No. 14-181

In the Supreme Court of the United States

ALFRED GOBEILLE, IN HIS OFFICIAL CAPACITY AS CHAIR 

OF THE VERMONT GREEN MOUNTAIN CARE BOARD,

PETITIONER

v.

LIBERTY MUTUAL INSURANCE COMPANY

ON WRIT OF CERTIORARI 

TO THE UNITED STATES COURT OF APPEALS 

FOR THE SECOND CIRCUIT 

BRIEF FOR THE UNITED STATES

AS AMICUS CURIAE SUPPORTING PETITIONER

M. PATRICIA SMITH

Solicitor of Labor

G. WILLIAM SCOTT

Associate Solicitor

ELIZABETH HOPKINS

Counsel

MELISSA MOORE

Attorney

Department of Labor

Washington, D.C. 20210

DONALD B. VERRILLI, JR. Solicitor General

Counsel of Record

EDWIN S. KNEEDLER

Deputy Solicitor General

JOHN F. BASH

Assistant to the Solicitor 

General

Department of Justice

Washington, D.C. 20530-0001

SupremeCtBriefs@usdoj.gov

(202) 514-2217
No. 14-181

In the Supreme Court of the United States

ALFRED GOBEILLE, IN HIS OFFICIAL CAPACITY AS CHAIR 

OF THE VERMONT GREEN MOUNTAIN CARE BOARD,

PETITIONER

v.

LIBERTY MUTUAL INSURANCE COMPANY

ON WRIT OF CERTIORARI 

TO THE UNITED STATES COURT OF APPEALS 

FOR THE SECOND CIRCUIT 

BRIEF FOR THE UNITED STATES

AS AMICUS CURIAE SUPPORTING PETITIONER

M. PATRICIA SMITH

Solicitor of Labor

G. WILLIAM SCOTT

Associate Solicitor

ELIZABETH HOPKINS

Counsel

MELISSA MOORE

Attorney

Department of Labor

Washington, D.C. 20210

DONALD B. VERRILLI, JR. Solicitor General

Counsel of Record

EDWIN S. KNEEDLER

Deputy Solicitor General

JOHN F. BASH

Assistant to the Solicitor 

General

Department of Justice

Washington, D.C. 20530-0001

SupremeCtBriefs@usdoj.gov

(202) 514-2217
(I) 

QUESTION PRESENTED

Whether the Employee Retirement Income Security Act of 1974, 29 U.S.C. 1001 et seq., preempts, as 

applied to self-insured health benefit plans or their 

third-party administrators, a Vermont statute that

requires healthcare payers to report claims and 

healthcare-services data to a state agency.
(III) 

TABLE OF CONTENTS

Page

Interest of the United States ........................................................1

Statutory and regulatory provisions involved ............................2

Statement.........................................................................................2

Summary of argument................................................................. 10

Argument:

The Vermont reporting requirements are not preempted 

by ERISA .................................................................................13

A. The Vermont reporting requirements do not fall 

within ERISA’s express preemption provision ............13

1. The Vermont reporting requirements serve 

objectives distinct from the basic purposes 

of ERISA .....................................................................15

2. The Vermont reporting requirements do not 

exert an impermissible effect on the design 

or administration of ERISA plans ...........................22

B. The Vermont reporting requirements are valid if 

 reviewed under general principles of field and 

conflict preemption ...........................................................30

Conclusion......................................................................................36

Appendix — Statutory and regulatory provisions.................1a

TABLE OF AUTHORITIES

Cases:

Aetna Health Inc. v. Davila, 542 U.S. 200 (2004).........24, 32

Alessi v. Raybestos-Manhattan, Inc., 451 U.S. 504 

(1981)......................................................................................23

Boggs v. Boggs, 520 U.S. 833 (1997)................................30, 32

California Div. of Labor Standards Enforcement v. 

Dillingham Constr., N.A., 519 U.S. 316 (1997).......passim

De Buono v. NYSA-ILA Med. & Clinical Servs. 

Fund, 520 U.S. 806 (1997) ...........................17, 23, 25, 27, 35

District of Columbia v. Greater Wash. Bd. of Trade, 

506 U.S. 125 (1992) ...............................................................14
IV

Cases—Continued: Page

Egelhoff v. Egelhoff, 532 U.S. 141 (2001).....................passim

English v. General Elec. Co., 496 U.S. 72 (1990).................31

FMC Corp. v. Holliday, 498 U.S. 52 (1990) .........................33

Fort Halifax Packing Co. v. Coyne, 482 U.S. 1 

(1987)..........................................................................16, 23, 32

Ingersoll-Rand Co. v. McClendon, 498 U.S. 133 

(1990)..........................................................................14, 15, 22

John Hancock Mut. Life Ins. Co. v. Harris Trust & 

Sav. Bank, 510 U.S. 86 (1993).............................................15

Keystone Chapter, Associated Builders & Contractors, Inc. v. Foley, 37 F.3d 945 (3d Cir. 1994), 

cert. denied, 514 U.S. 1032 (1995).......................................26

Mackey v. Lanier Collection Agency & Serv., Inc., 

486 U.S. 825 (1988) ...............................................................14

Massachusetts v. Morash, 490 U.S. 107 (1989)...................15

Metropolitan Life Ins. Co. v. Massachusetts, 

471 U.S. 724 (1985) .........................................................23, 31

New York State Conference of Blue Cross & Blue 

Shield Plans v. Travelers Ins. Co., 514 U.S. 645 

(1995).............................................................................passim

ONEOK, Inc. v. Learjet, Inc., 135 S. Ct. 1591 (2015).........31

Pegram v. Herdrich, 530 U.S. 211 (2000).............................18

Rice v. Santa Fe Elevator Corp., 331 U.S. 218 (1947)........31

Shaw v. Delta Air Lines, Inc., 463 U.S. 85 

(1983)................................................................9, 13, 20, 23, 24

Standard Oil Co. v. Agsalud, 633 F.2d 760 

(9th Cir. 1980), summarily aff’d, 454 U.S. 801 (1981)......16

UNUM Life Ins. Co. of Am. v. Ward, 526 U.S. 358 

(1999)................................................................................30, 33

United States v. Locke, 529 U.S. 89 (2000) ..........................32
V 

Statutes and regulations: Page

Employee Retirement Income Security Act of 1974, 

Pub. L. No. 93-406, 88 Stat. 829 (29 U.S.C. 1001 

et seq.) ...................................................................................1, 2

29 U.S.C. 1001(a).........................................................17, 1a

29 U.S.C. 1001(b)...............................................2, 16, 17, 2a

29 U.S.C. 1002(1)...........................................................2, 3a

29 U.S.C. 1002(13)...............................................................1

29 U.S.C. 1021-1024 ............................................................2

29 U.S.C. 1102(a)(1) ............................................................2

29 U.S.C. 1103(a).................................................................2

29 U.S.C. 1104(a)(1) ..................................................35, 15a

29 U.S.C. 1104(a)(1)(D).......................................32, 33, 15a

29 U.S.C. 1132-1135 ............................................................1

29 U.S.C. 1134......................................................................3

29 U.S.C. 1143(a)(1) ....................................................3, 16a

29 U.S.C. 1144(a)..............................................passim, 17a

29 U.S.C. 1144(b)(2)..................................................19, 18a

29 U.S.C. 1144(b)(2)(A).............................................13, 18a

29 U.S.C. 1144(b)(4)..................................................13, 18a

29 U.S.C. 1144(c)(1)...................................................13, 20a

29 U.S.C. 1144(d).......................................................19, 20a

29 U.S.C. 1181-1191c.....................................................3, 21

29 U.S.C. 1185d(a).....................................................21, 21a

29 U.S.C. 1191(a)(2) ..................................................21, 22a

29 U.S.C. 1191b(a).......................................................3, 23a

Health Insurance Portability and Accountability Act 

of 1996, Pub. L. No. 104-191, § 101(a), 

110 Stat. 1939 ..........................................................................3

Patient Protection and Affordable Care Act, 

Pub. L. No. 111-148, 124 Stat. 119........................................3
VI 

Statutes and regulations—Continued: Page

§ 1001, 124 Stat. 130............................................................3

§ 1563, 124 Stat. 264, 911....................................................3

§ 1563(e), 124 Stat. 270, 911 (29 U.S.C. 1185d)................3

§ 3021(a), 124 Stat. 389 (42 U.S.C. 1315a)......................20

§ 10332, 124 Stat. 968 (42 U.S.C. 1395kk(e)) .................21

42 U.S.C. 300gg et seq.........................................................3

42 U.S.C. 300gg-15a........................................4, 21, 22, 24a

42 U.S.C. 300gg-17....................................................21, 25a

42 U.S.C. 300gg-17(a) ...........................................4, 22, 25a

42 U.S.C. 300gg-17(b)...........................................4, 22, 26a

42 U.S.C. 300gg-23(a)(2)...........................................21, 28a

42 U.S.C. 300gg-94(c)(1)(C)...............................................7

42 U.S.C. 1315a(a)(1) ................................................20, 29a

42 U.S.C. 1315a(b)(2)(B)...........................................20, 30a

42 U.S.C. 1315a(b)(2)(B)(xi).....................................20, 30a

42 U.S.C. 1315a(b)(4)................................................20, 31a

42 U.S.C. 1395kk(e).....................................................7, 31a

42 U.S.C. 1395kk(e)(2)(A) ........................................21, 32a

42 U.S.C. 18031(e)(3)(A).......................................4, 22, 33a

42 U.S.C. 18041(d).....................................................21, 35a

Cal. Lab. Code § 1776 (West 1989)........................................26

Vt. Stat. Ann. tit. 18:

§ 9401(b) (2012)..........................................................16, 35a

§ 9401(b)(1)-(3) (2012).................................................4, 36a

§ 9402(8) (2012)............................................................5, 36a

§ 9410 (Supp. 2014) .....................................................4, 37a

§ 9410(a)(1) (Supp. 2014)......................................4, 16, 37a

§ 9410(a)(2)(A) (Supp. 2014).................................6, 16, 37a

§ 9410(b) (Supp. 2014).................................................5, 38a

§ 9410(c) (Supp. 2014)...............................................13, 39a
VII

Statutes and regulations—Continued: Page

§ 9410(c)-(d) (Supp. 2014)...........................................5, 39a

§ 9410(c)(1) (Supp. 2014) ............................................5, 39a

§ 9410(c)(3) (Supp. 2014) ............................................5, 39a

§ 9410(e) (Supp. 2014)...........................................6, 34, 39a

§ 9410(f) (Supp. 2014).................................................6, 39a

§ 9410(g) (Supp. 2014).................................................6, 39a

§ 9410(h)(2) (Supp. 2014)..........................................34, 40a

§ 9410(h)(3)(B) (Supp. 2014) ......................................5, 41a

§ 9410(h)(3)(C) (Supp. 2014) ......................................5, 42a

§ 9410(h)(3)(D) (Supp. 2014)......................................6, 42a

§ 9410(j)(1)(A) (Supp. 2014).......................................5, 43a

§ 9410(j)(1)(B) (Supp. 2014).......................................5, 43a

Wash. Rev. Code § 11.07.010(1) (1994).................................33

29 C.F.R. Pt. 2520......................................................................2

Reg. H-2008-01, 21-040-021 Vt. Code R. (2008) ............6, 44a

§ 3(X)...........................................................................13, 47a

§ 3(Ab)...........................................................................7, 48a

§ 3(Ac).....................................................................6, 17, 48a

§ 3(Ak).....................................................................6, 17, 49a

§ 3(As)...........................................................................7, 50a

§ 4 ...............................................................................13, 50a

§ 4(D).............................................................................6, 51a

§§ 5-8.............................................................................7, 52a

§ 5(A)(8)..................................................................6, 17, 54a

Miscellaneous:

Paul Fronstin, Self-Insured Health Plans: State 

Variation and Recent Trends by Firm Size, Emp. 

Benefit Res. Inst. Notes, Nov. 2012...................................19

S. Rep. No. 127, 93d Cong., 1st Sess. (1973)........................25
(1) 

In the Supreme Court of the United States

No. 14-181

ALFRED GOBEILLE, IN HIS OFFICIAL CAPACITY AS 

CHAIR OF THE VERMONT GREEN MOUNTAIN CARE 

BOARD, PETITIONER

v.

LIBERTY MUTUAL INSURANCE COMPANY

ON WRIT OF CERTIORARI 

TO THE UNITED STATES COURT OF APPEALS

FOR THE SECOND CIRCUIT

BRIEF FOR THE UNITED STATES

AS AMICUS CURIAE SUPPORTING PETITIONER

INTEREST OF THE UNITED STATES

This case concerns whether the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. 

1001 et seq., preempts a state law imposing certain 

reporting requirements on healthcare payers, including ERISA plans. The Secretary of Labor has primary authority for administering ERISA. 29 U.S.C. 

1002(13), 1132-1135. In response to an invitation from 

the Court, the United States filed an amicus brief in 

this case at the petition stage.
2 

STATUTORY AND REGULATORY 

PROVISIONS INVOLVED

The pertinent statutory and regulatory provisions 

are reproduced in the appendix to this brief. See 

App., infra, 1a-59a. 

STATEMENT

1. The Employee Retirement Income Security Act 

of 1974 (ERISA), 29 U.S.C. 1001 et seq., is designed to 

“protect * * * the interests of participants in employee benefit plans and their beneficiaries * * * by 

establishing standards of conduct, responsibility, and 

obligation for fiduciaries of employee benefit plans, 

and by providing for appropriate remedies, sanctions, 

and ready access to the Federal courts.” 29 U.S.C. 

1001(b). The statute governs both pension plans and 

“employee welfare benefit plan[s],” i.e., plans that, 

“through the purchase of insurance or otherwise,” 

provide medical, disability, unemployment, vacation, 

or certain other benefits. 29 U.S.C. 1002(1). ERISA

requires every plan to be established and maintained 

pursuant to a written instrument and to have named 

fiduciaries who have authority to control and manage 

the administration of the plan and its assets. 29 

U.S.C. 1102(a)(1), 1103(a). With specified exceptions, 

ERISA preempts “any and all State laws insofar as 

they * * * relate to any employee benefit plan.” 29 

U.S.C. 1144(a).

Plan administrators generally must file detailed financial and actuarial information with the Secretary 

of Labor (Secretary) and submit reports upon the 

occurrence of specific events, although the Secretary 

has exempted most welfare plans from the majority of 

those requirements. 29 U.S.C. 1021-1024; 29 C.F.R. 

Pt. 2520. In addition, the Secretary has authority to 
3 

investigate plans for ERISA violations by inspecting 

plan documents, administrative contracts, and claims 

records. 29 U.S.C. 1134. ERISA also authorizes the 

Secretary “to undertake research and surveys and in 

connection therewith to collect, compile, analyze and 

publish data, information, and statistics relating to 

employee benefit plans.” 29 U.S.C. 1143(a)(1).

ERISA includes certain provisions governing 

“group health plan[s],” i.e., ERISA welfare plans that 

provide medical benefits, 29 U.S.C. 1191b(a), that 

were originally enacted as part of the Health Insurance Portability and Accountability Act of 1996 

(HIPAA), Pub. L. No. 104-191, § 101(a), 110 Stat. 

1939. See 29 U.S.C. 1181-1191c. In 2010, Congress 

enacted the Patient Protection and Affordable Care 

Act (ACA), Pub. L. No. 111-148, 124 Stat. 119, which

imposes a number of new requirements on the group 

health-insurance market, such as a prohibition on 

charging different premiums based on health status. 

See § 1001, 124 Stat. 130; see also 42 U.S.C. 300gg et 

seq. In a section setting out “conforming amendments,” ACA § 1563, 124 Stat. 264, 911 (capitalization 

and emphasis omitted), the ACA also amended 

ERISA to provide that those new provisions generally 

apply to group health plans and that, in the event of a 

conflict between those ACA provisions and the sections of ERISA addressing group health plans, the 

ACA provisions govern. See id. § 1563(e), 124 Stat. 

270, 911 (29 U.S.C. 1185d). The new ACA provisions

applicable to group health plans include reporting and 

disclosure requirements related to such matters as 

claims-payment policies, out-of-network coverage, 

data on enrollment and denied claims, financial information, and information on the existence of any quali-
4 

ty initiatives or wellness programs under the plan. 

