# Health plan claims data access. What the Patients Deserve Price Tags Act would change.

Source: https://ethosbenefits.com/insights/health-plan-claims-data-access
Type: Insight
Topic: Compliance rules and deadlines
Author: Donovan Ryckis, Founder and CEO
Reviewed by: Patrick Ansara, Partner and Director of Client Operations
Publisher: Ethos Benefits
Published: 2026-08-19
Last updated: 2026-11-03
Cite as: "Health plan claims data access," Ethos Benefits, https://ethosbenefits.com/insights/health-plan-claims-data-access, updated 2026-11-03.

**Summary:** S. 2355 would give employer health plans a legal right to their own claims data and audits. Where the bill stands, what it requires and what to do now.

## Key takeaways

- S. 2355, the Patients Deserve Price Tags Act, would make a vendor contract unreasonable under ERISA unless it gives the plan full access to its claims data, unmodified claim files and open audit rights.
- The Senate HELP Committee advanced the bill 21 to 1 on July 22, 2026, and it was placed on the Senate calendar July 27. On September 24, Sen. Rand Paul blocked an attempt to speed it through the Senate.
- As of October 27, 2026, Congress.gov shows no Senate floor vote, and the bill is not law. Trade press reports it may be considered for a year-end health package.
- If enacted as reported, the data provisions would apply from the first plan year beginning at least one year after enactment, to plans of employers averaging 50 or more employees, with penalties of up to $10,000 a day.
- You do not need to wait. Many contracts already allow more data and audit access than plans use.

*Status as of October 27, 2026: S. 2355 has passed committee and is on the Senate calendar. It has not passed the Senate or the House and is not law.*

## What happened to the bill in the Senate?

On July 22, 2026, the Senate Health, Education, Labor and Pensions (HELP) Committee voted to advance [S. 2355, the Patients Deserve Price Tags Act](https://www.congress.gov/bill/119th-congress/senate-bill/2355/all-actions), with an amendment that replaced the bill's text. Sen. Roger Marshall introduced the bill on July 17, 2025, with Sen. John Hickenlooper among the original cosponsors. According to the [Healthcare Financial Management Association](https://www.hfma.org/?p=121739), the committee vote was 21 to 1, with Sen. Rand Paul voting no.

The bill was formally reported to the Senate and placed on the legislative calendar on July 27, 2026. Most coverage has focused on its hospital price disclosure rules. For an employer that sponsors a health plan, the more important part is a set of ERISA amendments that would give the plan a legal right to its own claims data.

## Where does the bill stand now?

Since August, one thing has happened on the Senate floor. HFMA reported that the Senate appeared ready to pass the bill on an expedited basis on September 24, 2026, but Sen. Paul blocked the motion needed to speed the vote. As of HFMA's October 1 report, the bill remained in limbo while Congress weighs health policies for a year-end package, and HELP Chair Bill Cassidy was working to pass it before he leaves Congress at the end of the year.

As of October 27, 2026, the bill's record on Congress.gov lists no Senate floor vote after the July 27 calendar placement. Here is the path that remains:

| Step | Status as of October 27, 2026 |
|---|---|
| Introduced in the Senate | Done, July 17, 2025 |
| HELP Committee hearing | Done, March 19, 2026 |
| HELP Committee vote | Done, July 22, 2026 (21 to 1, per HFMA) |
| Reported and placed on the Senate calendar | Done, July 27, 2026 (Calendar No. 522) |
| Expedited Senate passage | Blocked September 24, 2026 (per HFMA) |
| Senate floor vote | Not yet held |
| House passage | Not yet held |
| Signed into law | No |

The House has its own versions. [H.R. 5582](https://www.congress.gov/bill/119th-congress/house-bill/5582) is the House companion, referred to committee in September 2025. A separate House transparency bill, [H.R. 9393, the Lower Costs, More Transparency Act of 2026](https://www.congress.gov/bill/119th-congress/house-bill/9393), was ordered reported by the Energy and Commerce Committee 45 to 0 on July 21, 2026. Any final law would need the House and Senate to agree on the same text, and the ERISA language could change along the way.

