“Dear Aetna, Blue Cross, Cigna, United HealthCare (pick one) please send us a copy of your hospital contract at ABC Hospital. Thank you.” – Plan Sponsor
The Gag Clause Quandary for Self-Insured Group Health Plans—New FAQ Guidance
By Christopher S. Lockman on January 24, 2025
Under the gag clause prohibition, a group health plan is prohibited from entering into an agreement with a third-party administrator (“TPA”), health care provider, or other vendor offering access to a network of health care providers that would prevent the plan from accessing certain cost, quality, and de-identified claims information and providing that information to its business associates.
The gag clause prohibition states that a group health plan cannot agree to restrictions in TPA or provider network contracts that would directly or indirectly prevent the plan from:
- disclosing provider-specific cost or quality-of-care information or data to referring providers, the plan sponsor, and individuals who are or are eligible to become participants or beneficiaries;
- electronically accessing de-identified claims information, including financial information, provider information, and service codes; or
- sharing this information with a business associate in accordance with applicable privacy protections.
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Plan sponsor mesmerized by new powers gifted by extraterrestrial beings in Washington………..
Imagine the fun you would have asking for a copy of the PPO contract at ABC Hospital! I’ll craft the letter if you need help…….