See 42 U.S.C. 300gg-15a (incorporating provisions of 

42 U.S.C. 18031(e)(3)); 42 U.S.C. 300gg-17(a) and (b). 

Those provisions of the ACA have not yet been implemented. The Department of Labor has informed 

this Office, however, that pursuant to the authority 

granted by ERISA and the ACA, and in consultation

with the Department of Health and Human Services

(HHS) and the Department of the Treasury, it is currently considering a rulemaking to require health 

plans to report more detailed information about various aspects of plan administration, such as enrollment, 

claims processing, and benefit offerings. 

2. The Vermont Legislature has enacted a comprehensive health law designed to “[m]aintain and 

improve the quality of health care services offered to 

Vermonters,” “[u]tilize planning, market, and other 

mechanisms that contain or reduce increases in the 

cost of delivering services,” and “[e]ncourage regional 

and local participation in decisions about health care 

delivery, financing, and provider supply.” Vt. Stat. 

Ann. tit. 18, § 9401(b)(1)-(3) (2012). One provision of 

the statute requires the Green Mountain Care Board

(Board), a state agency, to develop and maintain a 

database of information about healthcare expenditures in the State and out-of-state healthcare expenditures involving Vermont residents. See id. § 9410

(Supp. 2014) (Database Statute). The database is 

designed to help “identify[] health care needs,” “compar[e] costs between various treatment settings and 

approaches,” “determin[e] the capacity and distribution of existing resources,” and “provid[e] information 

to consumers and purchasers of health care.” Id. 

§ 9410(a)(1) (Supp. 2014). 
5 

The database must “reflect all health care utilization, costs, and resources” for medical services provided to Vermont residents or by Vermont facilities. 

Database Statute § 9410(b) (Supp. 2014). To that end, 

the Database Statute authorizes the Board to require

“[h]ealth insurers, health care providers, health care 

facilities, and governmental agencies” to submit “reports, data, schedules, statistics, or other information.” Id. § 9410(c)-(d) (Supp. 2014). The information may include “health insurance claims and enrollment information” and “any other information relating to health care costs, prices, quality, utilization, or 

resources.” Id. § 9410(c)(1) and (3) (Supp. 2014). The 

law’s definition of “[h]ealth insurer” includes any

health-insurance company and, “to the extent permitted under federal law, any administrator of an insured, self-insured, or publicly funded health care 

benefit plan offered by public and private entities,” 

Vt. Stat. Ann. tit. 18, § 9402(8) (2012), as well as any

third-party administrator that a self-insured health 

plan employs to handle such functions as claims processing, bill review, and claims payments, Database 

Statute § 9410(j)(1)(A) and (B) (Supp. 2014). 

The Database Statute provides that, “[t]o the extent allowed by HIPAA, the [collected] data shall be 

available as a resource for insurers, employers, providers, purchasers of health care, and State agencies 

to continuously review health care utilization, expenditures, and performance in Vermont.” § 9410(h)(3)(B)

(Supp. 2014); see id. § 9410(h)(3)(C) (Supp. 2014). It 

also requires the Board to establish “a consumer 

health care price and quality information system” to 

“empower individuals, including uninsured individuals, to make economically sound and medically appro-
6 

priate decisions.” Id. § 9410(a)(2)(A) (Supp. 2014). In 

addition, the statute directs that “[r]ecords of information * * * required by law to be held confidential[] shall be filed in a manner that does not disclose 

the identity of the protected person,” id. § 9410(e)

(Supp. 2014), requires the Board to “adopt a confidentiality code,” id. § 9410(f) (Supp. 2014), and prohibits 

the disclosure of “any data that contains direct personal identifiers,” id. § 9410(h)(3)(D) (Supp. 2014). 

Knowing violations of the statute or implementing 

rules promulgated by the Board are punished through

financial penalties. Id. § 9410(g) (Supp. 2014). 

The Board’s predecessor promulgated a regulation 

implementing the statute’s requirements with respect 

to healthcare payers. See Reg. H-2008-01, 21-040-021 

Vt. Code R. (2008) (Database Regulation). (The Board 

also administers a separate database for hospitaldischarge data that is not at issue here. See Pet. Br. 7 

& n.6.) The Database Regulation provides that 

“Health Insurers shall regularly submit medical 

claims data, pharmacy claims data, member eligibility 

data, provider data, and other information relating to 

health care provided to Vermont residents and health 

care provided by Vermont health care providers and 

facilities.” § 4(D). The claims data comprise only 

information about “non-denied adjudicated [medical 

and pharmacy] claims.” Id. § 3(Ac); see id. § 3(Ak); 

see also id. § 5(A)(8). The data include information 

about “member demographics, provider information, 

charge/payment information, and clinical diagnosis 

and procedure codes.” Id. § 3(Ac). The regulation

establishes requirements for how the data must be 

formatted, when it must be submitted, and under what 

circumstances different types of data will be released 
7 

to the public or to specific requestors, such as researchers. Id. §§ 5-8. It exempts health insurers with 

fewer than 200 enrolled or covered members in Vermont from the reporting requirements, although they 

may voluntarily report. Id. § 3(Ab) and (As). 

The Board uses the claims database in fulfilling its 

statutory responsibilities, such as approving insurance 

rates and reviewing hospital budgets. See Pet. Br. 15-

16, 33-35. In 2014, HHS issued a grant to the Board 

to expand its use of the database in connection with

Vermont’s rate-review authority under the ACA. Id.

at 49-50 & n.29; see 42 U.S.C. 300gg-94(c)(1)(C). In 

addition, HHS supplies Medicare data to the Board, 

see 42 U.S.C. 1395kk(e), and has authorized the Board 

to include Medicaid data, see Pet. Br. 10. Over a dozen other States have enacted legislation to build similar databases. See N.Y. et al. Cert. Amicus Br. 1 & 

n.3. 

3. Respondent is the named fiduciary and administrator of an ERISA self-insured health plan for its 

employees. Pet. App. 7. A self-insured plan is one in 

which the plan sponsor pays claims out of its own 

assets or from a trust, rather than contracting with an 

insurance company to pay claims under an insurance 

policy. Because only 137 persons covered by respondent’s health plan live in Vermont, respondent is not 

itself required to report healthcare-expenditure information to the Board. Id. at 7-8. But respondent’s 

plan is administered by a third-party administrator—

Blue Cross Blue Shield of Massachusetts, Inc. (Blue 

Cross)—that qualifies as a mandatory reporter under 

the Database Regulation because it administers 

claims for thousands of individuals in Vermont. Id. at 

8; see J.A. 205. In August 2011, the Board’s predeces-
8 

sor issued a subpoena to Blue Cross, seeking eligibility information and medical- and pharmacy-claims 

files for Vermont residents covered by respondent’s 

plan, which had not been reported as required by the 

Database Statute and Regulation. J.A. 30-33. Respondent, believing that the request was preempted 

by ERISA, instructed Blue Cross not to comply with 

the subpoena. Pet. App. 9. 

Respondent then filed suit in the United States 

District Court for the District of Vermont against the 

Board’s predecessor. J.A. 12-28. Respondent sought 

a declaratory judgment that the Database Statute and 

Regulation “are preempted by ERISA to the extent 

they require the reporting, production, or disclosure 

of any confidential health care information or medical 

records or data relating to [respondent’s health] [p]lan 

or its participants and beneficiaries.” J.A. 27. Respondent also sought to enjoin the Commissioner 

“from attempting to obtain, from [Blue Cross] or any 

other source, any medical records or data relating to 

the [p]lan or its participants and beneficiaries.” J.A. 

28.

The district court dismissed the complaint, holding 

that the Vermont reporting requirements are not 

preempted by ERISA. Pet. App. 48-80. The court 

explained that although “[c]ompliance with the reporting requirements * * * may have some indirect 

effect on health benefit plans,” the possible “effect is 

so peripheral that the regulation cannot be considered 

an attempt to interfere with the administration or 

structure of a welfare benefit plan.” Id. at 78. The 

court emphasized that respondent had “not submitted

any information about any actual burden suffered by 
9 

itself or [Blue Cross] in producing this information.” 

Id. at 73 n.5. 

4. The court of appeals reversed, holding that 

ERISA preempts the Vermont reporting requirements. Pet. App. 1-30. The court explained that under this Court’s interpretation of ERISA’s preemption 

provision, 29 U.S.C. 1144(a), “a state law is preempted 

if ‘it [1] has a connection with or [2] reference to [an 

ERISA] plan.’” Pet. App. 14 (brackets in original)

(quoting Shaw v. Delta Air Lines, Inc., 463 U.S. 85, 97 

(1983)). The court concluded that “the reporting requirements of the Vermont statute and regulation 

have a ‘connection with’ ERISA plans (though no 

‘reference to’ them)” because “‘reporting’ is a core 

ERISA function shielded from potentially inconsistent 

and burdensome state regulation.” Id. at 23. The 

court noted that Vermont could change the requirements at any time, id. at 27, and it postulated that if 

respondent were subject to “one of several or a score 

of uncoordinated state reporting regimes,” the burden 

would be “obviously intolerable,” id. at 25.

Judge Straub dissented in relevant part. Pet. App. 

30-47. “Many state laws,” he wrote, “may have an 

impact on the administration of an ERISA plan—for 

example, a work-place safety law, a prevailing wage 

law, or a law that requires companies to report employment data.” Id. at 42. Although “[s]uch laws may 

impose additional costs,” he concluded, “none of these 

laws impact how benefits are administered to beneficiaries and, therefore, they are not preempted by 

ERISA.” Ibid. Judge Straub also found that “on the 

record before [the court,]” no basis existed to conclude 

that the Vermont reporting requirements would “hin-
10

der the national administration of employment benefit 

plans in any way.” Id. at 44; see id. at 41-42.

SUMMARY OF ARGUMENT

ERISA does not preempt the Vermont reporting 

requirements. 

A. Under this Court’s precedents construing 

ERISA’s preemption provision, 29 U.S.C. 1144(a), the 

Vermont reporting requirements do not “relate to” 

ERISA plans because they have neither a “reference 

to” nor a “connection with” such plans. Egelhoff v. 

Egelhoff, 532 U.S. 141, 147 (2001) (citation omitted). 

As the court of appeals acknowledged, the requirements do not have a “reference to” ERISA plans because they operate on many healthcare payers, not 

only on ERISA plans, and the existence of an ERISA 

plan is not logically necessary to their operation. Pet. 

App. 23 n.9 (citations omitted). Preemption therefore 

turns on whether the requirements have a forbidden 

“connection with” ERISA plans. Although this Court 

has not defined that concept with great precision, it 

has evaluated the preemption question by “look[ing] 

both to the objectives of the ERISA statute as a guide 

to the scope of the state law that Congress understood

would survive” and “to the nature of the effect of the 

state law on ERISA plans.” Egelhoff, 532 U.S. at 147

(citations and internal quotation marks omitted). 

Under that approach, the requirements are not 

preempted.

1. The Database Statute and ERISA serve different purposes. ERISA governs the design and administration of employee benefit plans, including vesting 

requirements, health-benefit mandates, fiduciary 

duties, and remedies for breach. Its reporting and 

disclosure requirements further those purposes. The 
11

Database Statute, in contrast, is designed to improve 

the quality, utilization, and cost of healthcare in Vermont by providing consumers, government officials, 

and researchers with comprehensive data about the 

healthcare-delivery system. Although those data are

reflected in claims paid by various entities, including 

ERISA plans, the focus of the Vermont statute has 

nothing to do with the claims-payment process. That

is why Vermont does not seek information on denied 

claims.

Because the Vermont reporting requirements operate in the traditional state sphere of health and 

safety, while ERISA is principally concerned with the 

distinct subject of ensuring that plans provide covered 

benefits, the reporting requirements are entitled to a 

presumption of validity under Section 1144(a). As this 

Court has cautioned, it would be “unsettling” to conclude that ERISA squelches an entire area of state 

regulation about which ERISA itself says little. California Div. of Labor Standards Enforcement v. Dillingham Constr., N.A., 519 U.S. 316, 330 (1997) (citation omitted). That discomfiting result would be particularly harmful here, because the data collected by 

the Vermont reporting requirements are integral to 

achieving the objectives of other federal statutory 

provisions. 

2. The Vermont reporting requirements do not exert impermissible effects on the design or administration of ERISA plans. ERISA generally preempts 

those laws that prescribe binding rules for “a central 

matter of plan administration,” such as “the payment 

of benefits,” Egelhoff, 532 U.S. at 148, but it does not 

guarantee “cost uniformity” among different States 

where a plan might operate, New York State Confer-
12

ence of Blue Cross & Blue Shield Plans v. Travelers 

Ins. Co., 514 U.S. 645, 662 (1995). The Vermont reporting requirements do not impose binding obligations with respect to any core matter of plan administration, such as the vesting of benefits, claims processing, or the designation of beneficiaries. Respondent’s contrary argument essentially rests on the view 

that all reporting of information acquired or generated during the administration of a plan qualifies as a 

central matter of plan administration. But that argument conflicts with this Court’s prior decisions and, 

taken to its logical conclusion, would sweep away 

virtually all state-law reporting requirements incident 

to laws of general applicability. And although this

Court has suggested in dicta that a law imposing costs 

that are so acute as to effectively dictate how a plan is 

designed or administered would be preempted, no 

such extreme economic effects have been established

here. 

B. Some Justices have suggested in separate opinions that this Court should clarify its ERISA preemption jurisprudence by holding that Section 1144(a) 

merely calls for the application of ordinary principles 

of field and conflict preemption. Under those principles, the Vermont reporting requirements are not 

preempted. The requirements do not invade the exclusive federal field of the design and administration 

of ERISA plans. Nor do they conflict with 

any specific provision of ERISA or with Section 

1144(a)’s basic objective to establish a uniform body of 

employee-benefits law.
13

ARGUMENT

THE VERMONT REPORTING REQUIREMENTS ARE NOT 

PREEMPTED BY ERISA

A. The Vermont Reporting Requirements Do Not Fall 

Within ERISA’s Express Preemption Provision

Section 1144(a) of ERISA expressly preempts state 

statutes and regulations that “relate to” an ERISA 

plan, except for “any law * * * which regulates insurance, banking, or securities,” “any generally applicable criminal law,” and other specified categories of 

state laws. 29 U.S.C. 1144(a), (b)(2)(A), (4), and (c)(1). 

Under this Court’s precedents construing that provision, “[a] law ‘relates to’ an employee benefit plan 

* * * if it has a connection with or reference to such 

a plan.” Shaw v. Delta Air Lines, Inc., 463 U.S. 85, 

96-97 (1983); see, e.g., Egelhoff v. Eglelhoff, 532 U.S. 

141, 147 (2001); New York State Conference of Blue 

Cross & Blue Shield Plans v. Travelers Ins. Co., 514 

U.S. 645, 656 (1995) (Travelers). 

The court of appeals correctly concluded (and respondent has not contested) that the Vermont reporting requirements do not have a “reference to” ERISA 

plans. Pet. App. 23 n.9 (citations omitted). A law has 

a “reference to” ERISA plans if it “acts immediately 

and exclusively upon ERISA plans” or “the existence 

of ERISA plans is essential to the law’s operation.” 

California Div. of Labor Standards Enforcement v. 

Dillingham Constr., N.A., 519 U.S. 316, 325-326 

(1997) (Dillingham). The Vermont reporting requirements apply to many healthcare payers, not only 

to ERISA plans. Database Statute § 9410(c) (Supp. 

2014); see Database Regulation §§ 3(X), 4. And they

could function independently of the existence of 

ERISA plans, though excluding ERISA plans would 
14

render Vermont’s database far less comprehensive

and thus less useful. For these reasons, the reporting 

requirements do not resemble the state laws that this 

Court has held to have a specific “reference to” 

ERISA plans. Those laws have targeted ERISA plans 

with specificity. See District of Columbia v. Greater 

Wash. Bd. of Trade, 506 U.S. 125, 128, 129-133 (1992) 

(workers’ compensation law that required employee 

benefits “set by reference to [ERISA] plans”) (citation 

omitted); Ingersoll-Rand Co. v. McClendon, 498 U.S. 

133, 135-136, 140 (1990) (common-law claim for wrongful discharge to prevent attainment of ERISA benefits); Mackey v. Lanier Collection Agency & Serv., 

Inc., 486 U.S. 825, 828 & n.2, 829-830 (1988) (exemption from garnishment statute for ERISA plans).

