Did you know you have the legal right to access critical health plan data, including claims? Thanks to the Consolidated Appropriations Act of 2021 (CAA), health plans must now disclose pricing, giving you the tools to see where your healthcare dollars go and ensure your employees get the most cost-effective, high-quality care.

Your duty to protect your plan participants' best interests

Under ERISA, employer plan sponsors have a fiduciary duty to act in the best interests of their plan participants. As a plan sponsor, you have the right to access claims and financial data, even when working with a third-party administrator (TPA). This access allows you to ensure proper plan management, compliance with rules, and transparency of fees. Be sure to review your TPA contract for details on fiduciary responsibilities, audit rights, and oversight provisions.

Protection against hidden healthcare agreements

The Gag Clause Prohibition Rule ensures health plans cannot enter agreements that restrict sharing critical information about healthcare costs and quality. This rule empowers employer plan sponsors with access to data on what they’re paying for, medical services, and the quality of care provided - removing contractual barriers to transparency.

Your right to access health data under HIPAA

Under HIPAA Right of Access, employer plan sponsors have the legal right to access certain protected health information (PHI), including claims and payment data, as necessary for plan administration purposes. Even when managed by a third-party administrator (TPA), this data cannot be withheld or claimed as proprietary, provided the access complies with HIPAA privacy rules and is limited to authorized uses. This ensures plan sponsors can meet their fiduciary and compliance obligations.

Audit rights ensure accountability and compliance

Under ERISA, group health plans are required to undergo annual audits by an independent qualified public accountant. These audits rely on access to key records, including those held by third-party administrators. Employer plan sponsors must ensure they have access to these books and records to meet compliance obligations.

Learn more about plan sponsor rights to access claims data

Federal policymakers have recognized the importance of leaving no room for doubt that employer plan sponsors should have access to both medical and pharmacy claims data for their plan participants.

^{Note: This view is informed by Transcarent's experience and advocacy work; it does not constitute or substitute for legal advice.}