## What would the bill give plan sponsors?

The reported bill, in [Section 7](https://www.govinfo.gov/content/pkg/BILLS-119s2355rs/html/BILLS-119s2355rs.htm), ties claims data access to [ERISA section 408(b)(2)](https://www.law.cornell.edu/uscode/text/29/1108), the rule that a plan's service contracts must be reasonable. A contract with a covered service provider would not count as reasonable unless it meets the new data rules. Covered service providers include providers, networks, third-party administrators, insurers, pharmacy benefit managers and intermediaries between them and the plan.

| Provision in the reported bill | What it would mean for your plan |
|---|---|
| Access to all claims and encounter data and supporting documentation | The plan can check whether claims were paid accurately and reasonably |
| Access within 15 days of a request at most | Vendors cannot stall a data request |
| No limits on audit volume, auditor choice, scope or frequency | You pick the auditor and decide what gets reviewed |
| Disclosure of value-based and capitated payment terms | You see the formulas, quality measures and incentives behind those contracts |
| Disclosure of fees, including access, repricing, renegotiation and enhanced review fees | Fees cannot stay buried in the fine print |
| Unmodified 837 claim files and 835 remittance files, at no cost | You can verify claims independently instead of relying on summary reports |
| Disclosure of ownership interests between vendors and providers | You can see when a vendor has a stake in the providers it pays |
| Contract terms that limit access are void as against public policy | Restrictive clauses would not hold |
| Civil penalty of up to $10,000 per day | The Department of Labor could enforce the rules against vendors |

The bill also changes the annual gag clause attestation. Plans would have to attest that the data is available and that no contract term restricts audits, and a plan could not hand the attestation off to its TPA. If a plan cannot get the data, it would file a written statement explaining why and naming the vendor. Our explainer on the [gag clause attestation](https://ethosbenefits.com/benefits-101/gag-clause-attestation) covers how the current rule works.

## Who would the rules apply to, and when?

As reported, the data access rules apply to group health plans offered by an employer that averaged at least 50 employees in the prior year, or plans that averaged at least 50 participants. They would take effect with the first plan year that begins at least one year after the bill is signed. The Department of Labor would implement them through notice and comment rulemaking.

The bill protects privacy. Vendors would provide data under HIPAA's privacy rules and would not have to disclose information that could identify a member. A plan receiving the data could use it only for plan administration and could not sell or license it.

## How is this different from price transparency rules?

The Transparency in Coverage rules already require insurers and self-funded plans to post machine-readable files of negotiated rates, and the Departments [finalized updates to those rules](https://www.cms.gov/newsroom/fact-sheets/transparency-coverage-final-rules-cms-9882-f) in October 2026. Those files show what the market charges. They are large and aggregated, which makes them useful for research and comparison, and hard to use to check whether your own plan paid a claim correctly.

Claims data access works at the other end. It is claim-level, specific to your plan and backed by audit rights. Price transparency answers "what does the market charge." Claims data access answers the question a plan sponsor has to answer: what did we pay, and was it reasonable?

## Why does this matter for fiduciary risk?

Employees have sued large employers under ERISA, alleging that plan fiduciaries failed to monitor their PBM and let the plan overpay for drugs. Several of the best-known cases were dismissed for lack of standing and are on appeal, and at least one has a claim still moving forward. The [ERISA health plan litigation tracker](https://ethosbenefits.com/insights/erisa-health-plan-litigation) follows each case.

The legal outcomes are unsettled, but the argument is the same in every case: a fiduciary cannot prudently manage what it has never looked at. A legal right to claims data would not end that risk. It would remove the easiest excuse. An employer that has the data and uses it is in a very different position from one that never asked.