Accordingly, whether Section 1144(a) preempts the 

Vermont reporting requirements turns on whether 

the requirements have an impermissible “connection 

with” ERISA plans. This Court has acknowledged 

that the phrase “‘connection with’ is scarcely more

restrictive than ‘relate to’” and has therefore “cautioned against an uncritical literalism that would make 

pre-emption turn on infinite connections.” Egelhoff, 

532 U.S. at 147 (citation and internal quotation marks 

omitted). To avoid such an expansive breadth, the

Court has “look[ed] both to the objectives of the 

ERISA statute as a guide to the scope of the state law 

that Congress understood would survive” and “to the 

nature of the effect of the state law on ERISA plans.” 

Ibid. (citations and internal quotation marks omitted); 

see Travelers, 514 U.S. at 655-656. 

Much like ordinary field preemption, the first inquiry essentially asks whether the challenged state 

law is directed at “an area of core ERISA concern”: 
15

the design and administration of employer-sponsored 

pension and welfare plans. Egelhoff, 532 U.S. at 147; 

see, e.g., Dillingham, 519 U.S. at 330-331. The second 

inquiry asks whether, even if the law is not overtly 

directed at that field, its application would frustrate

the purpose of ERISA’s preemption provision “to 

ensure that plans and plan sponsors [are] subject to a 

uniform body of benefits law,” Ingersoll-Rand, 498 

U.S. at 142, by prescribing binding rules for the design or administration of ERISA plans. See Egelhoff, 

532 U.S. at 148-149. In this case, the answer to each 

inquiry is no.

1. The Vermont reporting requirements serve objectives distinct from the basic purposes of ERISA

The Vermont reporting requirements operate in an 

area of traditional state regulation and bear only an 

attenuated relation to the purposes of ERISA. As 

such, they are entitled to a presumption of nonpreemption under Section 1144(a)—a presumption 

fortified by the requirements’ important role in 

achieving the goals of other federal legislation. 

a. As discussed above, ERISA imposes a number 

of reporting requirements on plans, such as the submission of financial and actuarial information to the 

Secretary. See pp. 2-3, supra. Those requirements 

serve ERISA’s basic purposes: to prevent the “mismanagement of funds accumulated to finance 

employee benefits and the failure to pay employees 

benefits from accumulated funds,” Dillingham, 519 

U.S. at 326-327 (quoting Massachusetts v. Morash, 

490 U.S. 107, 115 (1989)), by enforcing “fiduciary 

standards on persons whose actions affect the amount 

of benefits * * * plan participants will receive,”

John Hancock Mut. Life Ins. Co. v. Harris Trust & 
16

Sav. Bank, 510 U.S. 86, 96 (1993). See 29 U.S.C. 

1001(b). Any state-law reporting requirements for the 

same purposes would raise a substantial preemption 

question. See Standard Oil Co. v. Agsalud, 633 F.2d 

760, 763-766 (9th Cir. 1980) (holding preempted Hawaii reporting requirements incident to law requiring 

employers to provide prepaid health plan), summarily 

aff’d, 454 U.S. 801 (1981); see also Fort Halifax Packing Co. v. Coyne, 482 U.S. 1, 12-13 & n.7 (1987). That 

is because such requirements would effectively invade 

the field exclusively governed by ERISA and alter the 

approach that Congress adopted to ensure that plans 

are administered according to appropriate legal requirements. 

The Vermont reporting requirements, however,

have a different focus. The requirements are designed to populate a state database to be used to 

achieve a variety of general healthcare-related goals, 

including identifying the State’s healthcare needs, 

enhancing resource utilization, comparing treatment 

costs and approaches, improving patient outcomes, 

and “mak[ing] available to consumers transparent 

health care price information, quality information, and 

such other information as * * * is necessary to empower individuals, including uninsured individuals, to 

make economically sound and medically appropriate 

decisions.” Database Statute § 9410(a)(1) and (2)(A) 

(Supp. 2014). The Vermont reporting requirements, 

in other words, focus on the quality, cost, and transparency of medical treatment in the State. Those 

goals are part of an overall statutory scheme intended 

to “[m]aintain and improve the quality of health care 

services offered to Vermonters” and achieve other 

ends. Vt. Stat. Ann. tit. 18, § 9401(b) (2012). 
17

That purpose is “quite remote from the areas with 

which ERISA is expressly concerned.” Dillingham, 

519 U.S. at 330; see 29 U.S.C. 1001(a) and (b). The 

purpose of Vermont’s data collection is not to ensure

that ERISA plans are sufficiently funded, pay benefits 

covered under the plan or required by federal law, or 

are administered in accordance with fiduciary standards. Indeed, the Database Regulation does not even 

seek information about all claims submitted by participants in ERISA welfare plans, but only about claims 

that are paid. See § 3(Ac) and (Ak); see also id. 

§ 5(A)(8). That is because the focus of the regulation 

is not the claims processes of employee benefit plans, 

but rather healthcare expenditures, utilization, and 

cost. Vermont thus does not collect information about 

claims that are denied by ERISA plan administrators—a matter of central importance to ensuring that 

ERISA plans are being administered in accordance 

with their terms and with statutory requirements, but 

of relatively little importance to evaluating how 

healthcare dollars are spent in Vermont.

The Vermont reporting requirements, moreover, 

operate in an area squarely within the “historic police 

powers of the State”: “the regulation of matters of 

health and safety,” De Buono v. NYSA-ILA Med. & 

Clinical Servs. Fund, 520 U.S. 806, 814 (1997). Although state collection and analysis of healthcare data 

is a relatively recent phenomenon, the basic objectives 

of the data analysis—improving healthcare quality, 

reducing healthcare costs, and helping Vermonters 

make informed medical decisions—reflect the longstanding interest of States in promoting the health of 

their citizens, including through information-collection 

efforts. See Pet. Br. 4-7, 32-34. And precisely be-
18

cause ERISA does not focus on analyzing general data 

about medical treatment across payers, ERISA does 

not establish a federal scheme for collecting and aggregating a broad set of data about medical treatment

or provide any alternative mechanism by which state 

and local governments can do so. Cf. Pegram v. Herdrich, 530 U.S. 211, 214, 237 (2000) (explaining that 

medical-treatment decisions are not ERISA fiduciary 

acts despite their close relationship to decisions about 

what a health plan covers).

b. Because there exists little overlap between the 

objectives of ERISA and the objectives of the Vermont scheme, and because the Vermont scheme operates in an area of traditional state regulation, the 

reporting requirements are entitled to “the presumption that ERISA did not intend to supplant [them].” 

Dillingham, 519 U.S. at 331-332. As this Court has 

explained, “[a] reading of [Section 1144(a)] resulting 

in the pre-emption of traditionally state-regulated 

substantive law in those areas where ERISA has nothing to say would be ‘unsettling.’” Id. at 330 (quoting 

Travelers, 514 U.S. at 665). Congress does not typically enact legislation in one substantive field with the 

intention to “squelch * * * state efforts” in a distinct 

sphere that has historically been regulated at the 

state and local levels and that the federal statute does 

not address. Travelers, 514 U.S. at 665. That is especially true “in the field of health care,” where “there is 

no ERISA preemption without [a] clear manifestation 

of congressional purpose.” Pegram, 530 U.S. at 237 

(citing Travelers, 514 U.S. at 654-655). 

Applying preemption so broadly would be particularly troublesome here because it would create a vacuum in a critically important area for the future of 
19

healthcare. If reporting requirements like Vermont’s 

were held invalid, States would be foreclosed from 

collecting information from employer-sponsored plans

that are self-insured (except on a voluntary basis),*

despite the fact that over a dozen States have determined that such informational efforts can improve 

their citizens’ healthcare, lower costs, and enhance 

consumer choice. Pet. App. 7. That would create a 

significant gap; one study estimated that in 2011, 

58.5% of workers were covered by self-insured health 

plans. Paul Fronstin, Self-Insured Health Plans: 

State Variation and Recent Trends by Firm Size, 

Emp. Benefit Res. Inst. Notes, Nov. 2012, at 2. Respondent has pointed to no evidence that Congress 

intended ERISA to thwart States’ analytical initiatives. Particularly given that “nothing in the language 

of [ERISA] or the context of its passage indicates that 

Congress chose to displace general health care regulation” by the States, Travelers, 514 U.S. at 661, this 

Court should be extremely reluctant to read such a 

broad preemptive scope into Section 1144(a). 

c. There is another reason for caution before holding that the Vermont reporting requirements are 

preempted: Such a ruling would frustrate the objectives of other important federal statutory provisions. 

In construing Section 1144(a), this Court has carefully attended to the objectives of other federal statutes, particularly in light of Section 1144(d), which 

provides that “[n]othing in this subchapter shall be 

construed to alter, amend, modify, invalidate, impair, 

* The court of appeals had no occasion to address whether its 

preemption holding applies to companies that insure ERISA plans, 

in light of Section 1144(b)(2)’s exemption from preemption for 

insurance regulation.

 
20

or supersede any law of the United States.” Thus, for 

example, in Travelers, supra, the Court held a New 

York statute non-preempted in part because a federal 

statute subsequently enacted by the same Congress 

that enacted ERISA was “simply incompatible with 

pre-emption” of the state law. 514 U.S. at 666-667; see

also id. at 667 n.6. Similarly, in Shaw, supra, the 

Court held that a New York law was not preempted 

“to the extent that the [law] provides a means of enforcing Title VII’s commands.” 463 U.S. at 102. The 

Court explained that the contrary view “would frustrate the goal of encouraging joint state/federal enforcement of Title VII.” Ibid. 

Here, provisions of the ACA rely on or encourage 

state data-collection efforts similar to Vermont’s. 

Section 3021(a) of the ACA established the Center for 

Medicare and Medicaid Innovation (CMMI). See 124 

Stat. 389 (42 U.S.C. 1315a). CMMI’s charge is “to test 

innovative payment and service delivery models” that

reduce costs “while preserving or enhancing the quality of care.” 42 U.S.C. 1315a(a)(1). The ACA encourages CMMI to evaluate a variety of models, see 42 

U.S.C. 1315a(b)(2)(B), including by “[a]llowing States 

to test and evaluate systems of all-payer payment 

reform for the medical care of residents of the State,” 

42 U.S.C. 1315a(b)(2)(B)(xi). The ACA requires each 

model that CMMI tests to be evaluated by analyzing 

“the quality of care furnished under the model” and 

“the changes in spending under [Medicare, Medicaid 

and the Children’s Health Insurance Program 

(CHIP)] by reason of the model.” 42 U.S.C. 

1315a(b)(4). In part because models may shift costs 

among different payers or have health effects that are 

not reflected in the Medicare, Medicaid, and CHIP 
21

databases, access to comprehensive state-level databases is important for evaluating models. Accordingly, holding that initiatives like Vermont’s are invalid 

would impede CMMI’s statutory mission. 

Congress also expressly recognized the importance 

of efforts to collect and analyze healthcare data in 

Section 10332 of the ACA. 124 Stat. 968 (42 U.S.C. 

1395kk(e)). That provision requires the Secretary of 

HHS to make Medicare data available to entities that 

use claims data “to evaluate the performance of providers of services and suppliers on measures of quality, efficiency, effectiveness, and resource use.” 42 

U.S.C. 1395kk(e)(2)(A). It is unlikely that Congress 

would have encouraged the development of such analytical efforts by making Medicare data available if it 

believed that States were prohibited by ERISA from 

obtaining data from other healthcare payers.

As discussed above (see pp. 3-4, supra), the ACA 

established new reporting requirements that apply to 

group health plans and insurance companies. 42 

U.S.C. 300gg-15a, 300gg-17; see 29 U.S.C. 1185d(a). 

Respondent has not suggested that these new reporting requirements expand the scope of ERISA preemption in a way that is relevant to this case. Any such 

argument would conflict with the express terms of the 

ACA, which provides that “[n]othing in [ACA Title I, 

which includes the relevant provisions,] shall be construed to preempt any State law that does not prevent 

the application of the provisions of [ACA Title I],” 42 

U.S.C. 18041(d). It would also conflict with ERISA 

itself. See 29 U.S.C. 1191(a)(2) (“Nothing in this part 

[29 U.S.C. 1181-1191c] shall be construed to affect or 

modify the provisions of section 1144 of [ERISA] with 

respect to group health plans.”); see also 42 U.S.C. 
22

300gg-23(a)(2). And in any event, those ACA reporting requirements focus on plans as such, seeking

information on such matters as claims-payment policies, cost sharing for out-of-network coverage, enrollment figures, and whether certain types of benefits 

are being included in healthcare plans. 42 U.S.C.

300gg-15a (incorporating provisions of 42 U.S.C. 

18031(e)(3)); 42 U.S.C. 300gg-17(a). They therefore 

would not fill the void left by invalidating state-level 

efforts to compile databases of healthcare-expenditure 

information across the board. 

2. The Vermont reporting requirements do not exert 

an impermissible effect on the design or administration of ERISA plans

Because the Vermont reporting requirements operate in an area of traditional state regulation that is

remote from the basic purposes of ERISA, they are 

entitled to a presumption against preemption under 

Section 1144(a). Dillingham, 519 U.S. at 330-332. 

That presumption could be overcome if the Vermont 

scheme, though not overtly directed at ERISA plans, 

nevertheless operated to prescribe binding rules for

the design or administration of ERISA plans or exerted such powerful economic effects as to practically

bind plan administrators to a particular course of 

conduct. But neither type of forbidden effect has been 

demonstrated here.

a. The purpose of ERISA’s preemption provision is

“to ensure that plans and plan sponsors [are] subject 

to a uniform body of benefits law” so that they are not 

required to “tailor[] * * * plans and employer conduct to the peculiarities of the law of each jurisdiction.” Ingersoll-Rand, 498 U.S. at 142. That animating purpose “reflect[s] recognition of the administra-
23

tive realities of employee benefit plans”: If multistate plans were governed by different legal rules for 

core administrative functions, it “would produce considerable inefficiencies, which the employer might 

choose to offset by lowering benefit levels.” Fort 

Halifax, 482 U.S. at 9-10. 

For that reason, this Court has held that state laws 

“relate to” ERISA plans under Section 1144(a) if they

“bind[] ERISA plan administrators to a particular 

choice of rules” for “a central matter of plan administration.” Egelhoff, 532 U.S. at 147-148. For example, this Court has held that laws “relate to” ERISA 

plans when they designate beneficiaries of ERISA 

plans, id. at 143; “forbid[] a method of calculating 

pension benefits that federal law permits,” De Buono, 

520 U.S. at 814-815 (citing Alessi v. RaybestosManhattan, Inc., 451 U.S. 504 (1981)); or “require[] 

employers to provide certain benefits,” id. at 815 

(citing Shaw, supra, and Metropolitan Life Ins. Co. v. 

Massachusetts, 471 U.S. 724 (1985)). 

Conversely, this Court has held that laws of general applicability that merely influence the choices 

made by ERISA sponsors or fiduciaries, but do not 

prescribe binding rules governing plan design or administration, are not preempted. See Dillingham, 519 

U.S. at 329; Travelers, 514 U.S. at 657, 660, 664. If 

such laws were preempted, this Court has explained, 

the courts would “scarcely see the end of ERISA’s 

pre-emptive reach, and the words ‘relate to’ would 

limit nothing.” Dillingham, 519 U.S. at 329. The 

Court accordingly has sustained laws that “increase[] 

[the] costs of providing certain benefits, and thereby 

potentially affect[] the choices made by ERISA 

plans,” ibid., or that exert only an “indirect economic 
24

influence” by making certain plan-administration

choices more economically attractive, Travelers, 514 

U.S. at 659. ERISA thus does not guarantee “cost 

uniformity” among States where a plan might operate. 

Id. at 662. After all, ordinary tax, wage, property, and 

health laws can vary from State to State and entail 

substantial administrative costs.

b. The Vermont reporting requirements do not exert an impermissible effect on ERISA plans because 

they do not prescribe binding rules for a central matter of plan administration. The reporting provisions

do not dictate features of ERISA plans—vesting requirements, benefit levels, and so forth—nor do they 

impose rules on plan administrators for how claims 

should be processed and paid. See Pet. App. 72. They 

do not enhance or alter plan administrators’ fiduciary 

duties or supplement ERISA’s remedial scheme. See 

Aetna Health Inc. v. Davila, 542 U.S. 200, 214-215

(2004). The Vermont scheme does not, in other words,

dictate how a plan must be administered. It therefore 

differs fundamentally from, for example, state-law 

rules governing beneficiary designations, which, if

sustained, would demand that a fiduciary maintain 

familiarity with every relevant State’s laws just to 

complete the basic functions of plan administration. 

