Sponsor
Lucy Mcbath
Representative · D-GA
Representative · D-GA
The bill increases transparency about claim denials, outcomes, and use of automated decision tools—helping patients, employers, and regulators spot and correct problematic denials—but does so at the cost of added compliance burdens and privacy risks, especially for small plans and vulnerable patients.
Patients with chronic or serious conditions and people with disabilities get clearer, standardized information on claim denials, reasons, appeal outcomes, and use of AI/automated decision tools, helping them and their clinicians file better appeals, plan care, and enabling detection of automated denial patterns.
All plan enrollees and employers gain greater transparency on overall claim outcomes (approved/denied/appealed) and dollars paid/denied, improving consumers' plan choice and employers' oversight of plan performance.
State and federal regulators and public officials get standardized claims data to identify systemic denial patterns and enforce ERISA rules on timeliness and nondiscrimination, enabling targeted audits and corrective action.
Detailed reporting of sensitive claim categories (mental health, substance use disorder, cancer, prescription drugs) risks beneficiary privacy if data are not thoroughly de‑identified, potentially exposing vulnerable patients.
Insurers and plans will face higher administrative costs to collect and report granular claim data, which may be passed on to enrollees through higher premiums or reduced benefits.
Small employers and smaller plans bear disproportionate new compliance burdens and costs to implement the reporting requirements.
Based on analysis of 2 sections of legislative text.
Requires ERISA group health plans to report detailed claims-denial and adjudication data (counts, dollars, reasons, timeliness, and AI use) in annual reports, with limited small-plan exemptions.
Official title: To direct the Secretary of Labor to require group health plans include certain information on claim denials in annual reports, and for other purposes.
Introduced July 16, 2026 by Lucy Mcbath · Last progress July 16, 2026
Requires group health plans governed by ERISA to report detailed claims-denial and adjudication data in their annual ERISA reports. The rule directs the Secretary of Labor to issue a regulation within one year that specifies counts and dollar amounts for submitted, paid, denied, and appealed claims, breakdowns by claim type and setting, reasons for denials, timeliness breaches, and use of automated/AI decision tools, with limited exemptions for very small plans.