Compliance News Week Ending March 14, 2025

Compliance News Week Ending March 14, 2025

In this Article

1. All Payer Claims Databases - Can Self-Funded Plans Opt-Out?
2. Supreme Court to Hear Case on ACA Preventive Coverage Requirements

All Payer Claims Databases – Can Self-Funded Plans Opt-Out? 

Submitting data to an All Payer Claims Database (APCD) is not a federal requirement, but rather one that has been adopted by many states. Fully insured and non-ERISA plans may be required by state mandate to report plan eligibility and claims information to the applicable state database which is then used to gain better intel about healthcare costs, trends, etc. 

Self-funded plans are not required to participate, but can choose to; in other words, for self-funded ERISA plans, participation is completely optional. For self-funded ERISA plans, the major benefit of choosing to participate is contributing to the effort to lower overall health care costs. However, some potential negatives are the administrative hassle of providing the information, especially if the TPA will charge additional fees for the administration, and privacy concerns both for plan participants as well as broader use of the shared data. 

Supreme Court to Hear Case on ACA Preventive Coverage Requirements 

In April the Supreme Court will hear the case Kennedy (Becerra) v. Braidwood Mgmt. challenging what must be covered by group health plans without cost-sharing as preventive. Specifically, the Supreme Court will rule on whether the U.S. Preventive Services Task Force (USPSTF) has the authority to make recommendations on preventive care. 

If the Supreme Court decides that the USPSTF does not have the authority to make such recommendations, group health plans would be allowed to impose cost-sharing for any preventive care recommendations that have been made or updated since the Affordable Care Act (ACA) went into effect back in 2010. Group health plans could, but would no longer be required, to cover certain treatment and services without cost-sharing. 

It's not clear how the current administration will defend this case or how employers might react if full coverage for certain preventive care becomes optional. In addition, fully insured plans would still be subject to state-level preventive coverage requirements.  

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