Cf. Egelhoff, supra. 

The court of appeals rested its contrary holding on 

the notion that all “reporting”—which the court defined as “plan record-keeping[] and filing with a thirdparty”—is “a core ERISA function.” Pet. App. 23-24. 

Based on that premise, the court held that any state 

law that imposes a reporting obligation on an ERISA 

plan that is more than “slight” is preempted. Ibid. 

(citing Shaw, 463 U.S. at 98). 
25

That conclusion was erroneous, even accepting the 

court of appeals’ belief that the burden here is more 

than “slight” (but see pp. 28-29, infra). ERISA imposes reporting and disclosure obligations that further the regulation of the design and administration of 

employee benefit plans. Those obligations are integral to achieving ERISA’s purposes, because they 

enable the Department of Labor and plan participants 

to ensure that the plan is being administered properly. But that does not mean that all reporting incident 

to state laws of general applicability that operate in 

disparate fields—taxes, property, wages—qualify as 

“core ERISA function[s].” And while decisions of this 

Court and the legislative history of ERISA identify

“reporting” and “disclosure” as a central ERISA subject matter, those brief general statements, read in 

context, are best understood to refer to reporting 

ancillary to the areas that ERISA governs, not to any 

reporting obligation that might be imposed on an 

ERISA plan incident to enforcing an otherwise applicable state law. E.g., Dillingham, 519 U.S. at 330 

(quoting Travelers, 514 U.S. at 661); see, e.g., S. Rep. 

No. 127, 93d Cong., 1st Sess. 35 (1973).

Any other reading would be untenable in light of 

the many types of general state laws to which ERISA 

plans are subject and would conflict with the Court’s 

holdings in other cases that state laws containing

reporting or record-keeping requirements are not 

preempted. In De Buono, for example, this Court 

held that a gross-receipts tax on patient services provided by a hospital operated by an ERISA plan was 

not preempted, see 520 U.S. at 809-810, 816, even 

though the administration of the tax required the 

filing of quarterly reports, see U.S. Amicus Br. at 2-3, 
26

De Buono, supra (No. 95-1594). And in Dillingham, 

the Court held that California’s prevailing-wage law 

was not preempted as applied to apprenticeship programs established as ERISA plans. See 519 U.S. at 

319. Prevailing-wage laws typically require employers 

to keep records of the wages paid to employees and 

make them available for review by state authorities. 

See, e.g., Cal. Lab. Code § 1776 (West 1989) (prevailing-wage law in Dillingham); see also, e.g., Keystone 

Chapter, Associated Builders & Contractors, Inc. v. 

Foley, 37 F.3d 945, 962-963 (3d Cir. 1994), cert. denied, 514 U.S. 1032 (1995). And as petitioner points 

out (Pet. Br. 41), “ERISA contemplates that plans 

may offer * * * day care centers, training programs, 

and legal services”—activities that undoubtedly may 

be subject to state regulation and reporting requirements. 29 U.S.C. 1002(1). The court of appeals thus 

erred in concluding that any state-law reporting obligation that is more than “slight” is preempted.

For its part, respondent distinguishes (Br. in Opp. 

26) other generally applicable state-law reporting 

obligations imposed on ERISA plans on the ground 

that the Vermont law “requires the reporting of information about core ERISA activities: the payment 

of claims under the plan.” Cf. Pet. App. 29 n.13. Respondent essentially contends that all reporting that 

involves information acquired or generated during the 

administration of a plan qualifies as a core matter of 

plan administration. 

That cannot be the test. Many generally applicable 

reporting requirements that apply to ERISA plans 

might seek for tax or other purposes information 

acquired or generated in the course of administering 

the plan—such as information about claims payments, 
27

pension disbursements, employer contributions, or 

assets held in trust. An ERISA plan, after all, is not 

likely to have much information about matters not 

related to the administration of the plan. The grossreceipts reporting in De Buono, for example, concerned the amount of money that the plan was taking 

in through the medical centers that the plan was operating. The logical consequence of respondent’s argument, therefore, is that almost no state-law reporting 

obligation would survive preemption, even those incident to otherwise valid laws of general applicability. 

Such a broad rule of preemption would conflict with 

this Court’s reluctance to invalidate state laws that 

operate in areas to which ERISA does not speak and 

would reflect an unrealistic view of Congress’s intent 

when it made reporting and disclosure in areas regulated by ERISA an exclusively federal concern.

c. This Court has suggested in dicta that “there 

might be a state law whose economic effects, intentionally or otherwise, were so acute as to force an 

ERISA plan to adopt a certain scheme of substantive 

coverage or effectively restrict its choice of insurers, 

and such a state law might indeed be pre-empted.” De 

Buono, 520 U.S. at 816 n.16 (quoting Travelers, 514 

U.S. at 668) (internal quotation marks omitted). It is 

therefore conceivable that a state-law reporting obligation that does not impose binding legal requirements on the design or administration of ERISA plans 

could be so costly as to be preempted. And in considering whether such an extreme economic effect exists, 

it is appropriate to consider the effect of a potential 

patchwork of state laws imposing different requirements. See Egelhoff, 532 U.S. at 149-150.
28

But in the posture of this case, no sound basis exists to conclude that the Vermont reporting requirements burden ERISA plans in a qualitatively different 

or more substantial way than “myriad state laws in 

areas traditionally subject to local regulation, which 

Congress could not possibly have intended to eliminate.” Travelers, 514 U.S. at 668. Indeed, there is no 

reason to conclude that the reporting requirements 

impose anything more than a de minimis financial 

burden, because respondent made no effort to quantify those costs in its filings below. As the district court 

explained after reviewing respondent’s summaryjudgment submissions, “[t]here is no evidence that the 

law * * * creates an economic effect so acute as to 

dictate certain administrative choices.” Pet. App. 72. 

The court of appeals nevertheless stated that “the 

reporting mandated by the Vermont statute and regulation is burdensome, time-consuming, and risky,” 

particularly when considered “as one of several or a 

score of uncoordinated state reporting regimes.” Pet. 

App. 25. Respondent contends (Br. in Opp. 20) that 

the court of appeals’ view “reflects a common sense 

assessment of the administrative realities of ERISA 

plans.” 

The supposition that Vermont’s requirements impose a substantial burden, however, is not obvious, or 

even particularly plausible, without any factual support. The Database Regulation essentially requires 

Blue Cross to take information generated in the ordinary course of its claims-payment operations and 

report that information in a prescribed format to the 

Board. Respondent has not suggested, let alone established, that Blue Cross has changed any aspect of 

its administration of the claims process because of 
29

that reporting obligation. While organizing and formatting the data requires some administrative resources, it is implausible to assume that the additional 

cost would meaningfully alter the claims-payment 

process or any other aspect of the plan’s administration. Indeed, Blue Cross presumably already has such

procedures in place, given that it reports data to the 

Board for over 7000 individuals, see J.A. 205. 

If the cost of compliance were in fact so significant 

as to alter Blue Cross’s administration of claims, respondent could have submitted a declaration quantifying, or at least estimating, the burden, and explaining 

ways in which the reporting obligation has changed 

how its plan operates. Or it could have submitted 

evidence estimating or describing the burden for 

ERISA plans generally. Respondent’s contentions

then could have been subject to adversarial testing in

the district court. But respondent’s only factual submission was a “fact sheet” printed from the Internet 

stating that it would be less costly if States with similar statutes standardized their data formats—which 

says nothing about whether the cost is so great as to 

fundamentally affect plan administration. See J.A. 

217-225; D. Ct. Doc. 59, at 2 (Oct. 7, 2012). Thus, as 

Judge Straub explained, “[o]n the record before [the 

court of appeals], there is no basis to find that the 

Vermont statute would cause [respondent] to increase 

its costs more than a de [minimis] amount to cover 

the cost of sending information to the state, much less 

that it would cause a fiduciary to change a plan in any 

way.” Pet. App. 40-41 (dissenting in part and concurring in part).
30

B. The Vermont Reporting Requirements Are Valid If 

Reviewed Under General Principles Of Field And 

Conflict Preemption

In separate opinions, four Justices have called for 

this Court to clarify that its framework for analyzing 

ERISA preemption questions essentially applies ordinary principles of field and conflict preemption. Under that view, “the ‘relate to’ clause of the preemption provision is meant, not to set forth a test for 

pre-emption, but rather to identify the field in which 

ordinary field pre-emption applies—namely, the field 

of laws regulating ‘employee benefit plan[s] described 

in section 1003(a) of this title and not exempt under 

section 1003(b) of this title,’ 29 U.S.C. § 1144(a).” 

Dillingham, 519 U.S. at 336 (Scalia, J., concurring, 

joined by Ginsburg, J.) (brackets in original); see

Egelhoff, 532 U.S. at 152-153 (Scalia, J., concurring, 

joined by Ginsburg, J.); id. at 153 (Breyer, J., dissenting, joined by Stevens, J.). And in Boggs v. Boggs, 520 

U.S. 833 (1997), the Court held a state law preempted 

“by simply asking if [the] state law conflicts with the 

provisions of ERISA or operates to frustrate its objects,” without “inquir[ing] whether the statutory 

phrase ‘relate to’ provides further and additional support for the pre-emption claim.” Id. at 841; cf. UNUM 

Life Ins. Co. of Am. v. Ward, 526 U.S. 358, 375-377 

(1999) (UNUM) (applying conflict-preemption analysis to state law falling within ERISA’s insurance savings clause). 

If the Court applies ordinary field and conflict 

preemption principles here as a means of giving content to (or checking the applicability of) the “relate to” 

language in Section 1144(a), the Vermont reporting 

requirements likewise are not preempted.
31

1. When a federal statute occupies a field of substantive regulation, the test for preemption “is whether the matter on which the State asserts the right to 

act is in any way regulated by the Federal Act.” Rice

v. Santa Fe Elevator Corp., 331 U.S. 218, 236 (1947). 

If so, the state law is preempted, even if it is consistent with federal objectives. See ONEOK, Inc. v. 

Learjet, Inc., 135 S. Ct. 1591, 1595 (2015); accord Metropolitan Life Ins. Co., 471 U.S. at 739 (“[ERISA’s] 

pre-emption provision was intended to displace all 

state laws that fall within its sphere, even including 

state laws that are consistent with ERISA’s substantive requirements.”). But this Court has also kept “in 

mind that not every state law that in some remote way 

may affect the [subject matter of the federal statute] 

can be said to fall within the pre-empted field.” English v. General Elec. Co., 496 U.S. 72, 85 (1990). 

Largely for the reasons given in Point A above, the 

Vermont reporting requirements do not improperly 

invade a field governed exclusively by ERISA. They 

do not target ERISA plans for special treatment. 

They have a different purpose and function than 

ERISA, focusing on the quality, utilization, and cost of 

medical services themselves, from a healthcaredelivery perspective, rather than the design of employee benefit plans or fiduciary conduct in delivering

promised benefits to ERISA participants and beneficiaries. And the requirements have not been shown to

exert more than a de minimis effect on the design or 

administration of ERISA plans.

2. a. Under conflict-preemption principles, a state 

law is invalid (as applied to ERISA plans) if “compliance with both [the state law] and [ERISA] is impossible, or when the state law stands as an obstacle to 
32

the accomplishment and execution of the full purposes 

and objective of [ERISA].” United States v. Locke, 

529 U.S. 89, 109 (2000) (citation and internal quotation 

marks omitted); see Boggs, 520 U.S. at 844. Thus, in 

Boggs, this Court held that a state law permitting a 

non-participant to effect a testamentary transfer of 

her spouse’s undistributed pension benefits was 

preempted after finding a “direct clash between [the] 

state law and the provisions and objectives of ERISA” 

with respect to the designation of beneficiaries of

survivor annuities. 520 U.S. at 843-844. Similarly, in 

a line of cases, this Court has held that certain state 

laws conflict with the objectives of ERISA’s exclusive 

remedial scheme. See Aetna Health, 542 U.S. at 214-

215. A law would also be preempted if it frustrated

the central purpose of Section 1144(a) itself, which is

to avoid “the prospect that an employer’s administrative scheme would be subject to conflicting requirements.” Fort Halifax, 482 U.S. at 9-10.

It is not impossible to comply with both ERISA’s 

requirements and the Vermont reporting requirements. And for the reasons given above (see pp. 22-

29, supra), no sound basis exists to conclude that the 

requirements would pose an obstacle to the uniform 

administration of ERISA plans. 

b. Respondent has contended (Br. in Opp. 22-23) 

that the Vermont scheme conflicts with ERISA’s 

requirement that fiduciaries follow plan documents, 29 

U.S.C. 1104(a)(1)(D), because the plan documents in 

this case required respondent and Blue Cross to maintain the confidentiality of the medical records of participants and beneficiaries. Respondent essentially 

argues that a plan sponsor can evade a state legal 

obligation by drafting an incompatible plan term. But 
33

this Court rejected a materially identical argument in 

UNUM, where it held that an otherwise nonpreempted state insurance law did not conflict with 

Section 1104(a)(1)(D) merely because a plan sponsor 

had “insert[ed] a contrary term in plan documents,”

finding that argument to “make[] scant sense.” 526 

U.S. at 375-376; see FMC Corp. v. Holliday, 498 U.S. 

52, 54-65 (1990) (analyzing whether ERISA preempted a state law prohibiting a particular plan term under 

the normal ERISA preemption framework). 

As support for its anomalous position, respondent 

cites a footnote in Egelhoff, supra (Br. in Opp. 22-24),

but respondent misunderstands the import of that 

discussion. Egelhoff held preempted, as applied to 

ERISA plans, a Washington statute providing that the 

designation of a spouse as a beneficiary of a nonprobate asset was revoked automatically upon divorce. 

532 U.S. at 144 (citing Wash. Rev. Code § 11.07.010(1)

(1994)). The Court rejected the argument that the 

Washington statute was saved from preemption because employers could opt out of the automaticrevocation rule through an express plan term. See id.

at 150-151. In the cited footnote, the Court merely 

observed that a State could not save an otherwise 

preempted law from invalidation by permitting

ERISA plan sponsors to opt out by changing the 

terms of their plans, see id. at 151 n.4, and the Court 

went on to highlight the significant burden for fiduciaries in “maintain[ing] a familiarity with the laws of 

all 50 States so that they can update their plans as 

necessary,” id. at 151. Nothing in the Court’s discussion, however, supports the view that a state law that 

is otherwise not preempted could be circumvented by 
34

a contrary term in a particular plan, an argument this 

Court rejected in UNUM. 

In any event, there is no evident conflict between 

the terms of respondent’s plan and the Vermont reporting requirements. No provision of respondent’s 

plan documents states that the plan will refuse to

report claims information to state authorities in compliance with state law. To the contrary, the primary 

plan document expressly provides that “[t]he Plan 

shall comply with all * * * state and federal law to 

the extent not preempted by ERISA.” J.A. 57. Respondent appears to rely on two statements in a summary plan description stating that information relating to “well-baby programs” and “pharmagenomics”

will be kept confidential. J.A. 117-120 (capitalization 

and emphasis omitted); see Resp. C.A. Br. 7. But 

respondent’s primary plan document states that it 

trumps conflicting statements in the summary plan 

description, J.A. 40; the cited statements relate only 

to very specific medical programs; and, in any event,

the extensive confidentiality protections of the Vermont scheme (see p. 6, supra) preserve the confidentiality of reported information, see Database Statute 

§ 9410(e) and (h)(2) (Supp. 2014). Accordingly, even if 

ERISA called on courts to conduct the sort of plan-byplan preemption analysis that respondent suggests—

in which the validity of state law would be entirely 

subordinate to plan terms—preemption would not be 

warranted here.

c. Finally, respondent argued below that by complying with state-law reporting requirements, an 

ERISA fiduciary would violate its statutory duty to 

act “for the exclusive purpose of * * * providing 

benefits to participants and their beneficiaries; and 
35

* * * defraying reasonable expenses of administering the plan,” 29 U.S.C. 1104(a)(1); see Resp. C.A. Br. 

