HR-9486-119
Referred to the House Committee on Education and Workforce.
Sponsored by Mark Takano (D-CA)
What it does
The bill would amend ERISA so that a contract between a group health plan and a provider, network, third-party administrator, or pharmacy benefit manager is not "reasonable" unless it lets the plan audit de-identified claims data and does not limit audits, pricing disclosure, or auditor choice. It would allow the Labor Secretary to assess a $10,000 daily penalty on service providers that violate these rules. It would also make the collection of gag clause attestations a Secretary duty, expand the fiduciary definition to cover authority over plan data, and make it unlawful for employers, plan sponsors, administrators, and fiduciaries to discriminate against participants based on that data, with a $100 daily penalty per affected participant. Other limits apply, including HIPAA privacy compliance requirements.
Who benefits
Employers and other group health plan sponsors that would gain audit access to claims data and pricing terms. Plan participants and beneficiaries, who would gain a new anti-discrimination claim without having to exhaust administrative remedies first. Plan fiduciaries seeking data to judge whether compensation to vendors is reasonable. Independent auditors and benefits consultants who may see more demand for their work.
Who is hurt
Hospitals, physician groups, pharmacy benefit managers, third-party administrators, and provider networks, which would face contract restrictions, compliance costs, and daily civil penalties. Providers with confidential value-based pricing terms that could no longer shield them from plan audits. Employers and plan fiduciaries, who would face new discrimination liability and broader fiduciary duties over data. Plan costs could rise if vendors pass on compliance expenses.
Supporters argue
Supporters argue that employers are fiduciaries who must ensure plan spending is reasonable, yet contract clauses often block them from seeing claims and pricing data. They contend that guaranteed audit rights, tied to HIPAA de-identification standards, would help plans spot overcharges and overpayments while protecting patient privacy, and that anti-discrimination protections would keep participants from being penalized over their health data.
Opponents argue
Opponents argue that overriding negotiated contract terms, including confidential value-based pricing, would disrupt provider-payer relationships and could raise administrative costs for plans and vendors. They contend that unlimited audit access and $10,000 daily penalties are heavy burdens, that the expanded fiduciary definition adds litigation risk for employers, and that existing HIPAA and ERISA rules already address data privacy and discrimination.
Constitutional context
Congress regulates employer-sponsored health plans under the Commerce Clause, and ERISA's broad regulatory structure has long been upheld; Gonzales v. Raich (2005) supports federal reach over economic activity. The new civil penalties raise possible due process questions, and agency enforcement may face Loper Bright-era scrutiny of the Labor Department's interpretations.
Checks and balances
The bill expands the Labor Department's enforcement and penalty authority, with checks from federal court review of penalties, private suits under ERISA section 502, and congressional oversight.
Historical precedent
The Consolidated Appropriations Act, 2021 added ERISA transparency rules, including the gag clause prohibition and the attestation requirement that this bill's provisions build on.