is hurt
Health insurers and group health plan sponsors, who would bear new compliance and reporting costs and could face reputational harm from disclosure of high denial rates; employers who self-insure and administer their own plans, who would face similar administrative burdens; and companies that develop AI/automated prior authorization tools, whose usage would become subject to public disclosure.
Supporters argue
Supporters argue that prior authorization denials have become a major source of delayed or denied care, and that patients and employers currently have no way to compare insurers' denial rates or appeal-success rates before choosing a plan. They contend that public reporting requirements, similar to existing hospital price transparency rules, would create market pressure on insurers to reduce inappropriate denials and would reveal the growing and largely unregulated role of AI in coverage decisions.
Opponents argue
Opponents argue that the reporting requirements would impose significant new administrative costs on insurers and self-insured employers, particularly smaller plans that lack the data infrastructure to track appeals by item, service, and appeal level. They contend that raw denial-rate statistics, without context on medical necessity or plan design, could mislead consumers and create incentives for insurers to approve borderline claims simply to improve public metrics rather than to serve patients' actual medical needs.
Constitutional context
Congress is regulating group health plans and insurers engaged in interstate commerce and exercising its taxing power over employer plans through the Internal Revenue Code, both grounded in the Commerce Clause (Art. I, §8, cl. 3) and Taxing and Spending Clause (Art. I, §8, cl. 1). Because the bill only imposes disclosure requirements rather than compelling coverage decisions or purchases, it does not raise the individual-mandate concerns addressed in NFIB v. Sebelius.
Checks and balances
Congress would set the disclosure mandate directly in statute, while the Secretary of Health and Human Services (and equivalent regulators at Labor and Treasury) would determine implementation details such as timing and format, subject to standard administrative rulemaking review.
Historical precedent
The bill's transparency approach parallels the ACA's existing hospital and insurer price transparency requirements and the No Surprises Act's disclosure mandates, though this is the first federal requirement specifically targeting prior authorization denial-rate reporting.