39-40. If accepted, that argument not only would

preclude States from imposing any reporting requirements, but would also bar States from imposing 

taxes and other generally applicable obligations on 

ERISA plans that serve purposes other than providing benefits and defraying administrative expenses. 

Congress could not have intended ERISA’s fiduciaryduties provision to have that sweeping preemptive 

effect. And like respondent’s other arguments, it 

cannot be squared with this Court’s more circumscribed understanding of ERISA preemption or its 

decisions upholding state laws imposing obligations on 

ERISA plans.

* * * * * 

For the foregoing reasons, whether under this 

Court’s established framework for analyzing preemption questions under Section 1144(a), or viewed 

through the lens of ordinary field and conflict preemption, the Vermont reporting requirements are not 

preempted. Thus, like other record-keeping and reporting requirements incident to state tax, wage, 

property, and health laws, the Vermont reporting 

requirements are among the “myriad state laws of 

general applicability that impose some burdens on the 

administration of ERISA plans but nevertheless do

not ‘relate to’ them within the meaning of the governing statute.” De Buono, 520 U.S. at 815 (citation and 

internal quotation marks omitted).
36

CONCLUSION

The judgment of the court of appeals should be 

reversed. 

Respectfully submitted. 

M. PATRICIA SMITH

Solicitor of Labor

G. WILLIAM SCOTT

Associate Solicitor

ELIZABETH HOPKINS

Counsel

MELISSA MOORE

Attorney

DONALD B. VERRILLI, JR. Solicitor General

EDWIN S. KNEEDLER

Deputy Solicitor General

JOHN F. BASH

Assistant to the Solicitor 

General

SEPTEMBER 2015 
(1a) 

APPENDIX 

1. 29 U.S.C. 1001 provides:

Congressional findings and declaration of policy 

(a) Benefit plans as affecting interstate commerce and 

the Federal taxing power 

 The Congress finds that the growth in size, scope, and 

numbers of employee benefit plans in recent years has 

been rapid and substantial; that the operational scope and 

economic impact of such plans is increasingly interstate; 

that the continued well-being and security of millions of 

employees and their dependents are directly affected by 

these plans; that they are affected with a national public 

interest; that they have become an important factor affecting the stability of employment and the successful development of industrial relations; that they have become 

an important factor in commerce because of the interstate 

character of their activities, and of the activities of their 

participants, and the employers, employee organizations, 

and other entities by which they are established or maintained; that a large volume of the activities of such plans 

are carried on by means of the mails and instrumentalities 

of interstate commerce; that owing to the lack of employee information and adequate safeguards concerning 

their operation, it is desirable in the interests of employees and their beneficiaries, and to provide for the general 

welfare and the free flow of commerce, that disclosure be 

made and safeguards be provided with respect to the establishment, operation, and administration of such plans; 

that they substantially affect the revenues of the United 

States because they are afforded preferential Federal tax 
2a 

treatment; that despite the enormous growth in such 

plans many employees with long years of employment are 

losing anticipated retirement benefits owing to the lack of 

vesting provisions in such plans; that owing to the inadequacy of current minimum standards, the soundness and 

stability of plans with respect to adequate funds to pay 

promised benefits may be endangered; that owing to the 

termination of plans before requisite funds have been 

accumulated, employees and their beneficiaries have been 

deprived of anticipated benefits; and that it is therefore 

desirable in the interests of employees and their beneficiaries, for the protection of the revenue of the United 

States, and to provide for the free flow of commerce, that 

minimum standards be provided assuring the equitable 

character of such plans and their financial soundness. 

(b) Protection of interstate commerce and beneficiaries 

by requiring disclosure and reporting, setting standards of conduct, etc., for fiduciaries 

 It is hereby declared to be the policy of this chapter to 

protect interstate commerce and the interests of participants in employee benefit plans and their beneficiaries, by 

requiring the disclosure and reporting to participants and 

beneficiaries of financial and other information with respect thereto, by establishing standards of conduct, responsibility, and obligation for fiduciaries of employee 

benefit plans, and by providing for appropriate remedies, 

sanctions, and ready access to the Federal courts. 

 
3a 

(c) Protection of interstate commerce, the Federal taxing power, and beneficiaries by vesting of accrued 

benefits, setting minimum standards of funding, requiring termination insurance

 It is hereby further declared to be the policy of this 

chapter to protect interstate commerce, the Federal taxing power, and the interests of participants in private 

pension plans and their beneficiaries by improving the 

equitable character and the soundness of such plans by 

requiring them to vest the accrued benefits of employees 

with significant periods of service, to meet minimum 

standards of funding, and by requiring plan termination 

insurance. 

2. 29 U.S.C. 1002(1) provides: 

Definitions 

For purposes of this subchapter: 

 (1) The terms “employee welfare benefit plan” and 

“welfare plan” mean any plan, fund, or program which 

was heretofore or is hereafter established or maintained 

by an employer or by an employee organization, or by 

both, to the extent that such plan, fund, or program was 

established or is maintained for the purpose of providing 

for its participants or their beneficiaries, through the 

purchase of insurance or otherwise, (A) medical, surgical, 

or hospital care or benefits, or benefits in the event of 

sickness, accident, disability, death or unemployment, or 

vacation benefits, apprenticeship or other training programs, or day care centers, scholarship funds, or prepaid 

legal services, or (B) any benefit described in section 
4a 

186(c) of this title (other than pensions on retirement or 

death, and insurance to provide such pensions). 

3. 29 U.S.C. 1021(a) and (b) provide: 

Duty of disclosure and reporting 

(a) Summary plan description and information to be 

furnished to participants and beneficiaries 

 The administrator of each employee benefit plan shall 

cause to be furnished in accordance with section 1024(b) 

of this title to each participant covered under the plan and 

to each beneficiary who is receiving benefits under the 

plan— 

 (1) a summary plan description described in section 1022(a)(1)1

 of this title; and 

 (2) the information described in subsection (f) 

and sections 1024(b)(3) and 1025(a) and (c) of this title. 

(b) Reports to be filed with Secretary of Labor

 The administrator shall, in accordance with section 

1024(a) of this title, file with the Secretary— 

 (1) the annual report containing the information 

required by section 1023 of this title; and 

 (2) terminal and supplementary reports as required by subsection (c) of this section. 

 

 

1

 See References in Text note below. 
5a 

4. 29 U.S.C. 1023 provides in pertinent part: 

Annual reports 

(a) Publication and filing 

(1)(A) An annual report shall be published with respect to every employee benefit plan to which this part 

applies. Such report shall be filed with the Secretary 

in accordance with section 1024(a) of this title, and 

shall be made available and furnished to participants 

in accordance with section 1024(b) of this title. 

 (B) The annual report shall include the information described in subsections (b) and (c) and where applicable subsections (d), (e), and (f) and shall also 

include— 

 (i) a financial statement and opinion, as required by paragraph (3) of this subsection, and 

 (ii) an actuarial statement and opinion, as required by paragraph (4) of this subsection. 

 * * * * * 

 (3)(A) Except as provided in subparagraph (C), 

the administrator of an employee benefit plan shall 

engage, on behalf of all plan participants, an independent qualified public accountant, who shall conduct 

such an examination of any financial statements of the 

plan, and of other books and records of the plan, as the 

accountant may deem necessary to enable the accountant to form an opinion as to whether the financial 

statements and schedules required to be included in 

the annual reports by subsection (b) of this section are 

presented fairly in conformity with generally accepted 
6a 

accounting principles applied on a basis consistent 

with that of the preceding year. 

* * * * * 

 (4)(A) The administrator of an employee pension 

benefit plan subject to the reporting requirement of 

subsection (d) of this section shall engage, on behalf of all 

plan participants, an enrolled actuary who shall be responsible for the preparation of the materials comprising 

the actuarial statement required under subsection (d) of 

this section. 

* * * * * 

(b) Financial statement 

 An annual report under this section shall include a 

financial statement containing the following information: 

 (1) With respect to an employee welfare benefit 

plan: a statement of assets and liabilities; a statement of changes in fund balance; and a statement of 

changes in financial position. In the notes to financial 

statements, disclosures concerning the following items 

shall be considered by the accountant: a description 

of the plan including any significant changes in the 

plan made during the period and the impact of such 

changes on benefits; a description of material lease 

commitments, other commitments, and contingent liabilities; a description of agreements and transactions 

with persons known to be parties in interest; a general 

description of priorities upon termination of the plan; 

information concerning whether or not a tax ruling or 

determination letter has been obtained; and any other 
7a 

matters necessary to fully and fairly present the financial statements of the plan. 

* * * * * 

 (3) With respect to all employee benefit plans, the 

statement required under paragraph (1) or (2) shall have 

attached the following information in separate schedules: 

 (A) a statement of the assets and liabilities of 

the plan aggregated by categories and valued at 

their current value, and the same data displayed in 

comparative form for the end of the previous fiscal 

year of the plan; 

 (B) a statement of receipts and disbursements 

during the preceding twelve-month period aggregated 

by general sources and applications; 

 (C) a schedule of all assets held for investment 

purposes aggregated and identified by issuer, borrower, or lessor, or similar party to the transaction 

(including a notation as to whether such party is known 

to be a party in interest), maturity date, rate of interest, collateral, par or maturity value, cost, and current 

value; 

 (D) a schedule of each transaction involving a 

person known to be party in interest, the identity of 

such party in interest and his relationship or that of 

any other party in interest to the plan, a description of 

each asset to which the transaction relates; the purchase or selling price in case of a sale or purchase, the 

rental in case of a lease, or the interest rate and maturity date in case of a loan; expense incurred in connection with the transaction; the cost of the asset, the 
8a 

current value of the asset, and the net gain (or loss) on 

each transaction; 

 (E) a schedule of all loans or fixed income obligations which were in default as of the close of the plan’s 

fiscal year or were classified during the year as uncollectable and the following information with respect to 

each loan on such schedule (including a notation as to 

whether parties involved are known to be parties in 

interest): the original principal amount of the loan, the 

amount of principal and interest received during the 

reporting year, the unpaid balance, the identity and 

address of the obligor, a detailed description of the 

loan (including date of making and maturity, interest 

rate, the type and value of collateral, and other material terms), the amount of principal and interest overdue (if any) and an explanation thereof; 

 (F) a list of all leases which were in default or were 

classified during the year as uncollectable; and the following information with respect to each lease on such 

schedule (including a notation as to whether parties 

involved are known to be parties in interest): the type 

of property leased (and, in the case of fixed assets such 

as land, buildings, leasehold, and so forth, the location 

of the property), the identity of the lessor or lessee 

from or to whom the plan is leasing, the relationship of 

such lessors and lessees, if any, to the plan, the employer, employee organization, or any other party in 

interest, the terms of the lease regarding rent, taxes, 

insurance, repairs, expenses, and renewal options; the 

date the leased property was purchased and its cost, 

the date the property was leased and its approximate 

value at such date, the gross rental receipts during the 
9a 

reporting period, expenses paid for the leased property during the reporting period, the net receipts from 

the lease, the amounts in arrears, and a statement as 

to what steps have been taken to collect amounts due 

or otherwise remedy the default; 

 (G) if some or all of the assets of a plan or plans 

are held in a common or collective trust maintained by 

a bank or similar institution or in a separate account 

maintained by an insurance carrier or a separate trust 

maintained by a bank as trustee, the report shall include the most recent annual statement of assets and 

liabilities of such common or collective trust, and in the 

case of a separate account or a separate trust, such 

other information as is required by the administrator 

in order to comply with this subsection; and 

 (H) a schedule of each reportable transaction, the 

name of each party to the transaction (except that, in 

the case of an acquisition or sale of a security on the 

market, the report need not identify the person from 

whom the security was acquired or to whom it was 

sold) and a description of each asset to which the 

transaction applies; the purchase or selling price in 

case of a sale or purchase, the rental in case of a lease, 

or the interest rate and maturity date in case of a loan; 

expenses incurred in connection with the transaction; 

the cost of the asset, the current value of the asset, and 

the net gain (or loss) on each transaction. For purposes of the preceding sentence, the term “reportable 

transaction” means a transaction to which the plan is a 

party if such transaction is— 
10a 

 (i) a transaction involving an amount in excess of 3 percent of the current value of the assets of 

the plan; 

 (ii) any transaction (other than a transaction 

respecting a security) which is part of a series of 

transactions with or in conjunction with a person in 

a plan year, if the aggregate amount of such transactions exceeds 3 percent of the current value of the 

assets of the plan; 

 (iii) a transaction which is part of a series of 

transactions respecting one or more securities of 

the same issuer, if the aggregate amount of such 

transactions in the plan year exceeds 3 percent of 

the current value of the assets of the plan; or 

 (iv) a transaction with or in conjunction with a 

person respecting a security, if any other transaction with or in conjunction with such person in the 

plan year respecting a security is required to be 

reported by reason of clause (i). 

 (4) The Secretary may, by regulation, relieve any 

plan from filing a copy of a statement of assets and liabilities (or other information) described in paragraph (3)(G) 

if such statement and other information is filed with the 

Secretary by the bank or insurance carrier which maintains the common or collective trust or separate account. 

(c) Information to be furnished by administrator

 The administrator shall furnish as a part of a report 

under this section the following information: 

 (1) The number of employees covered by the 

plan. 
11a 

 (2) The name and address of each fiduciary. 

 (3) Except in the case of a person whose compensation is minimal (determined under regulations of the 

Secretary) and who performs solely ministerial duties 

(determined under such regulations), the name of each 

person (including but not limited to, any consultant, 

broker, trustee, accountant, insurance carrier, actuary, administrator, investment manager, or custodian 

who rendered services to the plan or who had transactions with the plan) who received directly or indirectly 

compensation from the plan during the preceding year 

for services rendered to the plan or its participants, 

the amount of such compensation, the nature of his 

services to the plan or its participants, his relationship 

to the employer of the employees covered by the plan, 

or the employee organization, and any other office, 

position, or employment he holds with any party in 

interest. 

 (4) An explanation of the reason for any change in 

appointment of trustee, accountant, insurance carrier, 

enrolled actuary, administrator, investment manager, 

or custodian. 

 (5) Such financial and actuarial information including but not limited to the material described in 

subsections (b) and (d) of this section as the Secretary 

may find necessary or appropriate. 

(d) Actuarial statement

 With respect to an employee pension benefit plan 

(other than (A) a profit sharing, savings, or other plan, 

which is an individual account plan, (B) a plan described in 

section 1081(b) of this title, or (C) a plan described both in 
12a 

section 1321(b) of this title and in paragraph (1), (2), (3), 

(4), (5), (6), or (7) of section 1081(a) of this title) an annual 

report under this section for a plan year shall include a 

complete actuarial statement applicable to the plan year 

which shall include the following: 

 * * * * * 

(e) Statement from insurance company, insurance service, or other similar organizations which sell or 

guarantee plan benefits 

If some or all of the benefits under the plan are purchased from and guaranteed by an insurance company, 

insurance service, or other similar organization, a report 

under this section shall include a statement from such 

insurance company, service, or other similar organization 

covering the plan year and enumerating— 

 (1) the premium rate or subscription charge 

and the total premium or subscription charges paid to 

each such carrier, insurance service, or other similar 

organization and the approximate number of persons 

covered by each class of such benefits; and 

 (2) the total amount of premiums received, the 

approximate number of persons covered by each class 

of benefits, and the total claims paid by such company, 

service, or other organization; dividends or retroactive 

rate adjustments, commissions, and administrative 

service or other fees or other specific acquisition costs 

paid by such company, service, or other organization; 

any amounts held to provide benefits after retirement; 

the remainder of such premiums; and the names and 

addresses of the brokers, agents, or other persons to 

whom commissions or fees were paid, the amount paid 
13a 

to each, and for what purpose. If any such company, 

service, or other organization does not maintain separate experience records covering the specific groups it 

serves, the report shall include in lieu of the information required by the foregoing provisions of this 

paragraph (A) a statement as to the basis of its premium rate or subscription charge, the total amount of 

premiums or subscription charges received from the 

plan, and a copy of the financial report of the company, 

service, or other organization and (B) if such company, 

service, or organization incurs specific costs in connection with the acquisition or retention of any particular plan or plans, a detailed statement of such costs. 

