Consumer Health Claim Assistance Act

This Act may be cited as the “Consumer Health Claim Assistance Act”.

Part 5 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1131 et seq.) is amended by adding at the end the following new section:

“524. Benefits assistance program.—

(a) Establishment.— Not later than January 1, 2027, the Secretary shall establish, within the Employee Benefits Security Administration of the Department of Labor, a Benefits Assistance Program (in this section, referred to as the “Program”) to improve access to benefits under employee welfare benefit plans.

(b) Duties.— The Program shall—

(1) establish a process for the receipt of inquiries or complaints from participants and beneficiaries, and health care providers (on behalf of participants and beneficiaries), relating to—

(A) adverse benefit determinations (as defined under section 2560.503–1(m)(4) of title 29, Code of Federal Regulations, as in effect on the date of enactment of the Consumer Health Claim Assistance Act); and

(B) alleged violations of—

(i) plan terms; and

(ii) any provision of this title;

(2) assist participants and beneficiaries in understanding their rights to benefits under their plan and the availability of internal appeals and external review (as such terms are defined under sections 2590.715–2719(a)(2) of title 29, Code of Federal Regulations, as in effect on the date of enactment of the Consumer Health Claim Assistance Act);

(3) directly assist participants and beneficiaries in filing appeals for denied benefits and navigating such appeals or reviews;

(4) make referrals to appropriate entities regarding any inquiries or complaints relating to adverse benefit determinations by a plan that may violate this title or any other law;

(5) provide additional training, technical assistance, and support to Department staff, including benefits advisors, to address adverse benefit determinations or any violations of this title; and

(6) if the inquiry or complaint was received as a result of a referral from a State office of health insurance consumer assistance, health insurance ombudsman, or other program that carries out the duties described in section 2793(c) of the Public Health Service Act (42 U.S.C. 300gg–93(c)), inform such office or program of the result of such inquiry or complaint.

(c) Annual report.— The Secretary of Labor shall, on an annual basis, submit to the Committee on Education and Workforce of the House of Representatives and the Committee on Health, Education, Labor, and Pensions of the Senate a report, with respect to the Program, on the following:

(1) The number of inquiries and complaints received (disaggregated by type of plan, size of plan, and type of assistance provided).

(2) The number of participants and beneficiaries who received assistance (disaggregated by type of plan, size of plan, and type of service provided).

(3) The dollar amounts of claims for benefits for which assistance was provided (disaggregated by type of plan, size of plan, and type of service provided).

(4) The total dollar amount expended to operate the Program and the number of full-time equivalents assigned by the Secretary to operate the Program.

(5) The number of referrals to appropriate entities and, when available, the disposition of such enforcement actions.

(6) The number and type of any non-monetary recoveries by participants and beneficiaries who received assistance.

(7) The average amount of time it takes to provide assistance.

(8) Recommendations regarding any additional authority or resources needed to improve the Program, including recommendations on necessary increases in filing fees under section 104(d).

(9) Any other data determined appropriate by the Secretary.”.

(a) Fees on filings.— Section 104 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1024) is amended by redesignating subsections (d) and (e) as subsections (e) and (f), respectively, and by inserting after subsection (c) the following new subsection:

“(d) Fees on filings with Secretary of Labor.—

(1) In general.— The administrator of any employee welfare benefit plan which is a single-employer plan shall pay to the Secretary a filing fee in the amount determined under paragraph (2) at the time of filing an annual report or a notice under subsection (a)(1)(A).

(2) Amount of fee.—

(A) Annual reports.— Subject to subparagraph (B), the amount of the fee under paragraph (1) with respect to each report or notice shall be—

(i) $250 if the plan had fewer than 100 participants as of the close of the plan year preceding the plan year in which such report or notice is filed;

(ii) $500 if the plan had 100 or more but fewer than 500 participants as of the close of such plan year; and

(iii) not less than $1,000 in the case of any other plan.

(B) Regulatory.— The Secretary may by regulation require a fee that is higher than is otherwise required under this paragraph. If the Secretary requires a higher fee, the Secretary shall establish a fee scale that increases the fee charged to a plan as the number of participants in a plan increases.

(3) Prohibition on use of plan assets.— Payment of a filing fee under this subsection may not be made using any funds that are assets of the plan.

(4) Use and availability of funds.—

(A) In general.— The Secretary of Labor shall expend the amounts received under this subsection for each fiscal year for enforcement of title I of the Employee Retirement Income Security Act of 1974 and to support operations of the Benefits Assistance Program described in section 524. Such funds shall be available without fiscal year limitation.

(B) Limitation.— At least 50 percent of the amounts described in subparagraph (A) shall be used to support operations of the Program.”.

(b) Effective date.— Section 104(d) of the Employee Retirement Income Security Act of 1974, as added by this section, shall apply to reports, descriptions, notices, and attestations filed after January 1, 2027.

(a) Minimum notice.— Section 104(a) of the Employee Retirement Income Security Act (29 U.S.C. 1024(a)) is amended—

(1) in paragraph (1), by inserting after “plan year” the following: “(or, if applicable, file with the Secretary a notice as described in paragraph (3)(B) for a plan year)”; and

(2) in paragraph (3)—

(A) by striking “The Secretary” and inserting “(A) Subject to subparagraph (B), the Secretary”; and

(B) by adding at the end the following:

“(B) In the case of any employee welfare benefit plan which is a single-employer plan that is not required to file an annual report for any year, the administrator of the plan shall file with the Secretary a notice containing the following information in relation to such plan for such year:

(i) The name of the employer maintaining such plan.

(ii) The number of employees covered by such plan.

(iii) The aggregate amount of benefits provided by such plan.

(iv) The method of funding of such plan (whether such plan is unfunded, insured, or a combination) and, if applicable, the name of any issuers contracted to provide health insurance coverage in connection with such plan.

(v) The name of any service providers that rendered services to the plan and received $5,000 or more in compensation, directly or indirectly, from the plan.”.

(b) Effective dates.— The amendments made by this section shall apply with respect to plan years ending after January 1, 2027.