Pharmacy data is already moving this way. Federal [PBM reform](https://ethosbenefits.com/insights/pbm-reform), enacted in February 2026, requires PBMs to report to plans and gives ERISA plans a yearly audit right. S. 2355 would extend the same idea to medical claims and every vendor that touches them.

## What should you ask your carrier, TPA or PBM today?

You do not need to wait for Congress. Many of the rights the bill would guarantee already exist in some form in vendor contracts and are rarely used. The [Consolidated Appropriations Act, 2021](https://ethosbenefits.com/benefits-101/gag-clause-attestation) already bars gag clauses that block a plan's access to cost and claims information. Bring these questions to your next vendor meeting or renewal:

- Can we receive our full, unmodified 837 and 835 files today, not a summary report?
- What do we pay in access, repricing or enhanced review fees, and where is that written in our contract?
- Who may audit our claims, how often, and is there a cap on how many claims they can review?
- What formulas and incentives drive payments under any value-based or capitated arrangement in our plan?
- Does any clause limit our right to see our own data, and would it survive if this bill becomes law?

Ethos Benefits helps employers request and read this data through its [claims analytics](https://ethosbenefits.com/services/claims-analytics) and [audit](https://ethosbenefits.com/services/audits) work. For a broader view of where plan dollars go, see [what happens behind the scenes with your health insurance](https://ethosbenefits.com/insights/what-happens-behind-the-scenes-with-your-health-insurance).

## What should employers do now?

Whether or not this bill passes in its current form, data access, audit rights and fee disclosure are becoming the expected baseline. The employers in the strongest position will already know what they would do with the data.

1. **Read your current contracts** for data, audit and confidentiality terms, and note every limit.
2. **Request your claims files now**, and record how long the vendor takes and what it provides.
3. **Build an audit plan**, not just an audit clause you have never used.
4. **Fix restrictive language at renewal**, before a law or a lawsuit forces it.
5. **Watch the year-end package.** If the bill moves, the effective date will be counted from enactment.

Insisting on full data rights can change a renewal. Axiom Healthcare Services moved to a carrier with full data and audit rights and turned a 2.6% renewal increase into a 13% decrease. The [Axiom Healthcare case study](https://ethosbenefits.com/results/axiom-healthcare) shows how.

*This article summarizes pending federal legislation for general information and is not legal advice. S. 2355 has passed committee but has not been enacted, and its provisions and timing may change before final passage. Status reflects Congress.gov and published reports as of October 27, 2026.*

## From the Ethos Benefits team

> Having access to the penny accounting, to your claims data, having a contract that allows you to have access to it, audit it, et cetera. That is real leverage.

Chelsea Ryckis, Founder and President, Ethos Benefits, on [The Business of Benefits, Episode 89](https://ethosbenefits.com/podcast/benefits-dirty-dozen-part-2)

## On the podcast

- [Benefits Dirty Dozen, Part 2: Health plan tactics 6 to 1](https://ethosbenefits.com/podcast/benefits-dirty-dozen-part-2), The Business of Benefits, Episode 89
- [Employer Health Coalitions and Smarter Purchasing: With Karen van Caulil](https://ethosbenefits.com/podcast/employer-health-coalitions-karen-van-caulil), The Business of Benefits, Episode 86
- [PBM Rebates and Who Really Pays: Mark Cuban](https://ethosbenefits.com/podcast/pbm-rebates-mark-cuban), The Business of Benefits, Episode 75
- [Hospital Bill Errors and 501(r) Financial Assistance: With Patrick Haig](https://ethosbenefits.com/podcast/hospital-bill-errors-patrick-haig), The Business of Benefits, Episode 71
- [Benefits Consultant Fees Are Only Part of the Price: Chris Deacon on paying more and getting less](https://ethosbenefits.com/podcast/benefits-consultant-fees-chris-deacon), The Business of Benefits, Episode 68
- [How One Employer Broke the Renewal Cycle: Axiom Healthcare Services](https://ethosbenefits.com/podcast/axiom-healthcare-services), The Business of Benefits, Episode 67
- [Self-Funding Explained: Stop-Loss, Captives and Claims: Spencer Smith of ParetoHealth](https://ethosbenefits.com/podcast/self-funded-health-insurance-spencer-smith), The Business of Benefits, Episode 66
- [How One Employer Took Control of Its Healthcare Costs: Bryan Orr of Kalos Services](https://ethosbenefits.com/podcast/employer-healthcare-costs-bryan-orr), The Business of Benefits, Episode 47