(f) Additional information with respect to defined benefit plans 

 (1) Liabilities under 2 or more plans 

 (A) In general

 In any case in which any liabilities to participants or their beneficiaries under a defined benefit 

plan as of the end of a plan year consist (in whole or 

in part) of liabilities to such participants and beneficiaries under 2 or more pension plans as of immediately before such plan year, an annual report 

under this section for such plan year shall include 

the funded percentage of each of such 2 or more 

pension plans as of the last day of such plan year 

and the funded percentage of the plan with respect 

to which the annual report is filed as of the last day 

of such plan year. 

 * * * * * 
14a 

5. 29 U.S.C. 1024 provides in pertinent part: 

Filing with Secretary and furnishing information to 

participants and certain employers

(a) Filing of annual report with Secretary

 (1) The administrator of any employee benefit 

plan subject to this part shall file with the Secretary 

the annual report for a plan year within 210 days after 

the close of such year (or within such time as may be 

required by regulations promulgated by the Secretary 

in order to reduce duplicative filing). The Secretary 

shall make copies of such annual reports available for 

inspection in the public document room of the Department of Labor. 

 (2)(A) With respect to annual reports required to 

be filed with the Secretary under this part, he may by 

regulation prescribe simplified annual reports for any 

pension plan which covers less than 100 participants. 

 (B) Nothing contained in this paragraph shall 

preclude the Secretary from requiring any information 

or data from any such plan to which this part applies 

where he finds such data or information is necessary to 

carry out the purposes of this subchapter nor shall the 

Secretary be precluded from revoking provisions for 

simplified reports for any such plan if he finds it necessary to do so in order to carry out the objectives of 

this subchapter. 

 (3) The Secretary may by regulation exempt any 

welfare benefit plan from all or part of the reporting 

and disclosure requirements of this subchapter, or 

may provide for simplified reporting and disclosure if 
15a 

he finds that such requirements are inappropriate as 

applied to welfare benefit plans. 

* * * * * 

 

6. 29 U.S.C. 1104(a)(1) provides: 

Fiduciary duties 

(a) Prudent man standard of care 

(1) Subject to sections 1103(c) and (d), 1342, and 

1344 of this title, a fiduciary shall discharge his duties 

with respect to a plan solely in the interest of the participants and beneficiaries and—

 (A) for the exclusive purpose of:

 (i) providing benefits to participants and 

 their beneficiaries; and 

 (ii) defraying reasonable expenses of adminis-

 tering the plan; 

 (B) with the care, skill, prudence, and diligence 

under the circumstances then prevailing that a prudent man acting in a like capacity and familiar with 

such matters would use in the conduct of an enterprise 

of a like character and with like aims; 

 (C) by diversifying the investments of the plan so 

as to minimize the risk of large losses, unless under the 

circumstances it is clearly prudent not to do so; and 

 (D) in accordance with the documents and instruments governing the plan insofar as such documents 

and instruments are consistent with the provisions of 

this subchapter and subchapter III of this chapter. 
16a 

7. 29 U.S.C. 1134(a) provides in pertinent part: 

Investigative authority 

(a) Investigation and submission of reports, books, etc. 

 The Secretary shall have the power, in order to determine whether any person has violated or is about to 

violate any provision of this subchapter or any regulation or order thereunder— 

 (1) to make an investigation, and in connection 

therewith to require the submission of reports, 

books, and records, and the filing of data in support 

of any information required to be filed with the 

Secretary under this subchapter, and 

 (2) to enter such places, inspect such books 

and records and question such persons as he may 

deem necessary to enable him to determine the 

facts relative to such investigation, if he has reasonable cause to believe there may exist a violation 

of this subchapter or any rule or regulation issued 

thereunder or if the entry is pursuant to an agreement with the plan. 

* * * * * 

8. 29 U.S.C. 1143(a) provides: 

Research, studies, and reports 

(a) Authorization to undertake research and surveys 

 (1) The Secretary is authorized to undertake research and surveys and in connection therewith to collect, 

compile, analyze and publish data, information, and sta-
17a 

tistics relating to employee benefit plans, including retirement, deferred compensation, and welfare plans, and 

types of plans not subject to this chapter. 

 (2) The Secretary is authorized and directed to undertake research studies relating to pension plans, including but not limited to (A) the effects of this subchapter upon the provisions and costs of pension plans, (B) the 

role of private pensions in meeting the economic security 

needs of the Nation, and (C) the operation of private pension plans including types and levels of benefits, degree of 

reciprocity or portability, and financial and actuarial 

characteristics and practices, and methods of encouraging 

the growth of the private pension system. 

 (3) The Secretary may, as he deems appropriate or 

necessary, undertake other studies relating to employee 

benefit plans, the matters regulated by this subchapter, 

and the enforcement procedures provided for under this 

subchapter. 

 (4) The research, surveys, studies, and publications 

referred to in this subsection may be conducted directly, 

or indirectly through grant or contract arrangements. 

9. 29 U.S.C. 1144 provides in pertinent part: 

Other laws 

(a) Supersedure; effective date 

 Except as provided in subsection (b) of this section, 

the provisions of this subchapter and subchapter III of 

this chapter shall supersede any and all State laws 

insofar as they may now or hereafter relate to any 

employee benefit plan described in section 1003(a) of 
18a 

this title and not exempt under section 1003(b) of this 

title. This section shall take effect on January 1, 

1975. 

(b) Construction and application

 (1) This section shall not apply with respect to any 

cause of action which arose, or any act or omission 

which occurred, before January 1, 1975. 

 (2)(A) Except as provided in subparagraph (B), 

nothing in this subchapter shall be construed to exempt or relieve any person from any law of any State 

which regulates insurance, banking, or securities. 

 (B) Neither an employee benefit plan described in 

section 1003(a) of this title, which is not exempt under 

section 1003(b) of this title (other than a plan established primarily for the purpose of providing death 

benefits), nor any trust established under such a plan, 

shall be deemed to be an insurance company or other 

insurer, bank, trust company, or investment company 

or to be engaged in the business of insurance or banking for purposes of any law of any State purporting to 

regulate insurance companies, insurance contracts, 

banks, trust companies, or investment companies. 

* * * * * 

 (4) Subsection (a) of this section shall not apply to 

any generally applicable criminal law of a State. 

 (5)(A) Except as provided in subparagraph (B), subsection (a) of this section shall not apply to the Hawaii 

Prepaid Health Care Act (Haw. Rev. Stat. §§ 393-1 

through 393-51). 
19a 

 (B) Nothing in subparagraph (A) shall be construed to exempt from subsection (a) of this section— 

 (i) any State tax law relating to employee benefit plans, or 

 (ii) any amendment of the Hawaii Prepaid 

Health Care Act enacted after September 2, 1974, 

to the extent it provides for more than the effective 

administration of such Act as in effect on such date. 

 (C) Notwithstanding subparagraph (A), parts 1 and 

4 of this subtitle, and the preceding sections of this 

part to the extent they govern matters which are governed by the provisions of such parts 1 and 4, shall 

supersede the Hawaii Prepaid Health Care Act (as in 

effect on or after January 14, 1983), but the Secretary 

may enter into cooperative arrangements under this 

paragraph and section 1136 of this title with officials of 

the State of Hawaii to assist them in effectuating the 

policies of provisions of such Act which are superseded 

by such parts 1 and 4 and the preceding sections of this 

part. 

 * * * * * 

 (7) Subsection (a) of this section shall not apply to 

qualified domestic relations orders (within the meaning of section 1056(d)(3)(B)(i) of this title), qualified 

medical child support orders (within the meaning of 

section 1169(a)(2)(A) of this title), and the provisions of 

law referred to in section 1169(a)(2)(B)(ii) of this title 

to the extent they apply to qualified medical child support orders. 
20a 

 (8) Subsection (a) of this section shall not be construed to preclude any State cause of action— 

 (A) with respect to which the State exercises its 

acquired rights under section 1169(b)(3) of this title 

with respect to a group health plan (as defined in 

section 1167(1) of this title), or 

 (B) for recoupment of payment with respect to 

items or services pursuant to a State plan for medical assistance approved under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] which 

would not have been payable if such acquired rights 

had been executed before payment with respect to 

such items or services by the group health plan. 

 (9) For additional provisions relating to group 

health plans, see section 1191 of this title. 

(c) Definitions

 For purposes of this section: 

 (1) The term “State law” includes all laws, decisions, rules, regulations, or other State action 

having the effect of law, of any State. A law of the 

United States applicable only to the District of Columbia shall be treated as a State law rather than a 

law of the United States. 

 * * * * * 

(d) Alteration, amendment, modification, invalidation, 

impairment, or supersedure of any law of the 

United States prohibited

 Nothing in this subchapter shall be construed to 

alter, amend, modify, invalidate, impair, or supersede 
21a 

any law of the United States (except as provided in 

sections 1031 and 1137(b) of this title) or any rule or 

regulation issued under any such law. 

10. 29 U.S.C. 1185d provides: 

Additional market reforms

(a) General rule

 Except as provided in subsection (b)— 

 (1) the provisions of part A of title XXVII of the 

Public Health Service Act [42 U.S.C. 300gg et seq.] (as 

amended by the Patient Protection and Affordable 

Care Act) shall apply to group health plans, and health 

insurance issuers providing health insurance coverage 

in connection with group health plans, as if included in 

this subpart; and 

 (2) to the extent that any provision of this part 

conflicts with a provision of such part A with respect to 

group health plans, or health insurance issuers providing health insurance coverage in connection with 

group health plans, the provisions of such part A shall 

apply. 

(b) Exception

 Notwithstanding subsection (a), the provisions of 

sections 2716 and 2718 of title XXVII of the Public Health 

Service Act [42 U.S.C. 300gg-16, 300gg-18] (as amended 

by the Patient Protection and Affordable Care Act) shall 

not apply with respect to self-insured group health plans, 

and the provisions of this part shall continue to apply to 
22a 

such plans as if such sections of the Public Health Service 

Act (as so amended) had not been enacted. 

11. 29 U.S.C. 1191(a) provides: 

Preemption; State flexibility; construction

(a) Continued applicability of State law with respect to 

health insurance issuers 

(1) In general

 Subject to paragraph (2) and except as provided 

in subsection (b) of this section, this part shall not be 

construed to supersede any provision of State law 

which establishes, implements, or continues in effect 

any standard or requirement solely relating to health 

insurance issuers in connection with group health insurance coverage except to the extent that such standard or requirement prevents the application of a requirement of this part. 

(2) Continued preemption with respect to group 

health plans 

 Nothing in this part shall be construed to affect 

or modify the provisions of section 1144 of this title 

with respect to group health plans. 

 
23a 

12. 29 U.S.C. 1191b(a)-(b) provides in pertinent part: 

Definitions

(a) Group health plan

 For purposes of this part— 

(1) In general

 The term “group health plan” means an employee welfare benefit plan to the extent that the plan 

provides medical care (as defined in paragraph (2) and 

including items and services paid for as medical care) 

to employees or their dependents (as defined under 

the terms of the plan) directly or through insurance, 

reimbursement, or otherwise. 

(2) Medical care

 The term “medical care” means amounts paid 

for— 

 (A) the diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for 

the purpose of affecting any structure or function of 

the body, 

 (B) amounts paid for transportation primarily 

for and essential to medical care referred to in 

subparagraph (A), and 

 (C) amounts paid for insurance covering medical care referred to in subparagraphs (A) and (B). 

(b) Definitions relating to health insurance 

 For purposes of this part— 
24a 

(1) Health insurance coverage 

 The term “health insurance coverage” means 

benefits consisting of medical care (provided directly, 

through insurance or reimbursement, or otherwise 

and including items and services paid for as medical 

care) under any hospital or medical service policy or 

certificate, hospital or medical service plan contract, or 

health maintenance organization contract offered by a 

health insurance issuer. 

(2) Health insurance issuer

 The term “health insurance issuer” means an insurance company, insurance service, or insurance organization (including a health maintenance organization, as defined in paragraph (3)) which is licensed to 

engage in the business of insurance in a State and 

which is subject to State law which regulates insurance 

(within the meaning of section 1144(b)(2) of this title). 

Such term does not include a group health plan. 

* * * * * 

13. 42 U.S.C. 300gg-15a provides: 

Provision of additional information 

 A group health plan and a health insurance issuer 

offering group or individual health insurance coverage 

shall comply with the provisions of section 18031(e)(3) 

of this title, except that a plan or coverage that is not 

offered through an Exchange shall only be required to 

submit the information required to the Secretary and 
25a 

the State insurance commissioner, and make such information available to the public. 

14. 42 U.S.C. 300gg-17 provides in pertinent part: 

Ensuring the quality of care 

(a) Quality reporting 

(1) In general 

 Not later than 2 years after March 23, 2010, the 

Secretary, in consultation with experts in health care 

quality and stakeholders, shall develop reporting requirements for use by a group health plan, and a health 

insurance issuer offering group or individual health 

insurance coverage, with respect to plan or coverage 

benefits and health care provider reimbursement 

structures that— 

 (A) improve health outcomes through the 

implementation of activities such as quality reporting, effective case management, care coordination, 

chronic disease management, and medication and 

care compliance initiatives, including through the 

use of the medical homes model as defined for purposes of section 36021 of the Patient Protection and 

Affordable Care Act, for treatment or services under the plan or coverage; 

 (B) implement activities to prevent hospital 

readmissions through a comprehensive program for 

hospital discharge that includes patient-centered 

education and counseling, comprehensive discharge 

 

1

 See References in Text note below. 
26a 

planning, and post discharge reinforcement by an 

appropriate health care professional; 

 (C) implement activities to improve patient 

safety and reduce medical errors through the appropriate use of best clinical practices, evidence 

based medicine, and health information technology 

under the plan or coverage; and 

 (D) implement wellness and health promotion 

activities. 

(2) Reporting requirements 

(A) In general 

 A group health plan and a health insurance issuer offering group or individual health insurance 

coverage shall annually submit to the Secretary, 

and to enrollees under the plan or coverage, a report on whether the benefits under the plan or 

coverage satisfy the elements described in subparagraphs (A) through (D) of paragraph (1). 

* * * * * 

 (b) Wellness and prevention programs 

 For purposes of subsection (a)(1)(D), wellness and 

health promotion activities may include personalized 

wellness and prevention services, which are coordinated, 

maintained or delivered by a health care provider, a 

wellness and prevention plan manager, or a health, wellness or prevention services organization that conducts 

health risk assessments or offers ongoing face-to-face, 

telephonic or web-based intervention efforts for each of 
27a 

the program’s participants, and which may include the 

following wellness and prevention efforts: 

 (1) Smoking cessation. 

 (2) Weight management. 

 (3) Stress management. 

 (4) Physical fitness. 

 (5) Nutrition. 

 (6) Heart disease prevention. 

 (7) Healthy lifestyle support. 

 (8) Diabetes prevention. 

* * * * * 

 (d) Regulations 

 Not later than 2 years after March 23, 2010, the 

Secretary shall promulgate regulations that provide criteria for determining whether a reimbursement structure 

is described in subsection (a). 

(e) Study and report

 Not later than 180 days after the date on which 

regulations are promulgated under subsection (c),2 the 

Government Accountability Office shall review such regulations and conduct a study and submit to the Committee 

on Health, Education, Labor, and Pensions of the Senate 

and the Committee on Energy and Commerce of the 

House of Representatives a report regarding the impact 

 

2

 So in original. Probably should be “subsection (d),”. 
28a 

the activities under this section have had on the quality 

and cost of health care. 

15. 42 U.S.C. 300gg-23(a) provides: 

Preemption; State flexibility; construction 

(a) Continued applicability of State law with respect to 

health insurance issuers 

(1) In general

 Subject to paragraph (2) and except as provided 

in subsection (b) of this section, this part and part C of 

this subchapter insofar as it relates to this part shall 

not be construed to supersede any provision of State 

law which establishes, implements, or continues in effect any standard or requirement solely relating to 

health insurance issuers in connection with individual 

or group health insurance coverage except to the extent that such standard or requirement prevents the 

application of a requirement of this part. 

(2) Continued preemption with respect to group health 

plans 

 Nothing in this part shall be construed to affect 

or modify the provisions of section 1144 of title 29 with 

respect to group health plans. 

 
29a 

16. 42 U.S.C. 1315a provides in pertinent part: 

Center for Medicare and Medicaid Innovation 

(a) Center for Medicare and Medicaid Innovation established

(1) In general 

 There is created within the Centers for Medicare 

& Medicaid Services a Center for Medicare and Medicaid Innovation (in this section referred to as the 

“CMI”) to carry out the duties described in this section. The purpose of the CMI is to test innovative 

payment and service delivery models to reduce program expenditures under the applicable subchapters 

while preserving or enhancing the quality of care furnished to individuals under such subchapters. In selecting such models, the Secretary shall give preference to models that also improve the coordination, 

quality, and efficiency of health care services furnished 

to applicable individuals defined in paragraph (4)(A). 

* * * * * 

 (b) Testing of models (phase I) 

(1) In general

 The CMI shall test payment and service delivery 

models in accordance with selection criteria under 

paragraph (2) to determine the effect of applying such 

models under the applicable subchapter (as defined in 

subsection (a)(4)(B)) on program expenditures under 

such subchapters and the quality of care received by 

individuals receiving benefits under such subchapter. 
30a 

(2) Selection of models to be tested

(A) In general 

 The Secretary shall select models to be tested 

from models where the Secretary determines that 

there is evidence that the model addresses a defined population for which there are deficits in care 

leading to poor clinical outcomes or potentially 

avoidable expenditures. The Secretary shall focus 

on models expected to reduce program costs under 

the applicable subchapter while preserving or enhancing the quality of care received by individuals 

receiving benefits under such subchapter. The 

models selected under this subparagraph may include, but are not limited to, the models described 

in subparagraph (B). 

(B) Opportunities 

 The models described in this subparagraph 

are the following models:

 * * * * * 

 (xi) Allowing States to test and evaluate 

 systems of all-payer payment reform for the 

 medical care of residents of the State, including 

 dual eligible individuals. 

 * * * * * 

 
31a 

(4) Evaluation 

(A) In general 

 The Secretary shall conduct an evaluation of 

each model tested under this subsection. Such 

evaluation shall include an analysis of— 

 (i) the quality of care furnished under the 

 model, including the measurement of patient- 

 level outcomes and patient-centeredness criteria 

 determined appropriate by the Secretary; and 

 (ii) the changes in spending under the ap-

 plicable subchapters by reason of the model. 

* * * * * 

17. 42 U.S.C. 1395kk(e) (as amended by Pub. L. No. 

114-10, § 105(c), 129 Stat. 137) provides in pertinent 

part: 

Administration of insurance programs 

(e) Availability of data 

 (1) In general 

 Subject to paragraph (4), the Secretary shall make 

available to qualified entities (as defined in paragraph 

(2)) data described in paragraph (3) for the evaluation 

of the performance of providers of services and suppliers. 

(2) Qualified entities

 For purposes of this subsection, the term “qualified entity” means a public or private entity that— 
32a 

 (A) is qualified (as determined by the Secretary) to use claims data to evaluate the performance of providers of services and suppliers on 

measures of quality, efficiency, effectiveness, and 

resource use; and 

 (B) agrees to meet the requirements described 

in paragraph (4) and meets such other requirements as the Secretary may specify, such as ensuring security of data. 

(3) Data described

 The data described in this paragraph are standardized extracts (as determined by the Secretary) of 

claims data under parts A, B, and D for items and 

services furnished under such parts for one or more 

specified geographic areas and time periods requested 

by a qualified entity. Beginning July 1, 2016, if the 

Secretary determines appropriate, the data described 

in this paragraph may also include standardized extracts (as determined by the Secretary) of claims data 

under subchapters XIX and XXI for assistance provided under such subchapters for one or more specified geographic areas and time periods requested by a 

qualified entity. The Secretary shall take such actions as the Secretary deems necessary to protect the 

identity of individuals entitled to or enrolled for benefits under such parts or under subchapters2 XIX or 

XXI. 

* * * * * 

 

2

 So in original. Probably should be “subchapter”. 
33a 

18. 42 U.S.C. 18031(e)(3) provides: 

Affordable choices of health benefit plans 

(e) Certification 

(3) Transparency in coverage 

 (A) In general 

 The Exchange shall require health plans 

seeking certification as qualified health plans to 

submit to the Exchange, the Secretary, the State 

insurance commissioner, and make available to the 

public, accurate and timely disclosure of the following information: 

 (i) Claims payment policies and practic-

 es. 

 (ii) Periodic financial disclosures. 

 (iii) Data on enrollment. 

 (iv) Data on disenrollment. 

(v) Data on the number of claims that are 

denied. 

(vi) Data on rating practices. 

(vii) Information on cost-sharing and 

payments with respect to any out-of-network 

coverage. 

(viii) Information on enrollee and participant rights under this title.3 

 

3

 See References in Text note below. 
34a 

(ix) Other information as determined appropriate by the Secretary. 

 (B) Use of plain language 

 The information required to be submitted under subparagraph (A) shall be provided in plain 

language. The term “plain language” means language that the intended audience, including individuals with limited English proficiency, can readily understand and use because that language is 

concise, well-organized, and follows other best 

practices of plain language writing. The Secretary and the Secretary of Labor shall jointly develop and issue guidance on best practices of plain 

language writing. 

(C) Cost sharing transparency 

 The Exchange shall require health plans seeking certification as qualified health plans to permit 

individuals to learn the amount of cost-sharing 

(including deductibles, copayments, and coinsurance) under the individual’s plan or coverage that 

the individual would be responsible for paying with 

respect to the furnishing of a specific item or service by a participating provider in a timely manner 

upon the request of the individual. At a minimum, 

such information shall be made available to such 

individual through an Internet website and such 

other means for individuals without access to the 

Internet. 

(D) Group health plans 

The Secretary of Labor shall update and harmonize the Secretary’s rules concerning the accu-
35a 

rate and timely disclosure to participants by group 

health plans of plan disclosure, plan terms and 

conditions, and periodic financial disclosure with 

the standards established by the Secretary under 

subparagraph (A). 

19. 42 U.S.C. 18041(d) provides: 

State flexibility in operation and enforcement of Exchanges and related requirements 

(d) No interference with State regulatory authority 

 Nothing in this title1 shall be construed to preempt 

any State law that does not prevent the application of 

the provisions of this title.1 

20. Vt. Stat. Ann. tit. 18, § 9401 (2012) provides: 

Policy

 (a) It is the policy of the state of Vermont that 

health care is a public good for all Vermonters and to 

ensure that all residents have access to quality health 

services at costs that are affordable. To achieve this 

policy, it is necessary that the state ensure the quality 

of health care services provided in Vermont and, until 

health care systems are successful in controlling their 

costs and resources, to oversee cost containment. 

 (b) It is further the policy of the state of Vermont 

that the health care system should: 

 

1

 See references in Text note below. 
36a 

 (1) Maintain and improve the quality of health 

care services offered to Vermonters. 

 (2) Utilize planning, market, and other mechanisms that contain or reduce increases in the cost of 

delivering services so that health care costs do not 

consume a disproportionate share of Vermonters’ 

incomes or the moneys available for other services 

required to insure the health, safety, and welfare of 

Vermonters. 

 (3) Encourage regional and local participation 

in decisions about health care delivery, financing, 

and provider supply. 

 (4) Utilize planning, market, and other mechanisms that will achieve rational allocation of health 

care resources in the state. 

 (5) Facilitate universal access to preventive 

and medically necessary health care. 

 (6) Support efforts to integrate mental health 

and substance abuse services with overall medical 

care.

21. Vt. Stat. Ann. tit. 18, § 9402(8) (2012) provides: 

Definitions 

 (8) “Health insurer” means any health insurance 

company, nonprofit hospital and medical service corporation, managed care organizations, and, to the 

extent permitted under federal law, any administrator 

of an insured, self-insured, or publicly funded health 

care benefit plan offered by public and private entities. 
37a 

22. Vt. Stat. Ann. tit. 18, § 9410 (Supp. 2014) provides: 

Health care database 

 (a)(1) The Board shall establish and maintain a 

unified health care database to enable the Commissioner and the Board to carry out their duties under 

this chapter, chapter 220 of this title, and Title 8, including: 

 (A) determining the capacity and distribution of 

existing resources; 

 (B) identifying health care needs and informing 

health care policy; 

 (C) evaluating the effectiveness of intervention 

programs on improving patient outcomes; 

 (D) comparing costs between various treatment 

settings and approaches; 

 (E) providing information to consumers and 

purchasers of health care; and 

 (F) improving the quality and affordability of 

patient health care and health care coverage. 

 (2)(A) The program authorized by this section 

shall include a consumer health care price and quality 

information system designed to make available to 

consumers transparent health care price information, 

quality information, and such other information as the 

Board determines is necessary to empower individuals, 

including uninsured individuals, to make economically 

sound and medically appropriate decisions. 
38a 

 (B) The Commissioner may require a health insurer covering at least five percent of the lives covered 

in the insured market in this State to file with the 

Commissioner a consumer health care price and quality information plan in accordance with rules adopted 

by the Commissioner. 

 (C) The Board shall adopt such rules as are necessary to carry out the purposes of this subdivision. 

The Board’s rules may permit the gradual implementation of the consumer health care price and quality 

information system over time, beginning with health 

care price and quality information that the Board 

determines is most needed by consumers or that can 

be most practically provided to the consumer in an 

understandable manner. The rules shall permit 

health insurers to use security measures designed to 

allow subscribers access to price and other information 

without disclosing trade secrets to individuals and 

entities who are not subscribers. The rules shall 

avoid unnecessary duplication of efforts relating to 

price and quality reporting by health insurers, health 

care providers, health care facilities, and others, including activities undertaken by hospitals pursuant to 

their community report obligations under section 

9405b of this title. 

 (b) The database shall contain unique patient and 

provider identifiers and a uniform coding system, and 

shall reflect all health care utilization, costs, and resources in this State, and health care utilization and 

costs for services provided to Vermont residents in 

another state. 
39a 

 (c) Health insurers, health care providers, health 

care facilities, and governmental agencies shall file 

reports, data, schedules, statistics, or other information determined by the Board to be necessary to carry 

out the purposes of this section. Such information 

may include: 

 (1) health insurance claims and enrollment information used by health insurers; 

 (2) information relating to hospitals filed under 

subchapter 7 of this chapter (hospital budget reviews); and 

 (3) any other information relating to health 

care costs, prices, quality, utilization, or resources 

required by the Board to be filed. 

 (d) The Board may by rule establish the types of 

information to be filed under this section, and the time 

and place and the manner in which such information 

shall be filed. 

 (e) Records or information protected by the provisions of the physician­patient privilege under 12 V.S.A. 

§ 1612(a), or otherwise required by law to be held confidential, shall be filed in a manner that does not disclose the identity of the protected person. 

 (f) The Board shall adopt a confidentiality code to 

ensure that information obtained under this section is 

handled in an ethical manner. 

 (g) Any person who knowingly fails to comply with 

the requirements of this section or rules adopted pursuant to this section shall be subject to an administrative penalty of not more than $1,000.00 per violation. 
40a 

The Board may impose an administrative penalty of 

not more than $10,000.00 each for those violations the 

Board finds were willful. In addition, any person who 

knowingly fails to comply with the confidentiality 

requirements of this section or confidentiality rules 

adopted pursuant to this section and uses, sells, or 

transfers the data or information for commercial advantage, pecuniary gain, personal gain, or malicious 

harm shall be subject to an administrative penalty of 

not more than $50,000.00 per violation. The powers 

vested in the Board by this subsection shall be in addition to any other powers to enforce any penalties, 

fines, or forfeitures authorized by law. 

 (h)(1) All health insurers shall electronically provide to the Board in accordance with standards and 

procedures adopted by the Board by rule: 

 (A) their health insurance claims data, provided 

that the Board may exempt from all or a portion of 

the filing requirements of this subsection data reflecting utilization and costs for services provided in 

this State to residents of other states; 

 (B) cross-matched claims data on requested 

members, subscribers, or policyholders; and 

 (C) member, subscriber, or policyholder information necessary to determine third party liability 

for benefits provided. 

 (2) The collection, storage, and release of health 

care data and statistical information that is subject 

to the federal requirements of the Health Insurance 

Portability and Accountability Act (“HIPAA”) shall be 
41a 

governed exclusively by the regulations adopted thereunder in 45 C.F.R. Parts 160 and 164. 

 (A) All health insurers that collect the Health 

Employer Data and Information Set (HEDIS) shall 

annually submit the HEDIS information to the 

Board in a form and in a manner prescribed by the 

Board. 

 (B) All health insurers shall accept electronic 

claims submitted in Centers for Medicare and Medicaid Services format for UB-92 or HCFA-1500 records, or as amended by the Centers for Medicare 

and Medicaid Services. 

 (3)(A) The Board shall collaborate with the Agency of Human Services and participants in the Agency’s 

initiatives in the development of a comprehensive 

health care information system. The collaboration is 

intended to address the formulation of a description 

of the data sets that will be included in the comprehensive health care information system, the criteria 

and procedures for the development of limited-use 

data sets, the criteria and procedures to ensure that 

HIPAA compliant limited-use data sets are accessible, 

and a proposed time frame for the creation of a comprehensive health care information system. 

 (B) To the extent allowed by HIPAA, the data shall 

be available as a resource for insurers, employers, 

providers, purchasers of health care, and State agencies to continuously review health care utilization, 

expenditures, and performance in Vermont. In presenting data for public access, comparative considerations shall be made regarding geography, de-
42a 

mographics, general economic factors, and institutional size. 

 (C) Consistent with the dictates of HIPAA, and 

subject to such terms and conditions as the Board may 

prescribe by rule, the Vermont Program for Quality in 

Health Care shall have access to the unified health 

care database for use in improving the quality of 

health care services in Vermont. In using the database, the Vermont Program for Quality in Health Care 

shall agree to abide by the rules and procedures established by the Board for access to the data. The 

Board’s rules may limit access to the database to 

limited-use sets of data as necessary to carry out the 

purposes of this section. 

 (D) Notwithstanding HIPAA or any other provision of law, the comprehensive health care information 

system shall not publicly disclose any data that contains direct personal identifiers. For the purposes of 

this section, “direct personal identifiers” include information relating to an individual that contains primary or obvious identifiers, such as the individual’s 

name, street address, e-mail address, telephone number, and Social Security number. 

 (i) On or before January 15, 2008 and every three 

years thereafter, the Commissioner shall submit a recommendation to the General Assembly for conducting 

a survey of the health insurance status of Vermont residents. The provisions of 2 V.S.A. § 20(d) (expiration 

of required reports) shall not apply to the report to be 

made under this subsection. 
43a 

 (j)(1) As used in this section, and without limiting 

the meaning of subdivision 9402(8) of this title, the 

term “health insurer” includes: 

 (A) any entity defined in subdivision 9402(8) of 

this title; 

 (B) any third party administrator, any pharmacy benefit manager, any entity conducting administrative services for business, and any other 

similar entity with claims data, eligibility data, provider files, and other information relating to health 

care provided to a Vermont resident, and health 

care provided by Vermont health care providers 

and facilities required to be filed by a health insurer 

under this section; 

 (C) any health benefit plan offered or administered by or on behalf of the State of Vermont or an 

agency or instrumentality of the State; and 

 (D) any health benefit plan offered or administered by or on behalf of the federal government 

with the agreement of the federal government. 

 (2) The Board may adopt rules to carry out the 

provisions of this subsection, including criteria for the 

required filing of such claims data, eligibility data, provider files, and other information as the Board determines to be necessary to carry out the purposes of this 

section and this chapter. 

 
44a 

23. Reg. H-2008-01, 21-040-021 Vt. Code R. (2008) 

provides in pertinent part: 

Section 1. Purpose. 

 The purpose of this rule is to set forth the requirements for the submission of health care claims data, 

member eligibility data, and other information relating 

to health care provided to Vermont residents or by 

Vermont health care providers and facilities by health 

insurers, managed care organizations, third party 

administrators, pharmacy benefit managers and others 

to the Department of Banking, Insurance, Securities 

and Health Care Administration and conditions for the 

use and dissemination of such claims data, all as required by and consistent with the purposes of 18 

V.S.A. § 9410. 

* * * * * 

Section 3. Definitions. 