## Frequently asked questions

### Do employers have a right to their health plan claims data today?

Partly. Since the Consolidated Appropriations Act, 2021 banned gag clauses, contracts with TPAs, networks and other service providers cannot stop a group health plan from getting de-identified claims and encounter data on request. What current law lacks is a firm deadline for delivery, guaranteed audit rights and a daily penalty, which S. 2355 would add.

### Has the Patients Deserve Price Tags Act become law?

No. The Senate HELP Committee advanced S. 2355 on July 22, 2026, and it was placed on the Senate calendar July 27. As of October 27, 2026, Congress.gov shows no Senate floor vote. It would still need to pass the full Senate and the House and be signed before any requirement takes effect.

### Which vendors would the claims data rules cover?

The reported bill covers any provider, network, third-party administrator, insurer, pharmacy benefit manager or intermediary that contracts with the group health plan. It calls them covered service providers. That means a fully insured plan's carrier and a self-funded plan's TPA, PBM and networks would all owe the plan its data within 15 days of a request.

### Would the bill apply to fully insured plans?

Yes, as written. The data access rule applies to group health plans offered by employers that averaged at least 50 employees, or plans with at least 50 participants, and covers contracts with insurers as well as TPAs and PBMs. Self-funded plans have the most at stake, because the claims are paid with plan money.

### What happens if a vendor refuses to provide claims data?

Under the reported bill, the Department of Labor could assess a civil penalty of up to $10,000 for each day the violation continues, and contract terms that unduly delay or limit access would be void as against public policy. Until a law like this passes, an employer's main tools are the existing gag clause ban and its contract's own data and audit terms.

### Should employers wait for the bill to pass before asking for claims data?

No. Many current contracts already include data and audit rights that plans rarely use, and the 2021 federal ban on gag clauses already bars contracts that block access to cost and claims information. Asking now shows where your contracts fall short before the next renewal.

## Sources

1. [S. 2355, Patients Deserve Price Tags Act, all actions](https://www.congress.gov/bill/119th-congress/senate-bill/2355/all-actions), Congress.gov
2. [S. 2355, reported in Senate with an amendment in the nature of a substitute (Calendar No. 522)](https://www.govinfo.gov/content/pkg/BILLS-119s2355rs/html/BILLS-119s2355rs.htm), U.S. Government Publishing Office
3. [Healthcare price transparency legislation hits a roadblock in the Senate (October 1, 2026)](https://www.hfma.org/?p=121739), Healthcare Financial Management Association
4. [H.R. 9393, Lower Costs, More Transparency Act of 2026](https://www.congress.gov/bill/119th-congress/house-bill/9393), Congress.gov
5. [H.R. 5582, Patients Deserve Price Tags Act (House companion)](https://www.congress.gov/bill/119th-congress/house-bill/5582), Congress.gov
6. [Transparency in Coverage Final Rules (CMS-9882-F) fact sheet](https://www.cms.gov/newsroom/fact-sheets/transparency-coverage-final-rules-cms-9882-f), Centers for Medicare & Medicaid Services
7. [29 U.S. Code § 1108, Exemptions from prohibited transactions (ERISA section 408)](https://www.law.cornell.edu/uscode/text/29/1108), Legal Information Institute, Cornell Law School