 As used in this Rule 

* * * * * 

 I. “Data set” means a collection of individual 

data records, whether in electronic or manual files. 

* * * * * 

 K. “De-identified health information” means information that does not identify an individual patient, 

member or enrollee and with respect to which no reasonable basis exists to believe that the information can 

be used to identify an individual patient, member or 

enrollee. De-identification means that health infor-
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mation is not individually identifiable and requires the 

removal of Direct Personal Identifiers associated with 

patients, members or enrollees. 

 L. “Direct personal identifiers” is information relating to an individual patient, member or enrollee that 

contains primary or obvious identifiers, including: 

 (1) Names; 

 (2) Business names when that name would 

serve to identify a person; 

 (3) Postal address information other than town 

or city, state, and 5-digit zip code; 

 (4) Specific latitude and longitude or other geographic information that would be used to derive 

postal address; 

 (5) Telephone and fax numbers; 

 (6) Electronic mail addresses; 

 (7) Social security numbers; 

 (8) Vehicle Identifiers and serial numbers, including license plate numbers; 

 (9) Medical record numbers; 

 (10) Health plan beneficiary numbers; 

 (11) Certificate and license numbers; 

 (12) Internet protocol (IP) addresses and uniform resource locators (URL) that identify a business that would serve to identify a person; 
46a 

 (13) Biometric identifiers, including finger and 

voice prints; and 

 (14) Personal photographic images. 

* * * * * 

 P. “Health benefit plan” means a policy, contract, 

certificate or agreement entered into, or offered by a 

health insurer to provide, deliver, arrange for, pay for 

or reimburse any of the costs of health care services. 

 Q. “Healthcare claims data” means information 

consisting of or derived directly from member eligibility files, medical claims files, pharmacy claims files and 

other related data pursuant to the Vermont Healthcare Claims Uniform Reporting and Evaluation System (VHCURES) in effect at the time of the data 

submission. “Healthcare claims data” does not include analysis, reports, or studies containing information from health care claims data sets if those analyses, reports, or studies have already been released in 

response to another request for information or as part 

of a general distribution of public information by 

BISHCA. 

* * * * * 

 T. “Health care” means care, services, or supplies related to the health of an individual. It includes but is not limited to (1) preventive, diagnostic, 

therapeutic, rehabilitative, maintenance, or palliative 

care, and counseling, service, assessment, or procedure with respect to the physical or mental condition, 

or functional status, of an individual or that affects the 

structure or function of the body; and (2) sale or dis-
47a 

pensing of a drug, device, equipment, or other item in 

accordance with a prescription [45 CFR § 160.103]. 

 U. “Health care facility” shall be defined as per 

18 V.S.A § 9432, as amended from time to time. 

 V. “Health care provider” means a person, partnership, corporation, facility or institution, licensed or 

certified or authorized by law to provide professional 

health care service in this state to an individual during 

that individual’s medical care, treatment or confinement, as per 18 V.S.A. § 9432. 

 W. “Health information” means any information, 

whether oral or recorded in any form or medium, that 

1) is created or received by a health-care provider, 

health plan, public health authority, employer, life 

insurer, school or university, or health-care clearinghouse; and 2) relates to the past, present, or future 

physical or mental health or condition of an individual, 

the provision of health care to an individual, or the 

past, present, or future payment for the provision of 

health care to an individual shall be as defined in 45 

CFR § 160.103. 

 X. “Health insurer” means those entities defined 

in 18 V.S.A. §§ 9402 and 9410(j)(1), and includes any 

health insurance company, nonprofit hospital and medical service corporation, managed care organization, 

third party administrator, pharmacy benefit manager, 

and any entity conducting administrative services for 

business or possessing claims data, eligibility data, 

provider files, and other information relating to health 

care provided to Vermont residents or by Vermont 

health care providers and facilities. The term may 
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also include, to the extent permitted under federal law, 

any administrator of an insured, self-insured, or publicly funded health care benefit plan offered by public 

and private entities. 

* * * * * 

 Z. “Indirect personal identifiers” means information relating to an individual patient, member or 

enrollee that a person with appropriate knowledge of 

and experience with generally accepted statistical and 

scientific principles and methods could apply to render 

such information individually identifiable by using 

such information alone or in combination with other 

reasonably available information. 

* * * * * 

 Ab. “Mandated Reporter” means a health insurer 

as defined herein and at 18 V.S.A. § 9410(j)(1) with two 

hundred (200) or more enrolled or covered members in 

each month during a calendar year, including both 

Vermont residents and any non-residents receiving 

covered services provided by Vermont health care providers and facilities. 

 Ac. “Medical claims file” means a data file composed of service level remittance information for all 

non-denied adjudicated claims for each billed service 

including, but not limited to member demographics, 

provider information, charge/payment information, 

and clinical diagnosis and procedure codes, and shall 

include all claims related to behavioral or mental 

health. 
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 Ad. “Member” means the insured subscriber and 

any spouse and/or dependent covered by the subscriber’s policy. 

 Ae. “Member eligibility file” means a data file containing demographic information for each individual 

member eligible for medical or pharmacy benefits for 

one or more days of coverage at any time during the 

reporting month. 

* * * * * 

 Ag. “Payer” means a third-party payer or thirdparty administrator. 

* * * * * 

 Ai. “Personal identifiers” means information relating to an individual that contains direct or indirect 

identifiers to which a reasonable basis exists to believe 

that the information can be used to identify an individual. 

* * * * * 

 Ak. “Pharmacy claims file” means a data file containing service level remittance information from all 

non-denied adjudicated claims for each prescription 

including, but not limited to: member demographics; 

provider information; charge/payment information; 

and national drug codes. 

* * * * * 

 Aq. “Third-party Administrator” means any person who, on behalf of a health insurer or purchaser of 

health benefits, receives or collects charges, contribu-
50a 

tions or premiums for, or adjusts or settles claims on 

or for residents of this State or Vermont health care 

providers and facilities. 

 Ar. “Vermont Healthcare Claims Uniform Reporting and Evaluation System” or “VHCURES” means 

the Department’s system for the collection, management and reporting of eligibility, claims and related 

data submitted pursuant to 18 V.S.A. § 9410. 

 As. “Voluntary Reporter” includes any entity other than a mandated reporter, including any health benefit plan offered or administered by or on behalf of the 

federal government where such plan, with the agreement of the federal government, voluntarily submits 

data to the BISHCA commissioner for inclusion in the 

database on such terms as may be appropriate. 

Section 4. Reporting Requirements. 

 Registration and Reporting Requirements 

 A. VHCURES Reporter Registration. On an 

annual basis prior to December 31, Health Insurers 

shall register with the Department on a form established by the Commissioner and identify whether 

health care claims are being paid for members who are 

Vermont residents and whether health care claims are 

being paid for non-residents receiving covered services 

from Vermont health care providers or facilities. 

Where applicable, the completed form shall identify 

the types of files to be submitted per Section 5. This 

form shall be submitted to BISHCA or its designee. 

See Appendix F. 

 B. Third Party Administrator Registration. 

Any person or entity that provides third party admin-
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istration services, a third party administrator or 

“TPA” as defined in Section 3, shall register with the 

Department on a form established by the Commissioner, both before doing business in Vermont and on 

an annual basis prior to December 31 thereafter. 18 

V.S.A. § 9410. See Appendix G. 

 C. Pharmacy Benefit Manager Registration. 

Any person or entity that performs pharmacy benefit 

management (a pharmacy benefit manager or “PBM”) 

shall register with the Department on a form established by the Commissioner both before doing business 

in Vermont and on an annual basis prior to December 

31. 18 V.S.A. § 9421. The registration requirement 

includes persons or entities in a contractual or employment relationship with a health insurer or PBM 

performing pharmacy benefit management for a health 

plan with Vermont enrollees or beneficiaries. 18 

V.S.A. § 9471. See Appendix H. 

 D. Health Insurers shall regularly submit medical claims data, pharmacy claims data, member eligibility data, provider data, and other information relating to health care provided to Vermont residents and 

health care provided by Vermont health care providers 

and facilities to both Vermont residents and nonresidents in specified electronic format to the Department for each health line of business (Comprehensive Major Medical, TPA/ASO, Medicare Supplemental, Medicare Part C, and Medicare Part D) per the 

data submission requirements contained in the appendices to this Rule. 

 E. Voluntary Reporters may, with the permission 

of the Commissioner, participate in VHCURES and 
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submit medical claims files, pharmacy claims files, 

member eligibility files, provider data, and other information relating to health care provided to Vermont 

residents and health care provided by Vermont health 

care providers and facilities to both Vermont residents 

and non-residents in specified electronic format to the 

Department per the data submission requirements 

contained in the appendices to this Rule. 

Section 5. Required Healthcare Data Files. 

 Mandated Reporters shall submit to BISHCA or its 

designee health care claims data for all members who 

are Vermont residents and all non-residents who received covered services provided by Vermont health 

care providers or facilities in accordance with the 

requirements of this section. Each Mandated Reporter is also responsible for the submission of all health 

care claims processed by any sub-contractor on its 

behalf unless such subcontractor is already submitting 

the identical data as a Mandated Reporter in its own 

right. The health care claims data submitted shall include, where applicable, a member eligibility file containing records associated with each of the claims files 

reported: a medical claims file and a pharmacy 

claims file. The data submitted shall also include 

supporting definition files for payer specific provider 

specialty taxonomy codes and procedure and/or diagnosis codes. 

 
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 A. General Requirements for Data Submission 

 * * * * * 

 (5) Codes and Encryption Requirements 

 (a) Code Sources. Unless otherwise specified in this regulation, the code sources listed 

and described in Appendix A shall be utilized in 

association with the member eligibility file and 

medical and pharmacy claims file submissions. 

 (b) Member Identification Code. Reporters 

shall assign to each of their members a unique 

identification code that is the member’s social 

security number. If a Reporter does not collect 

the social security numbers for all members, the 

Reporter shall use the social security number of 

the subscriber and then assign a discrete twodigit suffix for each member under the subscriber’s contract. 

 If the subscriber’s social security number is 

not collected by the Reporter, a version of the 

subscriber’s certificate or contract number shall 

be used in its place. The discrete two­digit suffix shall also be used with the certificate or contract number. The certificate or contract number with the two-digit suffix shall be at least 

eleven but not more than sixty-four characters in 

length. 

 The social security number of the member/ 

subscriber and the subscriber and member 

names shall be encrypted prior to submission 

by the Reporter utilizing a standard encryp- 
54a 

tion methodology provided by BISHCA or its 

designee. The unique member identification 

code assigned by each Reporter shall remain 

with each member/subscriber for the entire period of coverage for that individual. 

 * * * * * 

 (8) Denied Claims. Denied claims shall be 

excluded from all medical and pharmacy claims 

file submissions. When a claim contains both 

fully processed/paid service lines and partially 

processed or denied service lines, only the fully 

processed/paid service lines shall be included as 

part of the health care claims data set submittal. 

* * * * * 

 B. Detailed File Specifications. 

 (1) Filled Fields. All required fields shall be 

filled where applicable. Non-required text, date, 

and integer fields shall be set to null when unavailable. Non-applicable decimal fields shall be filled 

with one zero and shall not include decimal points 

when unavailable. 

 (2) Position. All text fields are to be left justified. All integer and decimal fields are to be right 

justified. 

 (3) Signs. Positive values are assumed and 

need not be indicated as such. Negative values 

must be indicated with a minus sign and must appear in the left-most position of all integer and 
55a 

decimal fields. Over-punched signed integers or 

decimals are not to be utilized. 

 (4) Individual Elements and Mapping. Individual data elements, data types, field lengths, field 

description/code assignments, and mapping locators 

(UB-04, HCFA 1500, ANSI X12N 270/271, 835, 837) 

for each file shall be as detailed in the following appendices: 

 (a) 

 (1) Member Eligibility File Specifications 

—Appendix C-1 

 (2) Member Eligibility File Mapping to 

National Standard Formats—Appendix C-2 

(b) 

 (1) Medical Claims File Specifications— 

Appendix D-1 

 (2) Medical Claims File Mapping to National Standard Formats—Appendix D-2 

(c) 

 (1) Pharmacy Claims File Specifications— 

Appendix E-1 

 (2) Pharmacy Claims File Mapping to National Standard Formats—Appendix E-2 

Section 6. Submission Requirements. 

 Data submission requirements shall be as detailed 

in the attached appendices. 

 A. Registration Form. It is the responsibility of 

each Health Insurer to resubmit or amend the regis-
56a 

tration form required by Section 4 (A) whenever modifications occur relative to the data files or contact 

information. 

 B. File Organization. The member eligibility file, 

medical claims file and pharmacy claims file shall be 

submitted to BISHCA or its designee as separate 

ASCII files. Each record shall terminate with a carriage return (ASCII 13) or a carriage return line feed 

(ASCII 13, ASCII 10). 

 C. Filing Media. Files shall be submitted utilizing one of the following media: diskette (1.44 MB), 

CD-ROM (650 MB), DVD, secure SSL web upload 

interface, or electronic transmission through a File 

Transfer Protocol. E-mail attachments shall not be 

accepted. Space permitting, multiple data files may 

be submitted utilizing the same media if the external 

label identifies the multiple files. 

 D. Transmittal Sheet. All file submissions on 

physical media shall be accompanied by a hard copy 

transmittal sheet containing the following information: 

identification of the Reporter, file name, type of file, 

data period(s), date sent, record count(s) for the file(s), 

and a contact person with telephone number and 

E-mail address. The information on the transmittal 

sheet shall match the information on the header and 

trailer records. See Appendix I. 

 E. Testing of Files. At least sixty days prior to 

the initial submission of the files or whenever the data 

element content of the files as described in Section 5 is 

subsequently altered, each Reporter shall submit to 

BISHCA or its desigee a data set for comparison to 
57a 

the standards listed in Section 7. The size, based upon a calendar period of one month, quarter, or year, of 

the data files submitted shall correspond to the filing 

period established for each Reporter under subsection 

I of this Section. 

 F. Rejection of Files. Failure to conform to subsections A, B, or C of this Section shall result in the 

rejection and return of the applicable data file(s). All 

rejected and returned files shall be resubmitted in the 

appropriate, corrected form to BISHCA or its designee within 10 days. 

* * * * * 

Section 8. Procedures for the Approval and Release of 

Claims Data. 

 The requirements, procedures and conditions under 

which persons other than the Department may have 

access to health care claims data sets and related information received or generated by the Department or 

its designee pursuant to this regulation shall depend 

upon the requestor and the characteristics of the particular information requested, all as set forth below. 

 A. Classification of Data Elements 

 (1) Unrestricted Data Elements: Data elements designated in Appendix J as “Unrestricted” 

shall be available for general use and public release 

as part of a Public Use File. 

 (2) Restricted Data Elements: Data elements 

designated in Appendix J as “Restricted” shall not 

be available for use and release outside the Department except as part of a Limited Use Research 
58a 

Health Care Claims Data Set approved by the 

commissioner pursuant to the requirements of this 

regulation. 

 (3) Unavailable Data Elements: Data elements which are not designated in Appendix J as 

either Unrestricted or Restricted, or are designated 

as “Unavailable”, shall not be available for release 

or use outside the Department in any data set or 

disclosed in publicly released reports in any circumstance. 

* * * * * 

 C. Limited Use Health Care Claims Research Data 

Sets—Release and Availability 

* * * * * 

 (2) The Commissioner may approve the release of 

limited use data sets only when the Commissioner is 

satisfied as to the following: 

 (a) The application submitted is complete and 

the requesting individuals or entities and principal 

investigator have signed a data use agreement as 

specified; 

 (b) Procedures to ensure the confidentiality of 

any patient and any confidential data are documented; 

 (c) The qualifications of the investigator and 

research staff, as evidenced by: 

 (1) Training and previous research, including 

prior publications; and 
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 (2) An affiliation with a university, private 

research organization, medical center, state 

agency, or other qualified institutional entity. 

 (d) No other state or federal law or regulation 

prohibits release of the requested information. 

* * * * * 

Section 10. Enforcement. 

 Violations of data submission requirements, confidentiality requirements, data use limitations or any 

other provisions of this rule shall be subject to sanction by the Commissioner as set out in 18 V.S.A. § 9410 

in addition to any other powers granted to the Commissioner to investigate, subpoena, fine or seek other 

legal or equitable remedies. 

* * * * *